A tuberculous abscess of the brain. Case report

Cerebral abscesses of tuberculosis origin: study of 8 cases at the University Hospital of Conakry

Introduction

Tuberculosis of the central nervous system (CNS) remains endemic in developing countries with high morbidity and mortality despite advances in imaging and treatment. The objective of our work was to describe the diagnostic and therapeutic difficulties of this pathology in the context of a country with limited health resources.

Materials and methods

We retrospectively studied 8 cerebral tuberculosis abscess files, collected in the archives of the neurosurgery department of the Conakry University Hospital over a 5-year period (January 2013–December 2017). The diagnosis was made by scanning and by isolation of acid-fast bacilli (AFB) by direct examination of pus.

Results

Mean age was 33 years (9–56 years), sex, 5H 5 men/3F 3 women. History of pulmonary TB, 3 cases; TB contagious, 5 cases; TST ITR positive, 5 cases; associated visceral TB, 5 cases; HIV positive serology, 2 cases. The clinic was dominated by altered consciousness, 7 cases; focal signs, 7 cases; and fever, 5 cases. The site was hemispherical in 7 cases and one case in the posterior brain fossa. Treatment was medico-surgical in all patients. The evolution was favorable in 3 cases, the neurological sequelae in 3 cases, 2 cases of death, and 2 cases of recurrence.

Conclusion

Cerebral tuberculous abscesses constitute a medico-surgical emergency. Despite their rarity, morbidity and mortality remains high in the context of developing countries due to diagnostic and therapeutic delays.

Clinicopathological study of tuberculous brain abscess

Central nervous system tuberculosis is still one of the leading causes of morbidity in the developing world, and tuberculous abscess is one of its uncommon manifesting forms. It closely mimics a pyogenic abscess clinically, radiologically, and histologically. An accurate diagnosis is imperative due to therapeutic implications. In this study, 21 cases of tuberculous abscesses encountered over a period of 13 years (1995-2007) were reviewed to study the clinical, radiological, and histopathological spectrum of the disease. The presence of palisading epithelioid cells and sheets of foamy histiocytes, enclosing a neutrophillic exudate rich in fibrin with nuclear debris, were clues as to suspicion of a tuberculous abscess. The demonstration of acid fast bacilli in the wall of the abscess or necrotic contents by microscopy or culture is essential to confirm the diagnosis of tuberculous abscess. A high index of clinical suspicion is necessary particularly in countries endemic for tuberculosis to ensure an accurate diagnosis and application of an appropriate therapy.

Bacterial infections

The organisms that produce bacterial infections of the nervous system in tropical regions are similar to those existing in the rest of the world. However, because of poor socio-economic conditions in the former areas, preventing the implementation of appropriate prophylactic and therapeutic measures, the incidence and course of these diseases may vary. In this paper the neuropathological appearances of the main bacterial diseases are reviewed and the main differences between those occurring in developed and developing countries emphasized. Despite great efforts by governments and communities, tuberculosis still remains a scourge in many countries and leprosy has not been eradicated from earth. Earlier optimism that antibiotics could finally put an end to syphilis have been dashed and the disease still persists. Moreover, the explosion of AIDS not only has produced a recrudescence of many of these diseases, but has also changed their clinical and pathological presentation.

Suprasellar tubercular abscess presenting as panhypopituitarism: a common lesion in an uncommon site with a brief review of literature

Following widespread use of imaging, detection rate of abnormal sites of parenchymal neuro-tuberculosis is on a rise. A handful of cases of tuberculomas/abscesses in hypothalamo-pituitary region have been reported and most of them are diagnosed on surgical histopathology. We describe a patient of suprasellar tubercular abscess, who presented with visual disturbances, diabetes insipidus with panhypopituitarism and on histopathology had granulomas and positive acid fast bacilli.

Atypical intradural spinal tuberculosis: report of three cases

OBJECTIVE

To report three cases of intradural spinal tuberculosis (TB) by calling attention to atypical forms of spinal TB.

SETTING

A University Hospital, Istanbul, Turkey.

METHODS

Histopathological, radiological, surgical and physical examination findings of three patients with spinal TB were retrospectively reviewed.

RESULTS

Based on histopathological, surgical and radiological findings, diagnosis of intramedullary abscess had been made in the first case and early and late phases of arachnoiditis in the other two patients, respectively. The clinical outcome was evaluated as satisfactory for the patient with intramedullary abscess who had been treated with medical and surgical interventions. The remaining two patients with arachnoiditis, who had been treated by shunting or simple decompression, had a relatively less favorable clinical outcome.

CONCLUSION

Spinal TB, in its atypical forms, is a rare clinical entity and low index of suspicion on the part of the surgeon may result in misdiagnosis such as neoplasm. In cases presenting with an intraspinal mass lesion, possibility of a tuberculous abscess and/or a granuloma should be considered in the differential diagnosis.

Flare up of tuberculous abscess following stereotactic aspiration--case report

A 16-year-old non-immunocompromised and otherwise healthy patient presented with a tuberculous brain abscess. The abscess was aspirated stereotactically. Following the aspiration the disease process flared up and multiple daughter abscess cavities were discovered. The daughter abscesses were removed via craniotomy. Stereotactic aspiration requires care to prevent such flare up of the disease.

Role of stereotactic aspiration in the management of tuberculous brain abscess

BACKGROUND

Intracranial tuberculous abscesses are uncommon clinical entities, even in countries where tuberculosis is endemic. Surgical excision and antituberculous treatment is the treatment of choice. The role of stereotactic aspiration in the management of these lesions is highlighted in this communication.

METHODS

Three patients, all receiving treatment for pulmonary tuberculosis, presented with symptoms of raised intracranial pressure and neurological deficits. Computed tomography (CT) scans revealed cystic lesions with enhancing rim in the thalamus in two patients and multiple coalescing cystic lesions in the deep temporal region in another.

RESULTS

Stereotactic aspiration of the cyst and biopsy of the cyst wall were performed in all. In two, the pus revealed acid fast bacilli (AFB). In another, though the pus did not reveal any AFB, the wall showed tuberculous granuloma. Antituberculous treatment was continued in all the patients. Follow-up CT revealed resolution of the lesions in all patients.

CONCLUSION

Stereotactic aspiration is an useful alternative modality of management of tuberculous abscesses in a selected group of patients.

Intramedullary tuberculous abscess: a case report

STUDY DESIGN

This case report shows an intramedullary thoracic spinal cord abscess secondary to Mycobacterium tuberculosis in a 7-year-old boy with chronic progressive paraparesis and hypesthesia below T10.

OBJECTIVES

The treatment of this patient involved drainage of pus followed by appropriate chemotherapy.

SUMMARY OF BACKGROUND DATA

Abscess and tuberculomas of the spinal cord are rare entities. They are indistinguishable from neoplasms. The possibility of tubercular abscess or granuloma should be kept in mind when an intraspinal mass is found, provided that the clinical history is unusual for tumor.

METHODS

A left T7-T8 hemilaminectomy was performed. A quantity of pus was drained through a small myelotomy. A small specimen was taken, and antituberculosis treatment was given after surgery.

RESULTS

Excellent clinical outcome was obtained with a combination of medical and surgical management.

CONCLUSION

The treatment of intramedullary abscess consists of surgical evacuation of the pus. Appropriate treatment offers a favorable prognosis even in cases with severe deficits.

Intracranial tuberculous abscess mimicking malignant glioma

Brain abscess is probably the least common manifestation of tuberculous infection of the central nervous system; meningitis and tuberculoma are much more common. A case of tuberculous brain abscess in a 23-year-old man with previous history of Tbc meningitis is presented. The computerized tomographic scan demonstrated a unilocular space-occupying lesion in the left thalamic region, surrounded by a thick hyperdense enhancing rim. It is suggested that a relatively long clinical history and previous Tbc meningitis history together with the appearance of a thick-walled abscess-like lesion on the CT scan may indicate the diagnosis of a tuberculous brain abscess. Only after neurosurgical removal of the abscess, the pathohistological examination reveal tuberculous etiology of the abscess. The patient later died from aspiration bronchopneumonia. Only 28 instances of tuberculous abscess have been reported in the literature.

Synthesis of 2-[123I and 124I]-iodoisonicotinic acid hydrazide--potential radiotracers for tuberculosis

The radiochemical syntheses of methyl 2-[123I]-iodoisonicotinate, 2-[123I]-iodoisonicotinic acid hydrazide and 2-[124I]-iodoisonicotinic acid hydrazide was accomplished. Iodine-123 was incorporated in the methyl ester molecule by an exchange reaction in glacial acetic acid. The average efficiency of iodine exchange reaction was (92.6 +/- 4.5)%. This radiotracer was extracted with ether and the solvent was evaporated. The residue was re-dissolved in anhydrous ethanol and treated with hydrazine under anhydrous conditions to obtain 2-[123I]-iodoisonicotinic acid hydrazide. The overall radiochemical yield was 69%. Biodistribution data of both radio-tracers in male Sprague-Dawley rats were collected. This is the first report of SPECT radiopharmaceuticals which may be useful for differential diagnosis of intracranial masses (tuberculoma vs glioma), and CNS tuberculosis in immunosuppressed subjects.

Tuberculous brain infection located in an old cerebral infarct: CT changes with successful conservative therapy

A case of tuberculous brain infection following tuberculous meningitis in a 67-year-old man is presented. It was located in an old cerebral infarct associated with left internal carotid artery occlusion. CT demonstrated capsule enhancement in the left temporal area after iodinated contrast medium. Chemotherapy with INH, RFP and SM diminished the lesion and the capsule disappeared thirteen months later. It is suggested that a relatively long clinical history together with the appearance of a thick-walled abscess-like lesion on the CT scan is consistent with the diagnosis of tuberculous brain infection, perhaps an abscess.

Successful treatment of tuberculous brain abscess

A case of tuberculous brain abscess occurred in spite of 4 months' treatment of pulmonary tuberculosis with a triple drug anti-tuberculous regimen. Surgical removal and further chemotherapy were successful.

Tuberculous brain abscess and its appearance on computerized tomography. Case report

✓ A case of tuberculous brain abscess in a 52-year-old woman is presented. The computerized tomographic (CT) scan demonstrated a multilocular space-occupying lesion in the right parietal area, surrounded by a thick hyperdense enhancing rim. It is suggested that a relatively long clinical history together with the appearance of a thick-walled abscess-like lesion on the CT scan may indicate the diagnosis of a tuberculous brain abscess.

Tuberculous brain abscess. Case report

An abscess was removed from the left occipital region in a 73-year-old woman with no previous history of tuberculosis. The patient later died from aspiration bronchopneumonia. Autopsy revealed a basilar tuberculous meningitis and miliary tuberculosis in the peritracheal lymphatic glands, the liver, the spleen, and in isolated areas of the lungs. No chronic tuberculous foci were noted in any area. Including this case, only 18 instances of tuberculous abscess have been reported.

Tuberculous abscess of the brain

A bacteriologically confirmed case of tuberculous abscess of the brain is reported. Tuberculous brain abscess unlike tuberculoma does not exhibit the typical granulomatous changes and the diagnosis is confirmed by demonstration of tubercle bacilli either by staining or culture. An antituberculous regime should be started immediately the diagnosis has been established.

Intracranial tuberculomas and the CAT scan

Tuberculomas of the brain are rare in the United States. Although CAT (computerized axial tomography) scanning cannot distinguish these infections from other intracranial mass lesions, it provides a non-invasive technique with which to follow the course of presumptive lesions during medical therapy, and with which to search for clinically unsuspected infections. The necessity for and timing of surgery can be considered more easily with this technique. Two cases are presented with their CAT scans, including one example of the disappearance of a presumptive tuberculoma, during appropriate medical therapy.

[Inflammatory chronic processes of the central nervous system. Neurosurgical aspects]

A study into the neurosurgical approach to thirty-five patients with increased intracranial pressure due to inflamatory diseases affecting the central nervous system and meninges is reported. The entitites under consideration were found to have similar surgical aspects despite the heterogeneity of etiologic agents. As regards the surgical treatment, two groups of cases were recognized. Group 1 comprises 7 patientes with symptoms of a space-occupying lesion; in these patients craniotomies were performed with good results. Group 2 included the remainder 28 cases with acquired hydrocephalus. In this group differents methods for ventricular drainage were used, but ventriculo-auriculostomy and specially ventriculo-peritoneal shunts proved to give more gratifying results. Chemotherapy was administred when the etiologic agent was disclosed. Corticosteroids were institued to reduce inflammatory reations and cerebral edema. A review of the literature supported the practical classification and surgical techniques employed.

Tuberculous brain abscess. Case report

The authors describe a case of tuberculous cerebral abscess of the frontal lobe that developed 1 year after an episode of acute miliary tuberculosis. The development of such a lesion indicates a persistence of infection and an immunological breakdown which may partly have been due to protein malnutrition.

Multiple tuberculomas of the brain. Report of a case

A case of multiple tuberculomas of the brain in a pregnant patient is reported. The symptoms and signs suggested a lesion of the cerebellum which was found to be only congested and oedematous at craniotomy. The correct diagnosis was made at autopsy.

[Intracraniel tuberculoma. Report of 2 cases]

Os tuberculomas intracranianos são de difícil diagnóstico pré-operatório e, atualmente, constituem raridade em alguns países. Os autores relatam dois casos, com extirpação total do processo, em que o diagnóstico foi feito após intervenção cirúrgica. São comentados vários aspectos referentes ao diagnóstico e a conduta terapêutica nos tuberculomas intracranianos.