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histology sections revealed multiple foci of caseating granulomas with central necrosis immediately surrounded by a dense rim of macrophages and a rim of lymphocytes , figures 2 and 3 .
tuberculosis is the world 's leading cause of death due to a single infectious agent .
the tuberculosis bacterium was discovered by koch in 1882 , but the description of the disease dates back to the times of hippocrates and galen ( macgregor , 1993 ) .
since the discovery of streptomycin in 1946 , the mortality rate due to tuberculosis has steadily declined , but due to hiv epidemic , the world is seeing a resurgence of this disease .
new multidrug resistant strains have emerged and pose a serious threat to the health of people exposed to it .
it was described first by whytt in 1768 , in a patient with hydrocephalus and febrile illness ( macgregor , 1993 ) .
tuberculosis can involve the nervous system in a number of ways like , meningitis , brain abscess , cerebral venous sinus thrombosis , transverse myelitis , and hydrocephalus .
however the kidneys , lymph nodes , spine , and cns may be infected first .
the cns may get involved due to dissemination of infection through the lymphohematogenous route from other primary sites ( rich and mccordick , 1933 ) .
the most common site of extrapulmonary tuberculosis is cervical lymph nodes but inguinal , axillary , mesenteric , mediastinal , and intramammary lymph node involvement have been seen ( artenstein et al . ,
tuberculous lymphadenitis has a peak age of onset of 2040  years , and in the united states it is most common in women and among immigrants from high risk areas .
patients without hiv infection typically present with chronic , non - tender lymphadenopathy ( jha et al . , 2001 ; marjorie et al . , 2005 ) .
it is usually formed by conglomeration of several miliary tubercles , which form around the outer sheaths of the cerebral blood vessels .
the incidence of tuberculoma among all intracranial neoplasm ranges from 0.2% in the industrialized world to around 8% in the developing world ( bouchama et al . , 1991 ; abdul - ghaffar et al . , 1998 ; artico et al .
, 1999).in north america the incidence of tuberculoma ranges from 0.7% to 1.4% ( sibley and o'brien , 1956 ) .
a tuberculoma is silent till neurological symptoms appear due to mass effect or when it communicates with the subarachnoid space causing meningitis ( bishburg et al . , 1986 ) .
patients usually present with malaise , low grade fever , headaches , confusion , or weight loss .
history of previous tuberculosis infection may be present in only half of the cases ( kent et al . , 1993 ) .
depending on the site of infection the patient may present with cranial nerve palsies ( traub et al . , 1984 ) , visual impairment ( teoh and humphries , 1991 ) , hemiparesis , ataxia , tremor , or seizures .
movement disorders like chorea , hemiballismus , myoclonus , and athetosis may also be seen ( alarcon et al . , 2000 ) .
patients with hiv infection are at a higher risk of tuberculosis , however there is controversial evidence if tuberculomas are seen with increased frequency in these patients ( whiteman , 1997 ) .
. presence of epithelioid cells and granulomatous inflammation , differentiate tuberculoma from a tubercular brain abscess
. ct or magnetic resonance imaging of the head may show meningeal enhancement , hydrocephalus , edema , or infarction , with a space occupying lesion ( draouat et al . , 1987 ) .
tuberculomas in younger patients are generally solitary ( 80% ) and appear isodense or hypodense areas with uniform enhancement . in later stages ring enhancement is seen ( kumar et al . , 1993).in the early stages , tuberculoma may be confused with a low grade astrocytoma .
later on , when there is a uniform enhancement , other differentials , such as sarcoid granulomas , mycotic granulomas , astrocytomas , lymphoma , toxoplasma , and metastasis should be considered .
the management of tuberculomas due to mycobacterium 
 tuberculosis includes institution of antitubercular drug regimen .
current regimen includes four drugs ( isoniazid , rifampicin , pyrazinamide , and ethambutol ) for 2  months followed by two drugs ( isoniazid and rifampicin ) for at least 10  months ( thwaites et al . , 2009 ) .
treatment of mycobacterium avium intracellulare constitutes azithromycin , clarithromycin with ethambutol or clofazimine ( kemper et al . , 1992 ) . in patients with hiv infection side effects
may be encountered in the first few months of the treatment . in such cases changing the drug regimen
surgery may be needed for large tuberculomas with mass effect and when diagnosis of tuberculosis is in doubt .
surgery has also been tried in patients not responding to treatment ( li et al . , 2006 ) . despite aggressive management and surgical intervention
the survival of patients with cns tuberculosis is not good . in a number of studies very high mortality rates of up to 50%
commonly , seizures , hemiparesis , ataxia , or cranial nerve palsies may be seen in survivors of tubercular infection ( ogawa et al . , 1987 ) . in children
cognitive and motor impairment may be seen and may not improve after treatment ( schoeman et al . ,
the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest .
a 34-year - old woman from india , presented with episodes of confusion and progressive speech deterioration 
 . she also had a painless neck  
 lump  , which persisted despite antibiotics . 
 she was diagnosed to have a space occupying lesion in the left parietal lobe , which was subsequently biopsied .