TUBERCULOMA

CASE OF FOCAL CASE OF FOCAL SEIZURESSEIZURES

PRESENTED BY: MAJ ARVIND KUMARPRESENTED BY: MAJ ARVIND KUMAR

DISCUSSED BY: WG CDR K S DISCUSSED BY: WG CDR K S MULTANI MULTANI

Case detailsCase details

11 yr old male child11 yr old male child Product of non consanguinous Product of non consanguinous

marriagemarriage Informant- fatherInformant- father Resident of BHIWANI(HARYANA)Resident of BHIWANI(HARYANA) Reliability -goodReliability -good

Presenting complaintsPresenting complaints

One episode of loss of consciousness One episode of loss of consciousness with generalized seizures - 24 hrs with generalized seizures - 24 hrs beforebefore

Weakness of left upper limb x 24 hrsWeakness of left upper limb x 24 hrs Headache ×24 hrsHeadache ×24 hrs

HISTORY OF PRESENT HISTORY OF PRESENT ILLNESSILLNESS

Apparently well child till one day backApparently well child till one day back while playing carrom ,he developed while playing carrom ,he developed

pain and numbness in left upper limb. pain and numbness in left upper limb. Soon he developed generalized Soon he developed generalized

seizuresseizures Associated with loss of consciousnessAssociated with loss of consciousness Deviation of angle of mouth Deviation of angle of mouth Up rolling of eye ballsUp rolling of eye balls Lasted for 03 minutesLasted for 03 minutes

HOPI contd…HOPI contd… H/O WEAKNESS UPPER LEFT LIMBH/O WEAKNESS UPPER LEFT LIMB

Acute onset,involving elbow ,wrist and finger gripsAcute onset,involving elbow ,wrist and finger grips NonProgressive NonProgressive

HEADACHEHEADACHE B/L FRONTAL REGIONB/L FRONTAL REGION MILD MILD CONTINOUSCONTINOUS

NEGATIVE HISTORYNEGATIVE HISTORY

No H/o ofNo H/o of NO BOWL/BLADDER INCOTINENCENO BOWL/BLADDER INCOTINENCE NO POOLING OF NO POOLING OF

SALIVA,DYSPHAGIA,NASAL SALIVA,DYSPHAGIA,NASAL REGURGITATIONREGURGITATION

FLUSHING/SWEATING/GIDDINESSFLUSHING/SWEATING/GIDDINESS FEVERFEVER COUGHCOUGH CHEST PAIN OR PALPITATIONCHEST PAIN OR PALPITATION VOMITING/DIARRHEAVOMITING/DIARRHEA

PAST HISTORYPAST HISTORY

No past h/o seizuresNo past h/o seizures No other significant historyNo other significant history

FAMILY HISTORYFAMILY HISTORY

Nonconsaguinous Nonconsaguinous marriagemarriage

No h/o No h/o seizures,neurologiseizures,neurological disorderscal disorders

Mother has Mother has completed ATT completed ATT course 07 yrs back course 07 yrs back for pulmonary T B .for pulmonary T B .

13yrs 13yrs 11yrs11yrs

IMMUNISATION HISTORYIMMUNISATION HISTORY

As per UIPAs per UIP No optional vaccinesNo optional vaccines BCG scar mark presentBCG scar mark present

DEVELOPMENTAL DEVELOPMENTAL HISTORYHISTORY

Studying in 7th class Studying in 7th class Good scholastic performance Good scholastic performance

SOCIAL HISTORYSOCIAL HISTORY

4 family members4 family members Nuclear middle classNuclear middle class 2 rooms + kitchen2 rooms + kitchen Ventilation adequateVentilation adequate

Summary after history Summary after history

11 yr old male child apparently well 11 yr old male child apparently well 1 days back, presented with h/o one 1 days back, presented with h/o one episode of generalized seizures of 3 episode of generalized seizures of 3 minutes duration followed by minutes duration followed by weakness and numbness in upper weakness and numbness in upper left limb and frontal headache with left limb and frontal headache with family h/o pulmonary tuberculosis in family h/o pulmonary tuberculosis in mother 07 yrs back,had completed mother 07 yrs back,had completed ATT course ATT course

General examinationGeneral examination Child is conscious ,oriented to time, Child is conscious ,oriented to time,

place ,sitting on bed comfortably place ,sitting on bed comfortably AfebrileAfebrile Pulse- 88/min,all peripheral pulses well Pulse- 88/min,all peripheral pulses well

felt,sinus arythmiafelt,sinus arythmia R/R- 20/minR/R- 20/min BP- 110/68mm Hg RASBP- 110/68mm Hg RAS CFT < 2 secCFT < 2 sec No pallor /icterus /cyanosis/ No pallor /icterus /cyanosis/

clubbing/lymphadenopathy/ pedal oedemaclubbing/lymphadenopathy/ pedal oedema No neurocutaneous markersNo neurocutaneous markers

AnthropometryAnthropometry

Weight- 35kg (25-50Weight- 35kg (25-50thth p ) p ) Height- 146.7 cm (50-75Height- 146.7 cm (50-75thth p) p) Nutritional status WNLNutritional status WNL

CNSCNS

HMF normalHMF normal Speech normalSpeech normal Cranial nerves normalCranial nerves normal

Fundoscopy normalFundoscopy normal

CNS contd…CNS contd…

MOTOR SYSTEMMOTOR SYSTEM Bulk normalBulk normal ToneTone

Power Power

UL UL NN

LLLL NN

PowePower r

Rt Rt LtLt

ULUL 5/55/5 4/54/5

LLLL 5/55/5 5/55/5

CNS contd…CNS contd…

Reflexes Reflexes

reflexreflex bicepbicep triceptricep supintsupintrr

kneeknee ankleankle plantplantarar

RTRT ++++ ++ ++ ++++ ++ flexorflexor

LTLT ++ ++ ++ ++++ ++ flexorflexor

Superficial reflexes intactSuperficial reflexes intact No sensory lossNo sensory loss Gait normalGait normal Skull/spine normalSkull/spine normal

Resp Resp B/L equal air entryB/L equal air entry vesicular breath soundsvesicular breath sounds

CVS –SI S2 normal,no murmurCVS –SI S2 normal,no murmur Abdomen – Abdomen –

Soft ,no organomegalySoft ,no organomegaly B/S +B/S +

SUMMARYSUMMARY

11 yr old male child apparently well 11 yr old male child apparently well 1 days back, presented with h/o one 1 days back, presented with h/o one episode of generalized episode of generalized seizures ,presently having some seizures ,presently having some weakness in left upper limb and weakness in left upper limb and frontal headachefrontal headache

INVESTIGATIONSINVESTIGATIONS Hb-12.3gm%Hb-12.3gm% TLC-9500TLC-9500 DLC-P53 L41DLC-P53 L41 Platelets- 2.6 lacsPlatelets- 2.6 lacs PBS for MP- NegPBS for MP- Neg ICT for MP –VEICT for MP –VE BUN-10BUN-10 Creatinine- 0.8Creatinine- 0.8

INVESTIGATIONINVESTIGATION

Na 140Na 140 K 4.2K 4.2 Cl 101Cl 101 Ca 3.6 repeat 4.4Ca 3.6 repeat 4.4 Urine normalUrine normal LFT normalLFT normal CPK 14 U/LCPK 14 U/L Montoux test negativeMontoux test negative

CXR normalCXR normal ECG normalECG normal USG abdomen normalUSG abdomen normal MRI Brain showed –ring enhancing MRI Brain showed –ring enhancing

lesions in posterior parietal lobe Rt lesions in posterior parietal lobe Rt side with perilesional side with perilesional edema,suggestive of tuberculoma.edema,suggestive of tuberculoma.

DIAGNOSISDIAGNOSIS

Functional -MonoparesisFunctional -Monoparesis

Anatomical - UMN typeAnatomical - UMN type

Etiological -TUBERCULOMAEtiological -TUBERCULOMA

FINAL DIAGNOSISFINAL DIAGNOSIS

TUBERCULOMA IN RT PARIETAL TUBERCULOMA IN RT PARIETAL LOBE LOBE

MANAGEMENTMANAGEMENT

DefinitiveDefinitive ATTATT

SupportiveSupportive STEROIDSSTEROIDS ANTI EPILEPTICANTI EPILEPTIC Watch out for SEIZURESWatch out for SEIZURES

COURSE IN HOSPCOURSE IN HOSP

Child was seizures free Child was seizures free Showed improvement in power in Showed improvement in power in

left upper limbleft upper limb Got relief from headacheGot relief from headache Tolerating ATT wellTolerating ATT well

THANK YOUTHANK YOU