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

Biller, José

Chugh, Chandril

Wadhwani, N.

English

PubMed

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

Chandril eChugh

Jose eBiller

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Frontiers in Neurology

Episodes of confusion and slurred speech in a 34-year-old woman from India

Chandril Chugh

N. Wadhwani

José Biller

Frontiers - Publisher Connector

Edited by:
Osvaldo Fustinoni, Universidad de 
Buenos Aires, Argentina
Reviewed by:
Osvaldo  Fustinoni, Universidad de 
Buenos Aires, Argentina
Fernando Goldenberg, University of 
Chicago Medical Center, USA
*Correspondence:
José Biller, Department of Neurology, 
Stritch School of Medicine, Loyola 
University Chicago, 2160 South First 
Avenue, Maywood, IL 60153, USA.
e-mail: jbiller@lumc.edu
The patient is currently being followed in the neurology outpa-
tient clinic and has improved since the surgery and institution 
of antitubercular drug therapy. The residual neck scar is shown 
in Figure 1 below.
Pathology
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. Ziehl–
Neelsen staining shows a single rod shaped, acid fast organism, 
Figure 4.
Discussion
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). Tuberculosis 
is more prevalent in the developing countries as compared to 
developed countries. 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.
Tuberculosis of the central nervous system (CNS) is a well known 
entity. 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.
Mycobacterium tuberculosis is an airborne microorganism. 
The lungs are usually the primary site of infection. 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 
A 34-year-old woman born in India, presented to our clinic with 
concerns of confusion and slurred speech. Three months before 
presentation, she had occasional episodes of confusion. During 
these episodes, she was unable to respond, but never lost con-
sciousness. These events were brief and resolved completely. She 
worked at a grocery store with her husband, who noticed she 
was having trouble tending right change to the customers. She 
also had difficulty remembering names of the employees. Two 
months earlier she started slurring and even her husband had 
difficulty understanding her. She then had a generalized tonic 
clonic seizure. She also complained of lethargy and body aches 
accompanied by a low grade fever. She did not have any weight 
loss or night sweats.
She was last seen by a physician a year earlier, for a “neck lump.” 
She was started on a course of antibiotics, but the lump persisted. 
She did not have a history of smoking, alcohol abuse, or intravenous 
drug abuse. There was no past history of hypertension, diabetes 
mellitus, cardiac arrhythmias, or stroke. Her father had a history of 
hypertension and pulmonary tuberculosis, but she was not living 
with him for the past 10 years.
She had an unremarkable physical exam, except for a left sided 
soft, non-tender, fluctuant, mobile neck mass, measuring around 
3 cm × 5 cm in size. Neurological examination showed deficits in 
attention and concentration. She had difficulty performing simple 
calculations. Speech was slurred but language was intact. She did not 
have any cranial nerve deficits, motor weakness, or sensory deficits. 
She had a normal gait and stance.
Laboratory testing showed normal blood indices. She had a 
mildly elevated erythrocyte sedimentation rate. HIV antibody 
testing was negative. Chest radiograph was unremarkable. She 
had an aspiration biopsy of the neck mass, which showed acid 
fast organisms on Ziehl–Neelsen staining. Cranial computer-
ized tomography (CT) showed a left parietal lobe mass lesion 
with surrounding edema. She had resection of the mass lesion. 
Confusion and slurred speech in a 34-year-old woman  
from India
Chandril Chugh1, N. Wadhwani2 and José Biller1*
1 Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
2 Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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.
Keywords: brain mass lesion, cerebral edema, speech deterioration, neck mass
www.frontiersin.org June 2011 | Volume 2 | Article 34 | 1
CPC ArtiCle
published: 06 June 2011
doi: 10.3389/fneur.2011.00034
Tubercular meningitis is the most common presentation of nerv-
ous system tuberculosis. Tuberculoma of the brain, on the other 
hand, is rare. It is usually formed by conglomeration of several miliary 
tubercles, which form around the outer sheaths of the cerebral blood 
vessels. Caseous necrosis ensues and the necrotic debris gets inspis-
sated and sometimes liquefied. A thick capsule may form around 
these lesions. 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. Confusion in the absence of fever may be seen. 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), hemipa-
resis, ataxia, tremor, or seizures. Movement disorders like cho-
rea, hemiballismus, myoclonus, and athetosis may also be seen 
(Alarcon et al., 2000). Patients with HIV infection are at a higher 
Figure 2 | Hematoxylin and eosin staining.
Figure 3 | Hematoxylin and eosin staining.
Figure 4 | Hematoxylin and eosin staining.
Figure 1 | Ziehl–Neelsen staining.
and McCordick, 1933). The most common site of extrapulmonary 
tuberculosis is cervical lymph nodes but inguinal, axillary, mesen-
teric, mediastinal, and intramammary lymph node involvement 
have been seen (Artenstein et al., 1995). Tuberculous lymphadenitis 
has a peak age of onset of 20–40 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).
Frontiers in Neurology | Neurology Education  June 2011 | Volume 2 | Article 34 | 2
Chugh et al. A 34-year-old woman from India
RefeRences
Abdul-Ghaffar, N. U., El-Sonbaty, M. R., 
and Rahman, N. A. (1998). Intracranial 
tuberculomas. Int. J. Tuberc. Lung Dis. 
2, 413–418.
Alarcon, F., Duenas, G., Ceballos, N., and 
Lees, A. J. (2000). Movement disorders 
in 30 patients with tuberculous men-
ingitis. Mov. Disord. 15, 561–569.
Artenstein, A. W., Kim, J. H., Williams, W. 
J., and Chung, R. C. (1995). Isolated 
peripheral tuberculous lymphadenitis 
in adults: current clinical and diagnos-
tic issues. Clin. Infect. Dis. 20, 876–882.
Artico, M., De Caro, G. M., Carloia, 
S., Salvati, M., D’Ambrosio, M., 
and Delfini, R. (1999). Advances in 
diagnosis, treatment and progno-
sis of intracerebral tuberculomas in 
the last 50 years: report of 21 cases. 
Neurochirurgie 45, 129–133.
Bishburg, E., Sunderam, G., Reichman, 
L. B., and Kapila, R. (1986). Central 
nervous system tuberculosis with 
the acquired immunodeficiency syn-
drome and its related complex. Ann. 
Intern. Med. 105, 210–213.
Bouchama, A., al-Kawi, M. Z., Kanaan, 
I., Coates, R., Jallu, A., Rahm, B., and 
Siqueira, E. B. (1991). Brain biopsy in 
tuberculoma: the risks and benefits. 
Neurosurgery 28, 405–409.
Draouat, S., Abdenabi, B., Ghanem, M., 
and Bourjat, P. (1987). Computed 
tomography of cerebral tuberculoma. 
J. Comput. Assist. Tomogr. 11, 594–597.
Jha, B. C., Dass, A., Nagarkar, N. M., 
Gupta, R., and Singhal, S. (2001). 
Cervical tuberculous lymphadenop-
athy: changing clinical pattern and 
concepts in management. Postgrad. 
Med. J. 77, 185–187.
Kemper, C. A., Tze-Chiang, M., Nussbaum, 
J., Chiu, J., Feigal, D. F., Bartok, A. E., 
Leedom, J. M., Tilles, J. G., Deresinski, 
S. C., and McCutchan, J. A. (1992). 
Treatment of Mycobacterium avium 
complex bacteremia in AIDS with a 
four-drug regimen: rifampin, etham-
butol, clofazimine, and ciprofloxacin. 
Ann. Intern. Med. 116, 466–472.
Kent, S. J., Crowe, S. M., Yung, A., 
Lucas, C. R., and Mijch, A. M. 
(1993). Tuberculous meningitis: a 
30-year review. Clin. Infect. Dis. 17, 
987–994.
Kumar, A., Montanera, W., Willinsky, 
R., TerBrugge, K. G., and Aggarwal, 
S. (1993). MR features of tubercu-
lous arachnoiditis. J. Comput. Assist. 
Tomogr. 17, 127–130.
Li, H., You, C., Yang, Y., He, M., Cai, 
B., Wang, X., and Ju, Y. (2006). 
Intramedullary spinal tuberculoma: 
report of three cases. Surg. Neurol. 65, 
185–188.
MacGregor, R. R. (1993). Tuberculosis: 
from history to current management. 
Semin. Roentgenol. 28, 101–108.
Marjorie, P., Golden, M. D., and 
Holenarasipur Vikram, R. (2005). 
Extrapulmonary tuberculosis: an 
overview. Am. Fam. Physician 72, 
1761–1768.
Ogawa, S. K., Smith, M. A., Brennessel, 
D. J., and Lowy, F. D. (1987). 
Tuberculous meningitis in an urban 
medical center. Medicine (Baltimore) 
66, 317–326.
Porkert, M. T., Blumberg, H. M., Parrott-
Moore, P., and Sotir, M. (1997). 
Tuberculous meningitis at a large 
inner-city medical center. Am. J. Med. 
Sci. 313, 325–331.
Rich, A. R., and McCordick, H. A. (1933). 
The pathogenesis of tuberculous men-
ingitis. Bull. Johns Hopkins Hosp. 52, 
5–37.
Schoeman, C. J., Herbst, I., and 
Nienkemper, D. C. (1997). The 
effect of tuberculous meningitis 
on the cognitive and motor devel-
opment of children. S. Afr. Med. J. 
87, 70–72.
Sibley, W. A., and O’Brien, J. L. (1956). 
Intracranial tuberculomas: a review 
of clinical features and treatment. 
Neurology 6, 157–165.
Small, P. M., Schecter, G. F., Goodman, 
P. C., Sande, M. A., Chaisson, R. E., 
and Hopewell, P. C. (1991). Treatment 
of tuberculosis in patients with 
advanced human immunodeficiency 
virus infection. N. Engl. J. Med. 324, 
289–294.
Teoh, R., and Humphries, M. (1991). 
“Tuberculous meningitis,” in Infections 
of the Central Nervous System, ed. H. 
P. Lambert (Philadelphia: BC Decker), 
189–206.
Thwaites, G., Fisher, M., Hemingway, 
C., Scott, G., Solomon, T., and Innes, 
J. (2009). British Infection Society 
guidelines for the diagnosis and treat-
ment of tuberculosis of the central 
nervous system in adults and children. 
J. Infect. 59, 167–187.
Traub, M., Colchester, A. C., Kingsley, D. P., 
and Swash, M. (1984). Tuberculosis of 
the central nervous system. Q. J. Med. 
53, 81–100.
Whiteman, M. L. (1997). Neuroimaging of 
central nervous system tuberculosis in 
HIV-infected patients. Neuroimaging 
Clin. N. Am. 7, 199–214.
Conflict of Interest Statement: The 
authors declare that the research was 
conducted in the absence of any com-
mercial or financial relationships that 
could be construed as a potential conflict 
of interest.
Received: 12 March 2011; accepted: 10 May 
2011; published online: 06 June 2011.
Citation: Chugh C, Wadhwani N and 
Biller J (2011) Confusion and slurred 
speech in a 34-year-old woman from 
India. Front. Neur. 2:34. doi: 10.3389/
fneur.2011.00034
This article was submitted to Frontiers 
in Neurology Education, a specialty of 
Frontiers in Neurology.
Copyright © 2011 Chugh, Wadhwani and 
Biller. This is an open-access article sub-
ject to a non-exclusive license between the 
authors and Frontiers Media SA, which 
permits use, distribution and reproduc-
tion in other forums, provided the origi-
nal authors and source are credited and 
other Frontiers conditions are complied 
with.
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 may be helpful (Small et al., 
1991). 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 num-
ber of studies very high mortality rates of up to 50% have been 
reported (Porkert et al., 1997). Neurological sequelae vary with 
age and demographics. 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., 1997).
risk of tuberculosis, however there is controversial evidence if 
tuberculomas are seen with increased frequency in these patients 
(Whiteman, 1997). Tuberculomas are most commonly seen in 
frontal lobe, cerebellum, and brainstem.
Diagnosis of tuberculoma is confirmed by imaging followed by 
biopsy or excision of the lesion. 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 tuber-
culosis includes institution of antitubercular drug regimen. Current 
regimen includes four drugs (isoniazid, rifampicin, pyrazinamide, 
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Chugh et al. A 34-year-old woman from India


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