Miliary tuberculosis and intramedullary tuberculoma of the conus medullaris

Introduction. This case is presented to illustrate the diagnostic and therapeutic dilemmas of a rare condition: intramedullary tuberculoma of the conus medullaris. Observation. A 49 year-old man was admitted in April 2005 for pain, paresthesias and weakness of lower limbs evolving for about 15 days. He had also unusual tiredness with mild fever and dry cough for more than a month. Chest x-ray then computed tomography suggested miliary tuberculosis and spinal MR showed a conus medullaris ring enhancing lesion suggestive of tuberculoma. Lumbar puncture or surgical biopsy was not performed. He responded well to a combination of four antituberculous drugs, with progressive clinical and radiological improvement. Conclusion. Although it is a very rare condition, conus terminalis tuberculoma can be suspected in the presence of typical MR image and clinical context. Treatment is primarily medical. Surgery is indicated only in case of rapid neurological deterioration or doubts about diagnosis.