Brain tuberculoma: a 52-year-old woman case report
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Introduction. One of the most serious extrapulmonary type of tuberculosis that affects people under the age of 40 is brain tuberculoma. They are space-occupying masses of granulomatous tissue that result from hematogenous spread from a distant focus of tuberculous infection by Mycobacterium tuberculosis . Symptoms and radiologic features being nonspecific usually leads to misdiagnosis and mimics a variety of other infectious diseases. Anti-tubercular drugs are essential for the successful treatment of cerebral tuberculomas.
Case Report. The authors present a case report of a 52-year-old diabetic woman, who presented to the Emergency Department of a tertiary care hospital and was diagnosed with brain tuberculomas with a brain biopsy. Brain tuberculomas are rare and could be overlooked. Therefore, this is an important consideration in cases with higher suspicions, given the rapid decline in patient condition.
Conclusion. Due to their rarity, ambiguous symptoms, and radiographic characteristics, intracranial tuberculomas continue to provide a clinical challenge and must always be considered in the differential diagnosis of cerebral space occupying lesions. As CSF may not yield positivity for both CBNAAT and smear examination, a brain biopsy specimen for culture should always be kept in mind for detecting tuberculoma and initiating anti-tubercular treatment at the earliest.
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The work presented is clear and the arguments well formed. This study would be a valuable contribution to the existing literature. This is a study that would be of interest to the field and community.
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1. Half the references are missing. Original version has 26 references and again this is incorrect as reference 26 is missing in the article. In addition, your revision appears to now have only 14 references. Please clarify. 2. The order of the cited references is incorrect or incorrectly cited. Example: In your original submission, “Line 47-48 Tuberculoma of the brain is one of the most serious extrapulmonary types that afflict people under the age of 40 was reference (2)” and this was about the Global tuberculosis report 2022. However, the same sentence in your revision is still reference (2) but it now references to “Virulence factors of the Mycobacterium tuberculosis complex”. This is causing confusion. Please amend this and verify that the proper is maintained. 3. In addition of the above issues, the authors introduced new …
1. Half the references are missing. Original version has 26 references and again this is incorrect as reference 26 is missing in the article. In addition, your revision appears to now have only 14 references. Please clarify. 2. The order of the cited references is incorrect or incorrectly cited. Example: In your original submission, “Line 47-48 Tuberculoma of the brain is one of the most serious extrapulmonary types that afflict people under the age of 40 was reference (2)” and this was about the Global tuberculosis report 2022. However, the same sentence in your revision is still reference (2) but it now references to “Virulence factors of the Mycobacterium tuberculosis complex”. This is causing confusion. Please amend this and verify that the proper is maintained. 3. In addition of the above issues, the authors introduced new references in their revision that are in the incorrect referencing style. Please do adhere to the uniform style and verify that other references are also in same style. Example: Reference (2) Virulence factors of the Mycobacterium tuberculosis complex - PMC [Internet]. [cited 2023 Mar 8]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544749/ 4. It is unclear if you have responded to the queries of Review 1, comment 8 &12. Please clarify this as it is not obvious. 5. Query of Reviewer 2 deals with removing reference 2. The authors have removed this reference but in doing so have not deal with the remaining sentences that still continue to cited Reference 2. This also connects to my earlier point 2. Please verify this.
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This study would be a valuable contribution to the existing literature. The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. The language used is poor, which can cause ambiguity at times. Please carefully rewrite it. We offer a discounted translation service, Editage (https://www.editage.com/; see https://www.microbiologyresearch.org/prepare-an-article#13 for more information).
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Comments to Author
The authors present a case report of a 52-year-old diabetic woman, who presented to the emergency department of a tertiary care hospital and was diagnosed with brain tuberculomas with a brain biopsy. Brain tuberculomas are rare and could be overlooked. Therefore, this is an important consideration in cases with higher suspicions, given the rapid decline in patient condition. Comments: 1. Line 41: "Fortunately, after falling from seventh to thirteenth rank in the previous ten years, it is no longer one of the top ten diseases in the world (2)." How is this statement relevant to the current case presentation? 2. Line 86: While CBNAAT is defined in the Abbreviations section, it might be best to mention what this abbreviation is in the first place used in the manuscript. 3. Line 92: "Although brain …
Comments to Author
The authors present a case report of a 52-year-old diabetic woman, who presented to the emergency department of a tertiary care hospital and was diagnosed with brain tuberculomas with a brain biopsy. Brain tuberculomas are rare and could be overlooked. Therefore, this is an important consideration in cases with higher suspicions, given the rapid decline in patient condition. Comments: 1. Line 41: "Fortunately, after falling from seventh to thirteenth rank in the previous ten years, it is no longer one of the top ten diseases in the world (2)." How is this statement relevant to the current case presentation? 2. Line 86: While CBNAAT is defined in the Abbreviations section, it might be best to mention what this abbreviation is in the first place used in the manuscript. 3. Line 92: "Although brain tuberculoma can be identified by PCR for CSF, it might not be helpful for an immediate diagnosis and course of treatment (14)." Would you please elaborate on why this is the case and what others are on the differential with this information? 4. Line 94: "More than 85% of cases of TB can be cured if therapy is started early." Is this true for brain tuberculomas also, or for TB pulmonary infections? 5. In Table 1, please define HD as a footnote for the table. 6. Figure 1: shows multiple Brain Enhancing lesions. However, only one is circled and highlighted. Please highlight the rest of them or change the wording of the figure legend to "red arrow showing brain enhancing lesion". Also, please state the Hospital Date of the MRI. Was more than one MRI taken during the course of the hospital stay? If so, more than one MRI could be used to show any progress or deterioration of the patient's condition as seen on MRI. 7. Figure 2: shows one clump of possible stained mycobacteria. Are there other slide images that show more of the stained pathogen?
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Comments 1: The title of manuscript does not provide accurate information and it will be modified as: "Meningitis tuberculosis: A fifty two year old woman case report". Or "Diagnosis and treatment of TB meningitis: A case report". Or "A case report: TB meningitis diagnosis and treatment? Author response: Comments 2: Lines 38, 53, 64, 143: You abbreviated Tuberculosis (TB); Extrapulmonary TB (EPTB); Pulmonary TB (PTB) and Mycobacterium tuberculosis (Mtb) etc. in starting in the introduction part but lines 39, 65, 54, 55, 58, 66, 67,69, 98 you did not used the abbreviations instead you write complete sentence i.e. Tuberculosis, Pulmonary tuberculosis, Mycobacterium tuberculosis (Mtb) again in whole manuscript. Further, for your manuscript accuracy you can use abbreviations only first starting …
Comments to Author
Comments 1: The title of manuscript does not provide accurate information and it will be modified as: "Meningitis tuberculosis: A fifty two year old woman case report". Or "Diagnosis and treatment of TB meningitis: A case report". Or "A case report: TB meningitis diagnosis and treatment? Author response: Comments 2: Lines 38, 53, 64, 143: You abbreviated Tuberculosis (TB); Extrapulmonary TB (EPTB); Pulmonary TB (PTB) and Mycobacterium tuberculosis (Mtb) etc. in starting in the introduction part but lines 39, 65, 54, 55, 58, 66, 67,69, 98 you did not used the abbreviations instead you write complete sentence i.e. Tuberculosis, Pulmonary tuberculosis, Mycobacterium tuberculosis (Mtb) again in whole manuscript. Further, for your manuscript accuracy you can use abbreviations only first starting point as: Tuberculosis (TB) Extrapulmpnart TB (EPTB) Pulmonary TB (PTB) Mycobacterium tuberculosis (Mtb) Isoniazid (INH), Rifampicin (RIF) I also recommend you can abbreviate some term in your manuscript as: MPT64 MRI ICU MICU Author response: Comments 3: Lines 135: Which one mycobactrial culture use for Mtb detection i.e. MGIT-960 or 460 in your study? Author response: Comments 4: Lines 124-125: Which one types of CBNAAT used for Mtb detection in the CSF i.e. GeneXpert or GeneXpert Ultra. Author response: Comments 5: Lines 167-168: Some previous studies also discuss in your manuscripts, which are more related to TB meningitis as: "Role of immuno-polymerase chain reaction (I-PCR) in resolving diagnostic dilemma between tuberculoma and neurocysticercosis: a case report". The American Journal of Case Report (2017). https://doi.org/10.12659/AJCR.908624 "Xpert MTB/RIF ultra for the diagnosis of tuberculous meningitis: a diagnostic accuracy study from India" Tuberculosis (2020). https://doi.org/10.1016/j.tube.2020.101990 "Comparison of Protein B Polymerase Chain Reaction (PCR) With IS6110 PCR for Diagnosis of Tuberculous Meningitis Patients" Cureus (2023). https://doi.org/10.7759/cureus.33783 "Molecular diagnosis of Tuberculous meningitis: sdaA-based multi-targeted LAMP and GeneXpert Ultra" Tuberculosis (2023). https://doi.org/10.1016/j.tube.2023.102339 "Diagnosis of osteoarticular tuberculosis by immuno‐PCR assay based on mycobacterial antigen 85 complex detection" Letter in Applied Microbiology (2022). https://doi.org/10.1111/lam.13567 To add the latest references in your manuscript for accuracy of your data with previous report on TB meningitis. Author response: Comments 6: Lines 186-187: Abbreviated Mycobacterium tuberculosis as Mtb. Author response: Comments 7: Lines 190: Mentioned the name of solid culture in your manuscript for your text accuracy. Author response: Comments 8: Lines 86-88: In other form of EPTB mentioned some names of their like EPTB is classified as per organ affected, e.g. TB lymphadenitis (30-40%), TB pleurisy (3-25%), osteoarticular TB (15-20%), genitourinary TB (4.5-28.3%), TB meningitis (~1%), abdominal TB (1-3%) and cutaneous TB (~0.5-2%), etc. (Khan et al., 2022) in your manuscript. "Diagnosis of osteoarticular tuberculosis by immuno‐PCR assay based on mycobacterial antigen 85 complex detection" Letter in Applied Microbiology (2022). https://doi.org/10.1111/lam.13567 Author response: Comments 9: How your results of study different from other already published study? Author response: Comments 10: Lines 92-93: PCR/M-PCR and LAMP are good techniques to detect EPTB form like OATB, GUTB, abdominal TB, etc. Why not you used PCR in your study? Author response: Comments 11: What is the limitation of your study? Author response: Comments 12: You could not perform the PCR technique for your study so discus some important drawbacks of PCR in your manuscript and quotes latest reference as: "Diagnosis of osteoarticular tuberculosis: multi-targeted loop-mediated isothermal amplification assay versus multiplex PCR" Future Microbiology (2021). https://doi.org/10.2217/fmb-2021-0030 Author response: Comments 13: Lines 168-170: Smear-microscopy results always low sensitivity and requires the presence of 104 bacilli/mL (1000 bacilli/mL) of sample to allow detection and its sensitivity is also often low in EPTB cases due to paucibacillary nature of specimens (Khan et al., 2022). Khan et al. (2022) reported sensitivities of 37.5% and 0% in confirmed and suspected OATB cases for detecting AFB by smear microscopy. While Marais et al. (2010) reported the sensitivity ranging from 2-30% in CSF by smear microscopy. You can also discuss other EPTB form by smear microscopy techniques in your manuscript. Author response: Comments 14: What is the limitation of GeneXpert assay? Author response: Comments 15: Your manuscript has 44% Similarity Check score or plagiarism by iThenticate software. It is high as compared to review article but you communicate research article in "Access Microbiology" journal, so reduced your similarity check score or plagiarism upto ~10. Author response:
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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