Tubercuolosis (TB) continues to be a major public health concern, especially in developing countries. TB is one of the top 10 causes of death worldwide . In 2016, 10.4 million people fell ill with TB; and 1.7 million died from the disease. In 2016, an estimated 1 million children became ill with TB and 250,000 children died of TB.
Tuberculosis of central nervous system (CNS) can be treated effectively with anti-tubercular therapy (ATT). ATT duration for treatment of CNS TB is 12 months ( 2 months intensive phase and 10 months continuation phase). Some cases of CNS TB require neurosurgical intervention. I am presenting 3 cases of cranial TB where the presentations were unusual leading to delay in the diagnosis. All these three cases were effectively treated with neurosurgery along with ATT.
Patient 1 was a middle aged female with history of headace of long duration. CT scan of head revealed extradural collection beneath the frontal bone. The frontal bone was thickened. This was unusual as duration of symptom was in years and the bone above the lesion was thickened.
Surgical image showing pus coming out of frontal bone bur hole
As intensity of the headadche increased , patient was advised surgery. On craniectomy about 60 ml of pus came out under pressure. Patient became asymptomatic after surgery and ATT.
Patient 2 was a middle aged male with history of trauma and swelling over the vertex of skull about 15 days back. Patient was suspected to have scalp hematoma and swelling and was advised antibiotics and analgesics. CT scan showed a scalp swelling over the cranium. Patient underwent surgery and about 40 mL of pus was drained and it was sent for culture/ sensititivity, Gram stain , AFB stain. It came out positive for Staphylococcus. But, despite of prescribing antibiotic according to sensitivity, wound was not healing. Later, wound was re-explored and remaining pus drained out and bony osteomyelitis of the cranium was evident. Craniectomy of the pariental bone at the vertex was done and sent for histopathological examination. Biopsy was suggestive of tuberculosis.
Surgical image of the patient showing calvarial osteomyelitis
Patient's surgical wound healed with antibiotic and ATT. He became asymtomatic after taking ATT.
Patient 3 was a child of about 14 year age. He presented in emergency of my Institute with history of headache, vomiting, deterioration of conscious level, weakness of right half of body and recurrent seizures. CT scan of the brain and MRI of brain with contrast revealed intracranial subdural hypodense collections in interhemispheric fissure and left fronto-parietal convexity of brain.
Frontal region incision was made and single burr hole made in frontal bone under general anesthesisa. Dura was coagulated and incision made in dura. About 80 mL of thick pus came out under pressure. Patient improved after surgery and ATT.
Many types of neurotuberculosis have been described; most common
intracranial forms are tuberculous meningitis and tuberculomas.Tuberculous
brain abscess and subdural empyema are extremely rare manifestations of central
nervous system tuberculosis. Subdural empyema or collection of pus in the
subdural space is mostly pyogenic. Intracranial
tubercular subdural empyema is very rare in pediatric population. Various diagnostic
modalities and treatment options are
available for managing central nervous system tuberculosis
(CNS TB). But, outcome
remains of CNS TB is poor as clinicians
face many challenges in
the management of
the tubercular infection of the brain
and spinal cord.
Treatment of CNS TB is challenging due to lack of specific
biochemical tests and inability to get the pathological sample from deeply
located eloquent areas of CNS without causing any neurological deficit.
Moreover, it is unnecessary to operate for biopsy in a patient who has
presented with a very small granulomatious lesion in brain or spinal cord. In
such as situations neuro-radiology helps in managing CNS TB and it may be the
only source of establishing diagnosis and evaluating treatment response. Role
of radiological investigation has expanded from the initial diagnosis to the
therapeutic interventions. In some Muli-drug- resistant (MDR) CNS TB cases, stereotaxy
or Ultrasonogram (USG) or CT guided biopsy helps in obtaining pathological
sample and drug sensitivity testing. A regular clinical and neuro-radiological
follow-up is mandatory during the entire course of anti tuberculous therapy to
take prompt decisions to change ATT and to reduce morbidity and mortality
associated with CNS TB.
Traditionally, culture for the mycobacterium is considered
as gold standard for diagnosis of TB. But, tuberculin
test, biochemical investigations and AFB
stain and culture
of the cerebrospinal fluid or
granulation tissue provide
little support for the management
of CNS TB or its sequelae. There should
be high index of suspicion for the CNS TB in a patient who is from an endemic
region. There may be extensive tubercular involvement of CNS even in
absence of the
history of pulmonary diseases,
tubercular contact or
any other neurological deficit.
It is difficult to assess the therapeutic response in the early follow
up period in view of the lack of sensitive and specific tests. Vigilant
clinical observation and imaging studies is required in the early follow up
period to identify the worsening or
new emerging signs
in the patients of
CNS TB. Imaging
studies are becoming the
major decisive tools
for the empirical therapy
and early follow
up of the patients to evaluate the therapy.
Intracranial tubercular subdural empyema can be effectively
treated with ATT and burr hole evacuation of pus. Close clinical observation,
neuroradiological assessment with CT scan or MRI and prompt therapeutic
interventions are necessary for starting the empirical anti-tuberculous therapy and early follow up of the patients to
evaluate the therapeutic response.
In all these cases pus was negative for Acid Fast Bacillus (AFB). This is very common observation. So, high index of suspicion and close follow up is required in suspected cases of cranial TB. Clinical observation with empirical ATT is key in the management of CNS TB cases.
References
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