however , this immunosuppressed condition can predispose the patient to opportunistic infections like tuberculosis . in these patients , tuberculosis can affect different systems and can have uncommon clinical presentations . a case of a young female of lupus ( on steroids ) with suprasellar tuberculoma a 22-year - old female was admitted through emergency with sudden onset severe headache , vomiting , and dimness of vision ( 6/60 ) in both eyes . she was diagnosed with systemic lupus erythematosus one year ago by clinical and laboratory criteria ( acr ) with nephropathy grade three . she had been given pulse cyclophosphamide 1 year earlier ( 6 doses , 21 days apart each ) . after that , she was put on oral steroids ( prednisolone , 7.5 mg / day oral ) and she continued the drug in the intervening period . at the time of admission she was still on oral steroids ( 7.5 mg / day ) . after admission , the patient developed low grade fever and her dimness of vision progressed . by third day , she had no perception of light in either eye . local examination of the eyes showed pupils to be dilated and non - reactive . ophthalmologists opined that the pathology was not intra - ocular ; neurologists were of the opinion that there was a vascular event in cranium . her blood glucose was raised ( fasting=144 mg / dl ) , probably due to long intake of steroids . due to the presence of papilledema , we did a ct scan of brain [ figure 1 ] which showed a calcified mass in suprasellar region with perilesional edema ( black arrow ) with obstructive hydrocephalous . the mantoux test of the patient was negative ( she was on steroids ) , sputum did not show any acid - fast bacilli and chest x - ray was also normal . the magnetic resonance imaging scan could not be done due to cost factor . in view of the emergent nature of the illness , we started her on oral anti tubercular drugs with an increased dose of oral steroids . subsequently , after 1 month , a brain biopsy was done and the lesion was found to be calcified granuloma with aggregates of epitheloid cells , calcifications , necrosis , blood vessel destructions , and few scattered caseations [ figure 2 ] . the lesion did not show any acid fast bacilli , but overall features were suggestive of tuberculosis . a csf sample collected at time of brain biopsy showed increased cells ( 45/l ) , increased protein ( 102 mg / dl ) . afb stain of csf was negative ; a pcr from csf was positive for mycobacterium tuberculosis . repeat ct scan [ figure 3 ] showed only a mild decrease in the size of the edema ; calcified mass size was the same . the ct scan of the patient showing suprasellar calcified mass ( upper left and upper right panels , perilesional edema ( black arrow ) , and hydrocephalous ( white arrow , right lower panel ) brain biopsy slide showing lymphocytes and areas of necrosis repeat ct scan of the patient after 5 months , showing only decrease of edema , calcification size same tuberculomas are an important cause of space occupying lesions in brain in developing countries like india . in cases like ours , with no extra cranial manifestations of tuberculosis however , non - invasive methods like pet scan can be useful ; if csf study can be done , pcr or elisa for mycobacterium tuberculosis from the fluid can be attempted . tuberculosis of central nervous system can have different forms like meningitis , abscess , tuberculoma , subdural collection or miliary form . suprasellar tuberculoma can present with diabetes insipidus , visual loss , or hypothyroidism . in resource - limited settings , and when the patient is severely ill , often diagnosis is not possible and empirical treatment is needed . calcified mass in brain seen in ct scan can have many etiologies . the following chart [ table 1 ] shows the different common etiologies of cerebral calcification and their differentiation with special reference to suprasellar lesions : table showing the characteristics of different lesions with cerebral calcification suprasellar lesions can present with hypogonadism , features of raised intracranial pressure and hemianopia . also , lesions with an infective cause should be differentiated from calcified tumors and aneurysms because drug treatment is helpful in tuberculoma , whereas in other cases prompt surgery is the only option . the idea of presenting this case is to draw attention on the catastrophic effects of long - term steroids . although tuberculosis is a known complication of long - term immunosuppression , tuberculomas are rare and suprasellar tuberculoma causing visual impairment is indeed very rare . very rarely , tuberculomas are found near optic chiasm , but when they occur , they can cause these catastrophic consequences . however , fortunately , that case was diagnosed before the calcification stage and the patient responded favorably to drugs . also , intracranial calcification is a vexing problem in a resource limited settings . proper differentiation of the lesions in ct scan is important to the treating physician . in a resource limited setting , anti - tubercular drug , even on empirical basis can be life saving and should be used without delay . newer diagnostic methods like pet scan can also help in distinguishing these lesions ( tuberculosis has lower fdg uptake than lymphoma ) . mr spectroscopy can also help in this regard ; tuberculoma shows prominent lipid peak at 1.3 ppm . the lesion of tuberculosis will show significant change in subsequent imaging following therapy although the radiological resolution may not match with the clinical improvement , especially in central nervous system lesions . this case shows the importance of brain imaging in suspected infective disorders and the need to interpret the images quickly for maximum benefit of the patients . especially in the background of the immunosuppressed state , any infection ( like tuberculosis ) can present with a catastrophe like blindness and timely therapy can prevent subsequent morbidity to a large extent . at times , empirical therapy can also be used , provided clinical suspicion is strong and diagnostic tests are unavailable or impractical . also , clinicians need to be well versed with the differential diagnoses of intra cranial calcification , which , though a common finding , can be a diagnostic dilemma at times .
tuberculosis can be an opportunistic infection complicating the course of patients receiving prolonged immunosuppression . in these patients 
 , the tuberculosis can involve the central nervous system and can cause diagnostic difficulty due to atypical features . 
 often , the diagnosis of central nervous system tuberculosis in resource limited settings is indirect , like imaging . 
 but anti - tubercular drugs , given even on empirical basis can be life saving . a case of a young female systemic lupus erythematosus patient ( on prolonged steroids ) with intracranial tuberculoma 
 is presented here . 
 she presented with blindness and headache and her computed tomography scan showed a calcified mass in the suprasellar location . 
 however , she responded well to anti - tubercular drugs . 
 the differential diagnoses of such lesions are also discussed .