|Year : 2014 | Volume
| Issue : 2 | Page : 132-134
Giant tubercular brainstem abscess: A case report
Pragati Chigurupati1, Phani Kumar2
1 Department of Microbiology, GSL Medical College, Rajahmundry, Andhra Pradesh, India
2 Department of Neurosurgery, GSL Medical College, Rajahmundry, Andhra Pradesh, India
|Date of Web Publication||11-Aug-2014|
80-26-10, Heritage Residency, A-3, A.V.A. Road, Rajahmundry - 533 103, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Tubercular brain abscesses are uncommon and tubercular brainstem abscesses are rarely reported. Most of these cases occur in immunocompromised patients. We report a case of giant brainstem abscess in a 5-year-old human immunodeficiency virus-seronegative female child who presented with complaints of headache, diplopia and unsteadiness of gait since 6 months. Diagnosis was made by a magnetic resonance imaging scan of brain. The patient demonstrated a remarkable clinical recovery after microsurgery combined with a course of antituberculous therapy. Microbiological and histological findings confirmed the diagnosis of a tuberculous abscess.
Keywords: Brainstem abscess, tubercular abscess
|How to cite this article:|
Chigurupati P, Kumar P. Giant tubercular brainstem abscess: A case report. J Mahatma Gandhi Inst Med Sci 2014;19:132-4
| Introduction|| |
Extrapulmonary tuberculosis (TB) is observed in approximately 20% of all TB cases.  Central nervous system (CNS) TB, the most dangerous form of TB, accounts for approximately 5% of extrapulmonary TB. Tuberculous meningitis (TBM) is the most common form of CNS TB, followed by solitary or multiple intracranial tuberculomas. Tubercular abscess, especially located in the brainstem, is the rarest form of presentation. , The initial diagnosis is based on radiological findings on magnetic resonance imaging (MRI) scan, but definitive diagnosis is performed by bacteriological methods. Differential diagnosis includes pyogenic abscess and cystic brainstem glioma. We report a case of giant brainstem abscess in a 5-year-old female child. The diagnosis of tubercular abscess was confirmed by the isolation of Mycobacterium tuberculosis from the drained pus.
| Case Report|| |
A 5-year-old female child presented with a 6-month history of headache, fever, diplopia, weakness of all four limbs and gait disturbance. On examination, she was conscious with bilateral sixth, seventh cranial nerve paresis, spastic qaudriparesis of power grade 4 and scissoring gait.
MRI scans revealed pontine-midbrain cystic space occupying lesion measuring 4.3 cm × 4.2 cm × 4 cm [[Figure 1], [Figure 2], [Figure 3]. The lesion was thought to be a cyctic glioma preoperatively. The patient was operated through a suboccipital craniotomy, transvermian approach. The lesion was found to be covered by thin friable capsule, which, on opening, revealed a thick, whitish-yellow colored odorless pus that was drained, and measured approximately 40 mL.
|Figure 1: Magnetic resonance imaging image T2-weighted axial section showing abscess|
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|Figure 2: Magnetic resonance imaging image T2-weighted coronal section showing abscess|
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|Figure 3: Magnetic resonance imaging image T2-weighted sagittal section showing abscess|
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The Gram-stained smear of pus showed pus cells with no organisms, while the Ziehl Neelsen (ZN) staining revealed acid fast bacilli and pus cells [Figure 4]. The sample was inoculated on Blood agar and Chocolate agar. No growth was observed on the Blood agar and Chocolate agar plates. Lowenstein-Jensen (LJ) medium however was not used due to its unavailability. The histopathological examination showed inflammatory cells, but there was no evidence of Langerhan's giant cells or caseation.
|Figure 4: Photomicrograph demonstrating acid fast bacilli on Zeihl-Nelson staining|
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The patient was put on Rifampicin, INH, Ethambutol and Pyrazinamide. Good recovery was noted at 3 months following surgery.
| Discussion|| |
The brainstem is an unusual location for an abscess. Pons is the most common site of these abscesses, followed by midbrain and medulla.  The organisms most frequently isolated from brain abscesses are Staphylococcus aureus, Gram-negative bacilli, anaerobes and Streptococcus viridans.  Cerebral TB manifests predominantly as tuberculous meninigitis, followed by tuberculomas; other forms of CNS TB include cerebral abscess, cerebral miliary TB, tuberculous encephalopathy, tuberculous encephalitis and tuberculous arteritis.  Tuberculous brainstem abscess of the brain is very uncommon.
The cause of brainstem abscess is hematogenous dissemination from a distant site. These patients may present with multiple cranial palsies, raised intracranial pressure, sepsis and, often, rapidly deteriorating sensorium. Patient survival till the attainment of large giant dimensions by the abscess, as was seen in our case, is very rare. The diagnosis requires a strong clinical suspicion and an urgent contrast-enhanced radiology in the form of computerized tomography or MRI. Radiologically and clinically, these abscesses are similar to pyogenic abscesses or any other space-occupying lesion like cystic glioma. The criteria for diagnosis include pus within brain and bacteriological proof or histological confirmation of the abscess. The management strategy includes stereotactic or microsurgical aspiration of pus to decompress the brain, confirmation of diagnosis on Zeihl-Nelson staining and culture in Lowenstein-Jensen medium if available, followed by prolonged administration of Rifampicin, INH, Ethambutol and Pyrazinamide for a minimum 1-year period. 
| Conclusion|| |
Despite its rarity, tuberculous brainstem abscess must be considered in the differential diagnosis of cystic brainstem mass lesions. Stereotactic or microsurgical management should be considered and diagnosis confirmed through demonstration of Mycobacterium tuberculosis using either staining or culture. Microsurgical excision combined with a complete course of antituberculous therapy will lead to a good outcome.
| References|| |
|1.||Oncul O, Baylan O, Muttu H, Cavulsu S, Dogan L. Tuberculous meningitis with multiple intracranial tuberculomas mimicking neurocysticercosis. Clinical and radiological findings. Jpn J Infect Dis 2005;58:387-9. |
|2.||Ramesh VG, Sundar KS. Concomittant tuberculosis and pyogenic cerebellar abscess in a patient with pulmonary tuberculosis. Neurol India 2008;56:91-2. |
|3.||Babu ML, Shavindar. Tuberculous brain abscesses. JK Practit 2002;9:262-3. |
|4.||Suzer T, Coskun E, Cirak B, Yagci B, Tahta K. Brain stem abscesses in childhood. Childs Nerv Syst 2005;21:27-31. |
|5.||Wanjar K, Baradkar VP, Nataraj G, Kumar S. A rare case of tubercular cerebellar abscess. Indian J Med Microbiol 2009;27:363-5. |
|6.||Gazzaz M, BonyaaKoub FA, Elkhamlichi A. Tuberculous cerebellar abscess. Acta Neurol Belg 2000;100:146-7. |
|7.||Fuentes S, Bouillot P, Regis J, Lena G, Choux M. Management of brain stem abscess. Br J Neurosurg 2001;15:57-62. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]