Right Temporal Lobe Tuberculoma Presenting as Seizures in a Patient With Pulmonary Tuberculosis

BACKGROUND Central nervous system (CNS) manifestations of tuberculosis (TB) account for approximately 1-2% of all TB cases worldwide. Tuberculomas, which are granulomatous lesions of the CNS diagnostically confirmed through biopsy, can mimic more common intracranial pathologies, including abscesses and neoplasms. This report describes a patient with pulmonary TB who presented with seizure and was ultimately diagnosed with a right temporal lobe TB mimicking a brain abscess. CASE REPORT A 30-year-old woman with alcohol use disorder, polysubstance use, and pulmonary TB previously treated with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) presented to the emergency department (ED) following a generalized seizure. Anti-tuberculous therapy had been interrupted for several months due to alcohol-related hepatotoxicity. Prior imaging demonstrated a small right temporal lobe lesion, which subsequently enlarged and developed rim-enhancing features after RIPE therapy was interrupted. Given the diagnostic uncertainty and her clinical course, neurosurgical intervention was pursued. Craniotomy with surgical exploration and biopsy revealed necrotizing granulomas and a Ziehl-Neelsen stain confirmed acid-fast bacilli (AFB), confirming intracranial tuberculoma. Postoperatively, she was restarted on a modified anti-tuberculous regimen. CONCLUSIONS Intracranial tuberculoma should remain a key differential diagnosis for ring-enhancing lesions, even in immunocompetent patients and in low-incidence regions. Further, it underscores the importance of maintaining therapy continuity to prevent disease progression. Importantly, when response to therapy is uncertain or adherence is questionable, clinicians should maintain a low threshold for deciding to perform early biopsy to confirm the etiology.