Ogbole et al. Journal of Medical Case Reports 2011, 5:100 http://www.jmedicalcasereports.com/content/5/1/100 symptoms without evidence of meningitis and when the CSF profile is normal. A previous series [15] has shown that it is impossible to differentiate tuberculomas from other masses on the basis of neurological symptoms as was presented in our patient, in whom the CT images showed no evidence of meningitis. Tuberculomas may be solitary or multiple and may grow intraparenchy- mally, or they may have a combined meningeal and par- enchymal course [1]. Since tuberculomas may be evolving, the neuroimaging appearance varies, depending on the time and stage of evolution during imaging. Tuberculomas have a central zone of caseation and necrosis surrounded by a capsule containing few bacilli [1]. Fewer than half of patients with tuberculomas have a known history of TB [1]. While some nonspecific investigations such as ESR may be positive, as in our patient, specific investigations such as acid-fast bacilli smear, CSF culture and chest x-ray may be negative, further confounding the diagnosis. However, the CSF culture may show an elevated protein level [16]. Imaging studies commonly reveal parenchymal disease involving the corticomedullary junction and periventricular regions, consistent with hematogenous spread of infec- tion [4]. On the basis of CT, tuberculomas are periph- eral, hypodense, ring-enhancing lesions sometimes showing central calcifications. Tuberculomas are usually isointense on T1-weighted images, and on T2-weighted images noncaseating lesions are bright with nodular enhancement, while caseating lesions vary from isoin- tense to hypointense and also exhibit ring enhancement. Thus it may be difficult to differentiate tuberculomas from other intracranial lesions such as toxoplasmosis, fungal or bacterial abscesses, sarcoidosis, lymphoma or metastases from imaging features alone [17]. In our patient, the initial CT impression of metastases must have been prejudiced by an earlier ultrasound diagnosis of a testicular tumor. An intracranial tubercu- loma is the least common presentation of CNS tubercu- losis, and neuroimaging findings are nonspecific except where magnetic resonance spectroscopy [18] is available. Histopathological diagnosis has a prime role in early diagnosis and proper management of these patients. In this context, a detailed history and high index of suspi- cion are very important in directing appropriate studies, including serum LCD and human chorionic gonadotro- pin, necessary to diagnose this life-threatening but trea- table disease [8]. The precise diagnosis in our patient was made much later on the basis of a postoperative testicular sample. Conclusion The clinical presentation of CNS tuberculosis is protean, and the differential diagnosis includes other granuloma- tous diseases, protozoa, inflammatory disease, primary Page 4 of 5 malignant lesions and metastases. Since routine tests may be negative and neuroimaging features are not pathognomonic, a high index of suspicion should be maintained in patients from regions of high prevalence presenting with extrapulmonary tuberculosis. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Author details 1Department of Radiology, University College Hospital, Ibadan, Nigeria. 2Department of Pathology, University College Hospital, Ibadan, Nigeria. Authors’ contributions GIO and OSB analyzed and interpreted the patient data regarding testicular disease and surgical findings. CAO performed the histological examination of the testicular specimen and was a major contributor in writing the manuscript. GIO and OSB reviewed the literature and wrote the first draft of the manuscript. AOO and GIO reviewed the manuscript for important intellectual content. SOU performed the sonography, provided images and made contributions to the draft. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 8 April 2010 Accepted: 13 March 2011 Published: 13 March 2011 References 1. Cortez K, Kottilli S, Mermel LA: Intracerebral tuberculoma misdiagnosed as neurosarcoidosis. South Med J 2003, 96:494-496. 2. Akriditis N, Galiatsou E, Kakadellis J, Dimas K, Paparounas K: Brain tuberculomas due to milliary tuberculosis. South Med J 2005, 98:111-113. 3. 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