Intramedullary Conus Medullaris Tuberculoma: A Case Report and Review of the Literature

Round 1

Reviewer 1 Report

The Authors present a very interesting case report titled: " Intramedullary conus medullaris tuberculoma: a case report and review of the literature". The reported case is a rare event but physicians could consider also this possibility in differential diagnosis and one case could teach and could induce to think at these rare events. They described the outcome and the treatment in a very precise and deep way clarifying the possible alternative diagnosis.

Also the reported review of the literature is exhaustive and updated. The only minor suggestion in the Conclusion is to insert a small table or diagram to synthesize the suggested steps in presence of a similar clinical situation (e.g. to consider adenosine deaminase (ADA) in the patient's cerebrospinal fluid (CSF) detection).

Author Response

Thank you very for your comments and suggestions.

We rewrite the conclusion in the ABSTRACT and in the CONCLUSION as reviewer 1 suggestion.

"CSF adenosine deaminase levels can be helpful in determining the presence of central nervous system tuberculosis when other systemic signs of disease are lacking."

 

Reviewer 2 Report

The authors report a case of intramedullary tuberculoma in a 78 year old man diagnosed and treated on the basis of elevated adenosine deaminase in the cerebrospinal fluid. Pathology of the lesion at surgery showed only gliosis and no systemic signs of tuberculosis are evident in the report. The value of the case is not adequately represented by the authors, who conclude in the ABSTRACT that tuberculoma should be suspected in patients with intramedullary spinal cord masses with malignancy without signs of systemic tuberculosis. This conclusion does not logically follow. More importantly, the authors should conclude that CSF adenosine deaminase levels  can be helpful in determining the presence of central nervous system tuberculosis when other systemic signs of disease are lacking.

Other suggestions to improve the manuscript are as follows:

1. Rewrite the conclusion in the ABSTRACT as indicated above.
2. Provide more background in the INTRODUCTION about the difficulties that can be present when a patient has central nervous system tuberculosis.
3. In the CASE REPORT, provide the thinking that lead to obtaining CSF adenosine deaminase in the patient.
4. In the CASE REPORT, provide information regarding skin test reactivity (result or why not performed) or quantiferon gold (result or why not performed) if tuberculosis was suspected.
5. In The DISCUSSION, provide exposition about the value of adenosine deaminase in making the diagnosis of tuberculosis with appropriate references. Explain the mechanism of its positivity in patients with tuberculosis as well.
6. In CONCLUSIONS, use the same conclusion as in the ABSTRACT, consistent with the suggestion above.  
7. Provide a post-treatment MRI figure showing resolution of the lesion.
8. In CASE REPORT, indicate if acid-fast staining of the histopathology was performed or if cultures for tuberculosis were sent.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The authors have significantly improved their manuscript in their revision. The conclusions have appropriately been changed to reflect the most salient point of the case - that CSF adenosine deaminase levels can be helpful in making the diagnosis of CNS tuberculosis. 

The manuscript would benefit but a bit more detail in the introduction and discussion about how adenosine deaminase is helpful in the diagnosis of tuberculosis and not other entities which create an inflammatory reaction. In addition, the authors should offer a brief comment about why staining for tuberculosis was not done on the pathological specimens. One would think that in a tuberculosis-endemic environment, pathological proof of a diagnosis of a suspected diagnosis would be sought.

Author Response

Response to Reviewer 2 Comments

For any revision, we use the "Track Changes" function in Microsoft Word with a yellow color highlight

Point 1 The manuscript would benefit but a bit more detail in the introduction and discussion about how adenosine deaminase is helpful in the diagnosis of tuberculosis and not other entities which create an inflammatory reaction.

Response 1 :  

In the DISCUSSION, We add ADA level is also increased in nontuberculous meningitis but it is marked significantly increased in tuberculous meningitis. So, detection of CSF ADA activity in the diagnosis of TBM had relatively high accuracy.[22] 

From reference 22 in the manuscript

Pormohammad A, Riahi SM, Nasiri MJ, Fallah F, Aghazadeh M, Doustdar F, Pouriran R. Diagnostic test accuracy of adenosine deaminase for tuberculous meningitis: a systemic review and meta-analysis. J Infect 2017;74:545-554.

Point 2 In addition, the authors should offer a brief comment about why staining for tuberculosis was not done on the pathological specimens. One would think that in a tuberculosis-endemic environment, pathological proof of a diagnosis of a suspected diagnosis would be sought.

Response 2 : 

In the CASE REPORT

Histopathology of the tissues revealed mild reactive gliosis. Neither granuloma nor a tumor was found then Ziehl-Neelsen stain and tissue culture for M.tuberculosis were not performed.

 

Author Response File: Author Response.docx