Thalamic Tuberculoma Presenting as Isolated Gait Disturbance Without Systemic or Meningeal Symptoms in a 2-Year-Old Child: A Case Report

Thalamic Tuberculoma Presenting as Isolated Gait Disturbance Without Systemic or Meningeal Symptoms in a 2-Year-Old Child: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Thalamic Tuberculoma Presenting as Isolated Gait Disturbance Without Systemic or Meningeal Symptoms in a 2-Year-Old Child: A Case Report Khadija Yasmin, Muhammad Abdullah, Sana Shaik, Minahil Zaheer, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9124856/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Intracranial tuberculoma is an important manifestation of pediatric central nervous system tuberculosis, especially in endemic regions. While seizures and signs of raised intracranial pressure are common presenting features, isolated focal neurological deficits without systemic or meningeal symptoms are rare, resulting in diagnostic delay. We report an unusual case of thalamic tuberculoma presenting primarily with gait disturbance in a young child. Case Presentation : A 2-year-old boy from Karachi, Pakistan, presented with increasing difficulty ambulating and unable to walk on his own. On neurological examination slight weakness on the left side. An MRI scan of his brain showed that a ring-enhancing lesion in the right thalamus extended into the midbrain, and it was surrounded by vasogenic edema. Magnetic resonance spectroscopy suggested an infectious etiology, most likely tuberculoma. There were no meningeal symptoms, fever or seizures in the child. There were no abnormal findings on routine laboratory testing and chest X-ray, however, screening at home confirmed latent TB exposure. Clinical Discussion : Although intracranial tuberculoma does not always present with systemic manifestations of tuberculosis in children as observed in the present study, it is also a challenging disease to diagnose in young children due to the atypical presentation. Neuroimaging: Early diagnosis is possible. For deep-seated lesions where operative therapy and surgical treatment are highly risky, conservative management is often effective with anti-tuberculous therapy and adjunctive corticosteroids. Early physiotherapy is important for achieving functional recovery. Conclusion The case illustrates the need for consideration of intracranial tuberculoma in an individual neurological impairment case, considering children with isolated neurological deficits, when systemic forms of tuberculosis do not develop, even in the absence of evidence of systemic tuberculosis symptoms. Prompt imaging and early development and treatment with early anti-tuberculous therapy may give good results. intracranial tuberculoma pediatric tuberculosis ring-enhancing lesion neuroimaging anti-tuberculous therapy Figures Figure 1 Figure 2 Figure 3 BACKGROUND Central nervous system (CNS) tuberculosis is a significant cause of neurological morbidity in children, especially in tuberculosis-endemic areas. Intracranial tuberculomas, the granulomatous lesions due to hematogenous dissemination of Mycobacterium tuberculosis, constitute a significant proportion of space-occupying brain lesions in developing countries. Their clinical characteristics are highly variable and are determined by the lesion location, size, and related edema [ 1 ]. Among pediatric populations, intracranial tuberculomas commonly present with seizures, increased intracranial pressure, or focal neurological deficits. However, isolated movement or gait disruptions without systemic or meningeal presentation remain remarkably rare features; therefore, rapid detection remains difficult [ 2 ]. The thalamus and brainstem are thought to be deeply deposited regions where lesions can lead to subtle or atypical neurological findings, particularly in very young children [ 3 ]. Neuroimaging is crucial for the diagnosis of this condition. Magnetic resonance spectroscopy demonstrated a prominent lipid peak with reduced N-acetyl aspartate and relatively preserved to mildly elevated choline, findings consistent with tuberculoma.[ 4 ]. However, without reference to systemic evidence of tuberculosis, differentiating tuberculoma from neoplasms, abscesses, or other types of granulomatous diseases can be challenging. Management is generally conservative with anti-tuberculous therapy (ATT) and adjunctive corticosteroids, especially for deep-seated lesions, where surgical resolution is of high risk [ 5 ]. Most pediatric cases yield favorable neurological outcomes with early treatment [ 6 ]. Here, we report a rare case of thalamic tuberculoma in a 2-year-old child who presented only with progressive gait disturbance and mild hemiparesis, without systemic or meningeal symptoms of tuberculosis, emphasizing the importance of maintaining a high clinical suspicion in endemic settings. CASE PRESENTATION A 2-year-old boy from Karachi, Pakistan, presented with difficulty walking independently and required assistance for ambulation. There was no history of seizures, fever, vomiting, altered consciousness, or meningeal symptoms. The child was born via normal vaginal delivery, cried immediately after birth, and had no perinatal complications. Developmental milestones were reportedly age-appropriate, and immunizations were up to date, including BCG at birth. There was no history suggestive of congenital tuberculosis or family history of active tuberculosis at presentation. On examination, the child was afebrile with a heart rate of 96 beats per minute, respiratory rate of 35 breaths per minute, capillary refill time < 3 seconds, and oxygen saturation of 98% on room air. The head circumference (FOC) measured 47 cm. Motor examination revealed a normal tone in all limbs. Muscle power in the right upper and lower limbs was 5/5, while the left upper and lower limbs demonstrated reduced strength of 4/5. Gait assessment showed clumsy independent walking. Magnetic resonance imaging (MRI) of the brain demonstrated a ring-enhancing lesion in the right thalamus extending into the midbrain, measuring approximately 2.1 × 1.8 × 2.8 cm, with surrounding vasogenic edema causing a mild mass effect on the third ventricle and mild dilatation of the lateral ventricles, without diffusion restriction (Fig. 1 , Fig. 2 ). Magnetic resonance spectroscopy revealed an elevated lipid peak along with decreased N-acetylaspartate, creatinine, and choline, indicative of an infective etiology consistent with tuberculoma (Fig. 3 ). Chest X-ray and routine laboratory tests, such as ESR and CBC, were normal. Definitive TB testing was not performed initially, and subsequent household screening revealed latent TB in all family members except the father. After multidisciplinary consideration involving neurosurgery and pediatrics, the patient was conservatively treated with anti-tuberculous therapy, and adjunctive corticosteroids, physiotherapy, and rehabilitation. Follow-up MRI at 1 month demonstrated slight interval increase in lesion size, suggestive of a possible paradoxical inflammatory response rather than treatment failure, as the patient remained clinically stable. The patient is scheduled for review at 2 months following treatment to evaluate clinical and radiological response, including monitoring of improvement in walking ability and neurological function, with subsequent MRI, MR spectroscopy, CBC, ESR, and TB testing as appropriate. This case is noteworthy to report, because it demonstrates an infrequent presentation of intracranial tuberculoma in a pediatric patient, which predominantly presents as isolated gait disturbance and unilateral limb weakness without systemic symptoms of tuberculosis, including fever, seizures, or meningeal signs. Since pediatric central nervous system tuberculosis often has less obvious clinical manifestations, the early establishment of the diagnosis is difficult, especially in the absence of known TB exposure or definitive laboratory evidence at presentation. We highlight the importance of high clinical suspicion, appropriate neuroimaging, and early initiation of anti-tuberculous therapy with adjunctive corticosteroids in these children, in order to avoid further neurological compromise and improve functional outcomes. Additionally, this study adds to the limited literature on atypical presentations of CNS tuberculosis in the pediatric population and offers guidance to assist clinicians with isolated neurological deficits seen in atypical presentations in pediatric populations, thus enabling rapid and efficient diagnosis, management, and follow-up in resource-limited settings. DISCUSSION This case presents an unusual form of intracranial tuberculoma presenting mainly as isolated gait disturbance with no systemic or meningeal features. Thus, although CNS tuberculosis is well established in the pediatric age, atypical focal manifestations are challenging for the diagnosis and can mimic neoplastic or other infectious etiologies [ 7 ]. Intracranial tuberculomas are established via hematogenous dissemination of Mycobacterium tuberculosis, resulting in granuloma development within the parenchyma of the brain. Involvement of deep gray matter lesions, most notably of the thalamus, is less frequent but clinically relevant, since even small lesions in this region may interfere with corticospinal and cerebellothalamic pathways, leading to motor impairment and gait abnormalities [ 8 ]. Our patient's MRI revealed several ring-enhancing lesions in the right thalamus and surrounding internal capsule, along with mild surrounding vasogenic edema and minimal hydrocephalus from the mass effect on the third ventricle. These findings were consistent with intracranial tuberculoma, and subsequent imaging revealed interval regression. In very young children, small deficits might be the sole presenting feature, making early detection that much more challenging. Radiologically, ring-enhancing lesions in endemic populations should be considered as a possible diagnostic differential for tuberculoma. MRI findings have great diagnostic specificity when used in combination with MR spectroscopy to show lipid peaks [ 9 ]. Microbiology confirmation is frequently absent in parenchymal disease, but, in many cases, only a clinicoradiological correlation can prove disease progression, and most of these are dependent on the therapeutic response [ 10 ]. The lack of pulmonary or systemic tuberculosis in our patient is consistent with previous reports in pediatric series that neurotuberculosis may develop in the absence of active extracranial disease [ 11 ]. This underlines the need for careful exposure history and continued clinical suspicion when initial laboratory and chest imaging are unremarkable. In cases such as deep-seated lesions, medical management remains the gold standard. Radiological resolution was demonstrated for most patients with standard ATT combined with adjunctive corticosteroids; surgical treatment is appropriate in the case of diagnostic uncertainty, obstructive hydrocephalus, or life-threatening mass effect [ 12 ]. Timely transient enlargements during treatment, sometimes referred to by the catchphrase paradoxical reaction, are not uncommon and, provided the clinical picture is stable, should not be confused with a failure of treatment [ 13 ]. The earlier physiotherapy and neurorehabilitation in toddlers are particularly essential, where neuroplasticity might result in remarkable functional recovery of motor behaviour. Close clinical and radiological follow-up is important for treatment response and to avoid long-term neurological sequelae. Overall, even in the absence of systemic or meningeal symptoms, this case emphasizes the significance of taking cerebral tuberculoma into account when making a differential diagnosis of isolated pediatric neurological impairments, especially in areas where tuberculosis is endemic. Follow-up after 2 Months Imaging and Treatment Response On 4 March 2026, a follow-up MRI examination of the brain, performed approximately two months after initiation of treatment, demonstrated redemonstration of clustered ring-enhancing lesions in the right thalamus extending toward the internal capsule, with surrounding mild vasogenic edema. There was mild mass effect on the third ventricle and minimal dilatation of the lateral ventricles. Compared with the previous MRI, the lesion size, associated edema, and mass effect were reduced, indicating interval regression of the disease process. There was no evidence of diffusion restriction, intracranial hemorrhage, or extra-axial fluid collection. The remaining intracranial structures, including the posterior fossa and optic pathways, appeared within normal limits. These findings suggested a favorable radiological response to ongoing anti-tuberculous therapy with adjunctive corticosteroid treatment, supporting continued conservative medical management with ongoing clinical and radiological follow-up. CONCLUSION This case presents with an atypical presentation of intracranial tuberculoma presenting as isolated gait disturbance and mild hemiparesis in a young child without systemic or meningeal features of tuberculosis. In areas endemic to tuberculosis, deep-seated ring-enhancing lesions, especially in the thalamus, may strongly signal tuberculoma, even without pulmonary disease or constitutional symptoms. Initial neuroimaging (e.g., MRI and MR spectroscopy) is essential for accurate diagnosis and for distinguishing between infectious granulomas and neoplastic lesions. Initiating anti-tuberculous therapy with adjunctive corticosteroids soon after presentation is key to achieving full neurological recovery and preventing long-term sequelae. This case illustrates the need to maintain a high clinical suspicion and ensure close radiological follow-up in pediatric patients presenting with isolated focal neurological deficits. Abbreviations CNS Central nervous system TB Tuberculosis BCG Bacillus Calmette–Guérin ATT Anti-tuberculous therapy MRI Magnetic resonance imaging MR Magnetic resonance CBC Complete blood count ESR Erythrocyte sedimentation rate FOC Fronto-occipital circumference CT Computed tomography bpm Beats per minute cm Centimeter ppm Parts per million Declarations Ethics Approval and Consent to Participate The study was approved by the Ethics Committee of PNS Shifa Hospital Karachi, Pakistan. Informed consent to participate was obtained from all participants included in the study and patient’s legal guardian. Consent for Publication Informed consent for publication of clinical details and images was obtained from the patient’s legal guardian and family of the patient. Availability of Data and Materials Statement All data generated or analyzed during this case report are included in this published article. Competing Interest The authors declare no competing interests. Funding The authors received no specific funding for this work. Authors' Contributions KY (Khadija Yasmin): Conception and design of the work, supervision, critical revision for important intellectual content, and final approval of the version to be published. MA (Muhammad Abdullah): Substantial contribution to literature review and drafting of the manuscript, critical revision, and final approval. SS (Sana Shaikh): Contribution to literature search, drafting assistance, manuscript revision, and final approval. MZ (Minahil Zaheer): Interpretation of clinical aspects, critical manuscript review, and final approval. AI (Aleena Ihtasham): Language editing, proofreading, manuscript refinement, and final approval. HHS (Hamna Hassan Siddiqui): Contribution to referencing, manuscript review, and final approval. SS (Saira Shamim): Intellectual input, critical revision of the manuscript, and final approval. HHS (Hudaifa Hassan Salad): Supervision, Contribution to manuscript revision, academic input, and final approval. *All authors have reviewed and approved the manuscript. Acknowledgments None Authors’ Information: Khadija Yasmin [email protected] Allama Iqbal Medical College, Lahore, Pakistan 0009-0008-3103-8163 Muhammad Abdullah [email protected] Bahria University Health Sciences Campus Karachi, Pakistan 0009-0005-4961-8359 Sana Shaik [email protected] Faculty of Medicine, Tbilisi State Medical University, Tbilisi, Georgia 0009-0008-8540-9484 Minahil Zaheer [email protected] HBS medical and dental college, Islamabad, Pakistan 0009-0007-5614-6411 Aleena Ihtasham [email protected] King Edward Medical University, Lahore, 54000, Pakistan 0009-0000-7250-7730 Hamna Hassan Siddiqui [email protected] Jinnah Sindh Medical University, Karachi, Pakistan 0009-0003-1562-0245 Saira Shamim [email protected] King Edward Medical University, Lahore, 54000, Pakistan 0009-0007-6141-3721 Hudaifa Hassan Salad [email protected] Faculty of Medicine and Surgery, Salaam University, Mogadishu, Somalia 0009-0001-9613-9271 References Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central Nervous System Tuberculosis: Pathogenesis and Clinical Aspects. Clin Microbiol Rev. 2008;21(2):243–61. 10.1128/CMR.00042-07 . Wang MS, Wang JL, Liu XJ, Zhang YA et al. The Sensitivity of Diagnostic Criteria of Marais S,. in Confirmed Childhood Tuberculous Meningitis. Front Pediatr. 2022;10:832694. 10.3389/fped.2022.832694 Wasay M, Kheleani BA, Moolani MK, Zaheer J, Pui M, Hasan S, et al. Brain CT and MRI findings in 100 consecutive patients with intracranial tuberculoma. J Neuroimaging. 2003;13(3):240–7. Morales H, Alfaro D, Martinot C, Fayed N, Gaskill-Shipley M. MR spectroscopy of intracranial tuberculomas: A singlet peak at 3.8 ppm as potential marker to differentiate them from malignant tumors. Neuroradiol J. 2015;28(3):294–302. 10.1177/1971400915592077 . DeLance AR, Safaee M, Oh MC, Clark AJ, Kaur G, Sun MZ, et al. Tuberculoma of the central nervous system. J Clin Neurosci. 2013;20(10):1333–41. 10.1016/j.jocn.2013.01.008 . Thwaites GE, Schoeman JF. Update on tuberculosis of the central nervous system: pathogenesis, diagnosis, and treatment. Clin Chest Med. 2009;30(4):745–54, ix. 10.1016/j.ccm.2009.08.018 Antony S, Bodhanwala M, Shah I. Clinical profile and outcomes of paediatric central nervous system tuberculomas. int j tuberc lung dis. 2021;25(11):953–5. 10.5588/ijtld.21.0063 . Jinkins JR. Computed tomography of intracranial tuberculosis. Neuroradiology. 1991;33(2):126–35. 10.1007/BF00588250 . Peng J, Ouyang Y, Fang WD, Luo TY, Li YM, Lv FJ, et al. Differentiation of intracranial tuberculomas and high grade gliomas using proton MR spectroscopy and diffusion MR imaging. Eur J Radiol. 2012;81(12):4057–63. 10.1016/j.ejrad.2012.06.005 . Synmon B, Das M, Kayal AK, Goswami M, Sarma J, Basumatary L, et al. Clinical and radiological spectrum of intracranial tuberculosis: A hospital based study in Northeast India. Indian J Tuberculosis. 2017;64(2):109–18. 10.1016/j.ijtb.2016.11.011 . Udani PM, Parekh UC, Dastur DK. Neurological and related syndromes in CNS tuberculosis Clinical features and pathogenesis. J Neurol Sci. 1971;14(3):341–57. 10.1016/0022-510X(71)90222-X . Marais S, Van Toorn R, Chow FC, Manesh A, Siddiqi OK, Figaji A, et al. Management of intracranial tuberculous mass lesions: how long should we treat for? Wellcome Open Res. 2020;4:158. 10.12688/wellcomeopenres.15501.3 . Cheng V, Ho P, Lee R, Chan K, Chan K, Woo P, et al. Clinical Spectrum of Paradoxical Deterioration During Antituberculosis Therapy in Non-HIV-Infected Patients. Eur J Clin Microbiol Infect Dis. 2002;21(11):803–9. 10.1007/s10096-002-0821-2 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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20:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9124856/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9124856/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107616201,"identity":"848eb0a5-9751-4f2f-a93b-a4533ce3b5e6","added_by":"auto","created_at":"2026-04-23 09:12:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":331404,"visible":true,"origin":"","legend":"\u003cp\u003eAxial T1-weighted post-contrast MRI demonstrates an area of contrast enhancement with surrounding vasogenic edema.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9124856/v1/139102bc48ceb8cb620973ae.png"},{"id":107868880,"identity":"4508889f-24e3-4187-9f3c-bc989a897adf","added_by":"auto","created_at":"2026-04-27 07:34:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":563865,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal MRI demonstrating superior–inferior extension of the thalamic lesion into the midbrain with mild mass effect.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9124856/v1/dcf2eb2f126799861e5c40a1.png"},{"id":107616210,"identity":"037de02b-1830-4928-a761-fa300813f955","added_by":"auto","created_at":"2026-04-23 09:12:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":303181,"visible":true,"origin":"","legend":"\u003cp\u003eMR spectroscopy demonstrating a prominent lipid peak with reduced N-acetylaspartate, consistent with tuberculoma.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9124856/v1/734fe9158cbb29e950f70c79.png"},{"id":107871714,"identity":"c385f2c7-36f6-4672-9dc3-e95b599d123e","added_by":"auto","created_at":"2026-04-27 07:53:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1367881,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9124856/v1/ab9e63ed-e044-4e4b-8efe-cbe04c366bef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Thalamic Tuberculoma Presenting as Isolated Gait Disturbance Without Systemic or Meningeal Symptoms in a 2-Year-Old Child: A Case Report","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eCentral nervous system (CNS) tuberculosis is a significant cause of neurological morbidity in children, especially in tuberculosis-endemic areas. Intracranial tuberculomas, the granulomatous lesions due to hematogenous dissemination of Mycobacterium tuberculosis, constitute a significant proportion of space-occupying brain lesions in developing countries. Their clinical characteristics are highly variable and are determined by the lesion location, size, and related edema [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among pediatric populations, intracranial tuberculomas commonly present with seizures, increased intracranial pressure, or focal neurological deficits. However, isolated movement or gait disruptions without systemic or meningeal presentation remain remarkably rare features; therefore, rapid detection remains difficult [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The thalamus and brainstem are thought to be deeply deposited regions where lesions can lead to subtle or atypical neurological findings, particularly in very young children [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Neuroimaging is crucial for the diagnosis of this condition. Magnetic resonance spectroscopy demonstrated a prominent lipid peak with reduced N-acetyl aspartate and relatively preserved to mildly elevated choline, findings consistent with tuberculoma.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, without reference to systemic evidence of tuberculosis, differentiating tuberculoma from neoplasms, abscesses, or other types of granulomatous diseases can be challenging. Management is generally conservative with anti-tuberculous therapy (ATT) and adjunctive corticosteroids, especially for deep-seated lesions, where surgical resolution is of high risk [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Most pediatric cases yield favorable neurological outcomes with early treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Here, we report a rare case of thalamic tuberculoma in a 2-year-old child who presented only with progressive gait disturbance and mild hemiparesis, without systemic or meningeal symptoms of tuberculosis, emphasizing the importance of maintaining a high clinical suspicion in endemic settings.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 2-year-old boy from Karachi, Pakistan, presented with difficulty walking independently and required assistance for ambulation. There was no history of seizures, fever, vomiting, altered consciousness, or meningeal symptoms. The child was born via normal vaginal delivery, cried immediately after birth, and had no perinatal complications. Developmental milestones were reportedly age-appropriate, and immunizations were up to date, including BCG at birth. There was no history suggestive of congenital tuberculosis or family history of active tuberculosis at presentation.\u003c/p\u003e \u003cp\u003eOn examination, the child was afebrile with a heart rate of 96 beats per minute, respiratory rate of 35 breaths per minute, capillary refill time\u0026thinsp;\u0026lt;\u0026thinsp;3 seconds, and oxygen saturation of 98% on room air. The head circumference (FOC) measured 47 cm. Motor examination revealed a normal tone in all limbs. Muscle power in the right upper and lower limbs was 5/5, while the left upper and lower limbs demonstrated reduced strength of 4/5. Gait assessment showed clumsy independent walking.\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI) of the brain demonstrated a ring-enhancing lesion in the right thalamus extending into the midbrain, measuring approximately 2.1 \u0026times; 1.8 \u0026times; 2.8 cm, with surrounding vasogenic edema causing a mild mass effect on the third ventricle and mild dilatation of the lateral ventricles, without diffusion restriction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMagnetic resonance spectroscopy revealed an elevated lipid peak along with decreased N-acetylaspartate, creatinine, and choline, indicative of an infective etiology consistent with tuberculoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eChest X-ray and routine laboratory tests, such as ESR and CBC, were normal. Definitive TB testing was not performed initially, and subsequent household screening revealed latent TB in all family members except the father. After multidisciplinary consideration involving neurosurgery and pediatrics, the patient was conservatively treated with anti-tuberculous therapy, and adjunctive corticosteroids, physiotherapy, and rehabilitation. Follow-up MRI at 1 month demonstrated slight interval increase in lesion size, suggestive of a possible paradoxical inflammatory response rather than treatment failure, as the patient remained clinically stable. The patient is scheduled for review at 2 months following treatment to evaluate clinical and radiological response, including monitoring of improvement in walking ability and neurological function, with subsequent MRI, MR spectroscopy, CBC, ESR, and TB testing as appropriate.\u003c/p\u003e \u003cp\u003eThis case is noteworthy to report, because it demonstrates an infrequent presentation of intracranial tuberculoma in a pediatric patient, which predominantly presents as isolated gait disturbance and unilateral limb weakness without systemic symptoms of tuberculosis, including fever, seizures, or meningeal signs. Since pediatric central nervous system tuberculosis often has less obvious clinical manifestations, the early establishment of the diagnosis is difficult, especially in the absence of known TB exposure or definitive laboratory evidence at presentation. We highlight the importance of high clinical suspicion, appropriate neuroimaging, and early initiation of anti-tuberculous therapy with adjunctive corticosteroids in these children, in order to avoid further neurological compromise and improve functional outcomes. Additionally, this study adds to the limited literature on atypical presentations of CNS tuberculosis in the pediatric population and offers guidance to assist clinicians with isolated neurological deficits seen in atypical presentations in pediatric populations, thus enabling rapid and efficient diagnosis, management, and follow-up in resource-limited settings.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis case presents an unusual form of intracranial tuberculoma presenting mainly as isolated gait disturbance with no systemic or meningeal features. Thus, although CNS tuberculosis is well established in the pediatric age, atypical focal manifestations are challenging for the diagnosis and can mimic neoplastic or other infectious etiologies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Intracranial tuberculomas are established via hematogenous dissemination of Mycobacterium tuberculosis, resulting in granuloma development within the parenchyma of the brain. Involvement of deep gray matter lesions, most notably of the thalamus, is less frequent but clinically relevant, since even small lesions in this region may interfere with corticospinal and cerebellothalamic pathways, leading to motor impairment and gait abnormalities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our patient's MRI revealed several ring-enhancing lesions in the right thalamus and surrounding internal capsule, along with mild surrounding vasogenic edema and minimal hydrocephalus from the mass effect on the third ventricle. These findings were consistent with intracranial tuberculoma, and subsequent imaging revealed interval regression. In very young children, small deficits might be the sole presenting feature, making early detection that much more challenging. Radiologically, ring-enhancing lesions in endemic populations should be considered as a possible diagnostic differential for tuberculoma. MRI findings have great diagnostic specificity when used in combination with MR spectroscopy to show lipid peaks [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Microbiology confirmation is frequently absent in parenchymal disease, but, in many cases, only a clinicoradiological correlation can prove disease progression, and most of these are dependent on the therapeutic response [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The lack of pulmonary or systemic tuberculosis in our patient is consistent with previous reports in pediatric series that neurotuberculosis may develop in the absence of active extracranial disease [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This underlines the need for careful exposure history and continued clinical suspicion when initial laboratory and chest imaging are unremarkable. In cases such as deep-seated lesions, medical management remains the gold standard. Radiological resolution was demonstrated for most patients with standard ATT combined with adjunctive corticosteroids; surgical treatment is appropriate in the case of diagnostic uncertainty, obstructive hydrocephalus, or life-threatening mass effect [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Timely transient enlargements during treatment, sometimes referred to by the catchphrase paradoxical reaction, are not uncommon and, provided the clinical picture is stable, should not be confused with a failure of treatment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The earlier physiotherapy and neurorehabilitation in toddlers are particularly essential, where neuroplasticity might result in remarkable functional recovery of motor behaviour. Close clinical and radiological follow-up is important for treatment response and to avoid long-term neurological sequelae. Overall, even in the absence of systemic or meningeal symptoms, this case emphasizes the significance of taking cerebral tuberculoma into account when making a differential diagnosis of isolated pediatric neurological impairments, especially in areas where tuberculosis is endemic.\u003c/p\u003e\n\u003ch3\u003eFollow-up after 2 Months Imaging and Treatment Response\u003c/h3\u003e\n\u003cp\u003eOn 4 March 2026, a follow-up MRI examination of the brain, performed approximately two months after initiation of treatment, demonstrated redemonstration of clustered ring-enhancing lesions in the right thalamus extending toward the internal capsule, with surrounding mild vasogenic edema. There was mild mass effect on the third ventricle and minimal dilatation of the lateral ventricles. Compared with the previous MRI, the lesion size, associated edema, and mass effect were reduced, indicating interval regression of the disease process. There was no evidence of diffusion restriction, intracranial hemorrhage, or extra-axial fluid collection. The remaining intracranial structures, including the posterior fossa and optic pathways, appeared within normal limits.\u003c/p\u003e \u003cp\u003eThese findings suggested a favorable radiological response to ongoing anti-tuberculous therapy with adjunctive corticosteroid treatment, supporting continued conservative medical management with ongoing clinical and radiological follow-up.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case presents with an atypical presentation of intracranial tuberculoma presenting as isolated gait disturbance and mild hemiparesis in a young child without systemic or meningeal features of tuberculosis. In areas endemic to tuberculosis, deep-seated ring-enhancing lesions, especially in the thalamus, may strongly signal tuberculoma, even without pulmonary disease or constitutional symptoms. Initial neuroimaging (e.g., MRI and MR spectroscopy) is essential for accurate diagnosis and for distinguishing between infectious granulomas and neoplastic lesions. Initiating anti-tuberculous therapy with adjunctive corticosteroids soon after presentation is key to achieving full neurological recovery and preventing long-term sequelae. This case illustrates the need to maintain a high clinical suspicion and ensure close radiological follow-up in pediatric patients presenting with isolated focal neurological deficits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral nervous system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBacillus Calmette\u0026ndash;Gu\u0026eacute;rin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnti-tuberculous therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComplete blood count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eErythrocyte sedimentation rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFronto-occipital circumference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ebpm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBeats per minute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentimeter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eppm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParts per million\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of PNS Shifa Hospital Karachi, Pakistan. Informed consent to participate was obtained from all participants included in the study and patient\u0026rsquo;s legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication of clinical details and images was obtained from the patient\u0026rsquo;s legal guardian and family of the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this case report are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKY (Khadija Yasmin): Conception and design of the work, supervision, critical revision for important intellectual content, and final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003eMA (Muhammad Abdullah): Substantial contribution to literature review and drafting of the manuscript, critical revision, and final approval.\u003c/p\u003e\n\u003cp\u003eSS (Sana Shaikh): Contribution to literature search, drafting assistance, manuscript revision, and final approval.\u003c/p\u003e\n\u003cp\u003eMZ (Minahil Zaheer): Interpretation of clinical aspects, critical manuscript review, and final approval.\u003c/p\u003e\n\u003cp\u003eAI (Aleena Ihtasham): Language editing, proofreading, manuscript refinement, and final approval.\u003c/p\u003e\n\u003cp\u003eHHS (Hamna Hassan Siddiqui): Contribution to referencing, manuscript review, and final approval.\u003c/p\u003e\n\u003cp\u003eSS (Saira Shamim): Intellectual input, critical revision of the manuscript, and final approval.\u003c/p\u003e\n\u003cp\u003eHHS (Hudaifa Hassan Salad): Supervision, Contribution to manuscript revision, academic input, and final approval.\u003c/p\u003e\n\u003cp\u003e*All authors have reviewed and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Information:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eKhadija Yasmin\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected] \u003c/p\u003e\n\u003cp\u003eAllama Iqbal Medical College, Lahore, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0008-3103-8163 \u003c/p\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003eMuhammad Abdullah\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eBahria University Health Sciences Campus Karachi, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0005-4961-8359\u003c/p\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eSana Shaik\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected] \u003c/p\u003e\n\u003cp\u003eFaculty of Medicine, Tbilisi State Medical University, Tbilisi, Georgia\u003c/p\u003e\n\u003cp\u003e0009-0008-8540-9484 \u003c/p\u003e\n\u003col start=\"4\"\u003e\n\u003cli\u003eMinahil Zaheer \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected] \u003c/p\u003e\n\u003cp\u003eHBS medical and dental college, Islamabad, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0007-5614-6411\u003c/p\u003e\n\u003col start=\"5\"\u003e\n\u003cli\u003eAleena Ihtasham\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected] \u003c/p\u003e\n\u003cp\u003eKing Edward Medical University, Lahore, 54000, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0000-7250-7730\u003c/p\u003e\n\u003col start=\"6\"\u003e\n\u003cli\u003eHamna Hassan Siddiqui\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eJinnah Sindh Medical University, Karachi, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0003-1562-0245\u003c/p\u003e\n\u003col start=\"7\"\u003e\n\u003cli\u003eSaira Shamim\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eKing Edward Medical University, Lahore, 54000, Pakistan\u003c/p\u003e\n\u003cp\u003e0009-0007-6141-3721\u003c/p\u003e\n\u003col start=\"8\"\u003e\n\u003cli\u003eHudaifa Hassan Salad\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eFaculty of Medicine and Surgery, Salaam University, Mogadishu, Somalia\u003c/p\u003e\n\u003cp\u003e0009-0001-9613-9271\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRock RB, Olin M, Baker CA, Molitor TW, Peterson PK. 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Wellcome Open Res. 2020;4:158. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12688/wellcomeopenres.15501.3\u003c/span\u003e\u003cspan address=\"10.12688/wellcomeopenres.15501.3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng V, Ho P, Lee R, Chan K, Chan K, Woo P, et al. Clinical Spectrum of Paradoxical Deterioration During Antituberculosis Therapy in Non-HIV-Infected Patients. Eur J Clin Microbiol Infect Dis. 2002;21(11):803\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-002-0821-2\u003c/span\u003e\u003cspan address=\"10.1007/s10096-002-0821-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"intracranial tuberculoma, pediatric tuberculosis, ring-enhancing lesion, neuroimaging, anti-tuberculous therapy","lastPublishedDoi":"10.21203/rs.3.rs-9124856/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9124856/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIntracranial tuberculoma is an important manifestation of pediatric central nervous system tuberculosis, especially in endemic regions. While seizures and signs of raised intracranial pressure are common presenting features, isolated focal neurological deficits without systemic or meningeal symptoms are rare, resulting in diagnostic delay. We report an unusual case of thalamic tuberculoma presenting primarily with gait disturbance in a young child.\u003c/p\u003e\u003ch2\u003eCase Presentation\u003c/h2\u003e \u003cp\u003e: A 2-year-old boy from Karachi, Pakistan, presented with increasing difficulty ambulating and unable to walk on his own. On neurological examination slight weakness on the left side. An MRI scan of his brain showed that a ring-enhancing lesion in the right thalamus extended into the midbrain, and it was surrounded by vasogenic edema. Magnetic resonance spectroscopy suggested an infectious etiology, most likely tuberculoma. There were no meningeal symptoms, fever or seizures in the child. There were no abnormal findings on routine laboratory testing and chest X-ray, however, screening at home confirmed latent TB exposure.\u003c/p\u003e\u003ch2\u003eClinical Discussion\u003c/h2\u003e \u003cp\u003e: Although intracranial tuberculoma does not always present with systemic manifestations of tuberculosis in children as observed in the present study, it is also a challenging disease to diagnose in young children due to the atypical presentation. Neuroimaging: Early diagnosis is possible. For deep-seated lesions where operative therapy and surgical treatment are highly risky, conservative management is often effective with anti-tuberculous therapy and adjunctive corticosteroids. Early physiotherapy is important for achieving functional recovery.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe case illustrates the need for consideration of intracranial tuberculoma in an individual neurological impairment case, considering children with isolated neurological deficits, when systemic forms of tuberculosis do not develop, even in the absence of evidence of systemic tuberculosis symptoms. Prompt imaging and early development and treatment with early anti-tuberculous therapy may give good results.\u003c/p\u003e","manuscriptTitle":"Thalamic Tuberculoma Presenting as Isolated Gait Disturbance Without Systemic or Meningeal Symptoms in a 2-Year-Old Child: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 09:11:01","doi":"10.21203/rs.3.rs-9124856/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f18ba9dc-7d9f-4ea8-b98b-e9e9d69df964","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T16:10:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 09:11:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9124856","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9124856","identity":"rs-9124856","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}