Case Presentation: A 79-year-old African American male patient with a past medical history of prostate cancer presented with progressive weakness, headache, and confusion. Free and total PSA levels were within normal limits. Brain MRI showed a 4.1×3.3×4.1 cm left frontal lesion at the surface of the left lateral ventricle with vasogenic edema and midline shift. The stereotactic biopsy of the lesion was inconclusive with showing the possibility of a non-caseating granuloma. This result was similar to the right para-adrenal mass that was biopsied a year ago. The pathologic diagnosis was in favor of sarcoidosis and metastatic prostate cancer ruled out. The patient was immigrated from Liberia and denied any constitutional symptoms. Quantiferon gold test was positive. Chest CT showed pleural calcifications without evidence of active tuberculosis(TB). Acid-Fast Basili (AFB) smear of blood was negative. Bone marrow AFB culture was negative. Rheumatologic and infectious workup of blood serum and cerebrospinal fluid were unremarkable. Stereotactic brain biopsy was inconclusive with showing astrocytosis. He subsequently, underwent left-sided frontal open brain biopsy which was compatible with granulomatous inflammation. Fungus tissue culture, sputum and blood cultures were negative. He was empirically started on anti-TB medications and dexamethasone treatment. We were unable to have significant clinical improvement two weeks after anti-TB treatment. Considering the possible diagnosis of neurosarcoidosis, we started him on intravenous methylprednisolone 1 g daily treatment for 3 days and tapered within 6 weeks. Later on, the culture of the brain biopsy showed acid-fast bacilli. We diagnosed him with tuberculoma of the brain. After a month control CT of head showed near resolution of the mid-line shift and decrease in the left frontal and bilateral parietal lobes edema.

Discussion: Central Nervous System (CNS) tuberculoma accounts for almost 1% of all tuberculosis (TB) presentations. The incidence of brain tuberculoma is increasing in developed countries due to AIDS and immigration from TB endemic countries. Symptoms and radiologic findings of CNS TB can be nonspecific and leading to misdiagnosis or mistreatment. We describe a case of brain tuberculoma in a patient who was thought to have a neuro-sarcoidosis due to non-caseating granuloma. Brain Tuberculoma can present with a seizure, intracranial hypertension or focal neurologic symptoms. A definitive diagnosis can be made with AFB in the pathologic specimen. In our case diagnosis was challenging between neurosarcoidosis and TB due to inconclusive results of stereotactic brain biopsy and clinical presentation. We proceed to open brain biopsy. It revealed non-caseating granuloma.

Conclusions: Diagnosing brain tuberculoma can be challenging due to atypical presentation and inconclusive pathological results. Considering the catastrophic course of brain tuberculoma, physicians should consider empiric anti-TB treatment in high-risk patients.