Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
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KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

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Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2011 | Month : October | Volume : 5 | Issue : 5 | Page : 1111 - 1113

Intramedullary Tuberculomas of Cervical Spinal Cord in a Young Immunocompetent Patient: A Case Report

Seshu Lakshmi Borra, Venkata Umakant Kodali, Mallikarjuna Rao Sanda, Rajeev Donepudi, Surendra Babu M.

Associate professor Department of Radio-diagnosis Mamata medical college Khammam, Andhra Pradesh, India. Assistant Professor Department of General medicine Mamata medical college Khammam, Andhra Pradesh, India. Assistant professor Department of General medicine Mamata medical college Khammam, Andhra Pradesh, India. Post graduate-final year Department of Radio-diagnosis Mamata medical college Khammam, Andhra Pradesh, India.Post graduate-final year Department of General medicine Mamata medical college Khammam, Andhra Pradesh, India.

Correspondence Address :
Venkata Umakant Kodali
Staff Qtrs, Godavari – 3,
Mamata General Hospital,
Giriprasad Nagar, Khammam – 507002
Andhra Pradesh, India.
Mobile: +919866181162
Res: 08742228302
Office: 08742-235160


Spinal intramedullary tuberculosis is a rare form of tuberculosis. We report a rare case of intramedullary tuberculomas in cervical spinal cord in young immunocompetent patient with no evidence of tuberculosis elsewhere in the body. Magnetic Resonance Imaging (MRI) showed cervical cord edema and circumscribed lesions at C4-C5 level. The lesions showed conglomerate ring enhancement with central hypointensity on contrast enhanced MRI, suggestive of granulomatous etiology. Patient received anti-tuberculous treatment following which patient was symptom free and MRI showed complete resolution of the lesions. Intramedullary tuberculosis if diagnosed early, usually has good response to medical treatment preventing the need for surgical intervention.


Intramedullary tuberculomas, Magnetic Resonance Imaging, Anti-tuberculous treatment

Tuberculosis involving the central nervous system is rare compared with other systems (1). The brain is far more commonly affected than the spinal cord, the ratio being 42:1(2). Intramedullary tuberculomas are seen in only 2 out of 100,000 cases of tuberculosis (3),(4). Intramedullary tuberculomas occur usually in young people and most commonly involve the thoracic spinal cord (5). Patients frequently present with quadriplegia/paraplegia and with other signs of spinal cord compression. We report a rare case of cervical intramedullary tuberculomas (IMT) in a young immunocompetent patient with no evidence of tuberculosis elsewhere in the body.

Case Report

A twenty-two year old female patient was admitted in our hospital one and half years back with complaints of sudden onset quadriparesis 15 days prior to admission. Her hemoglobin,TC,DC,ESR were within the normal range. Mantoux test,Hepatitis B surface antigen test and ELISA for HIV were negative. Cerebrospinal fluid analysis revealed lymphocytosis with elevated protein and lowsugar levels. Chest and cervical spine radiographs were normal (Table/Fig 1). MRI of cervical spine was performed before and after intravenous injection of Gadobenate Dimeglumine (MRI contrast agent). MRI showed diffuse enlargement of cervical spinal cord with edema, hypoisointense circumscribed lesion in the cervical cord at C4 vertebral level in T1 weighted images(WI) and iso-hyperintense in T2 WI (Table/Fig 2), (Table/Fig 3). On contrast administration, two conglomerate ring enhancing lesions were seen in the cervical cord at C4-C5 level (Table/Fig 4). Adjacent vertebral bodies and the paraspinal soft tissues were normal. The lesions due to their size, surrounding oedema along with thick and conglomerate ring enhancement on post contrast scans were highly suggestive of intramedullarytuberculomas and the diagnosis of intramedullary tuberculosis was made. Patient was kept on complete antituberculous treatment for eighteen months:four drug regimen (isoniazid, rifampicin, pyrazinamide and ethambutol) for three months followed by two drug regimen (rifampicin and isoniazid) for fifteen months. Patient improved clinically and was symptom free by two weeks. On completion of treatment, follow up MRI of cervical spine was done. MRI showed normal signal intensities of cervical spinal cord with no evidence of edema, focal lesions or abnormal enhancement (Table/Fig 5).


Extra-pulmonary tuberculosis occurs as a result of haematogenous spread from a primary focus, usually the lung.CNS involvement is less common as compared to the involvement of other systems and is seen in up to 10% of patients with systemic tuberculosis. (1).The brain is more commonly affected than the spinal cord; This may be due to the relative masses of neural tissue in them (2). There may be no evidence of extra-neural tuberculosis in up to a third cases of neurotuberculosis. Therefore, even in the absence of tuberculosis elsewhere in the body, as in our case, the possibility of CNS tuberculosis can not be ruled out.

Although spinal tuberculosis is common in geographic areas where tuberculosis is endemic, spinal IMT are rare. Spinal IMT occur usually in young people and commonly involve the thoracic spinal cord. IMT frequently presents with signs of subacute spinal cord compression, variable clinical presentations with Brown-Sequard syndrome and episodes of paraplegia have also been reported (2). Intramedullary tuberculomas are also seen in patients with HIV, auto-immune disease, especially systemic lupus erythematosus and patients undergoing immunosuppressive treatment due to liver transplantation (6).

The most common parenchymal form of central nervous system tuberculosis is tuberculous granuloma (tuberculoma). Tuberculoma may be secondary to haematogenous spread of systemic disease or may evolve from extension of cerebrospinal fluid infection into the adjacent parenchyma via cortical veins and penetrating arteries. Pathologically, tuberculoma is composed of a central zone of solid caseation necrosis, surrounded by a capsule of collagenous tissue, epitheloid cells, multinucleated giant cells (7). Outside the capsule, there is surrounding edema. The edema surrounding tuberculoma is relatively more prominent in the early stages of granuloma formation.

MRI has revolutionised the imaging of tuberculomas and the diagnosis can be made with reasonable certainty, avoiding the need for an invasive procedure (8), (9). On MRI, signal intensities of tuberculomas are compared to signal intensities of the normal spinal cord. Tuberculomas appear hypo-isointense in T1 weighted images and have a slightly hyperintense rim (6), (8). On T2 weighted images, tuberculomas exhibit variable signal. They are hypointense or isointense, this relative hypointensity is related to T2 shortening by paramagnetic free radicals produced by macrophages that are heterogeneously distributed throughout the caseous granuloma. The diminished signal on T2 Weighted images is due to the mature tuberculoma being of greater cellular density (10). Tuberculomas may also be hyperintense on T2 weighted images and this is due to a greater degree of central liquefactive necrosis in these lesions (6),(11). In our case, the lesions showed hyperintensity in T2WI, this may be due to central liquefactive necrosis.

Postgadolinium images of tuberculomas demonstrate intense nodular and ring like enhancement. Healed tuberculomas calcify in 23% of cases. Institution of anti-tuberculous treatment is the primary modality of treatment for spinal IMT. If diagnosed early in the course of disease, IMT resolve completely with anti-tuberculous treatment and surgery can be prevented (12),(13). Tuberculous abscess is a rare complication of IMT.

The differential diagnosis of intramedullary tuberculomas includes cysticercal granulomas, and astrocytoma. However, in this case, the clinical picture and the size of the lesion combined with the classical thick and conglomerate ring enhancement with surrounding oedema was highly suggestive of tuberculoma. The complete resolution of the lesions in the follow-up MRI after the institution of anti-tuberculous treatment was confirmative of the diagnosis of IMT.


Intramedulary tuberculomas of spinal cord are rare. Gadolinium enhanced MRI helps in the accurate diagnosis of IMT. MRI is also useful in monitoring the response to treatment and in the follow-up of these patients. In cases with early diagnosis of IMT, immediate medical treatment with anti-tuberculous treatment is sufficient and complete resolution of lesions is seen. Surgery may be indicated for large lesions with rapid deterioration of the neurological status or when there is paradoxical increase in the size of the lesion following anti-tuberculous treatment.

Key Message

Early diagnosis and treatment with antitubercular therapy of IMT is sufficient for complete resolution of lesions.


1. Dr.Y.Mallikarjuna, Prof and HOD General Medicine, Mamata Medical College, Khammam, Andhra Pradesh, India.2. Dr.V.Dharma Rao, Associate Prof General Medicine, Mamata Medical College, Khammam, Andhra Pradesh, India.


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