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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 20  |  Issue : 1  |  Page : 77-78

Tubercular cerebellar abscess in a child


1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Pathology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication19-Feb-2015

Correspondence Address:
Dr. Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.151750

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  Abstract 

Tubercular abscess of the brain are rare lesions and usually occur in the supratentorial compartment in immune-compromised hosts. We report an uncommon case 12-year-child with otogenic tubercular cerebellar abscess that was managed successfully with surgical excision and anti-tubercular treatment and review the literature.

Keywords: Cerebellar, cerebellar abscess, tuberculous abscess


How to cite this article:
Agrawal A, Shanthi V, Ramakrishna BA. Tubercular cerebellar abscess in a child. J Mahatma Gandhi Inst Med Sci 2015;20:77-8

How to cite this URL:
Agrawal A, Shanthi V, Ramakrishna BA. Tubercular cerebellar abscess in a child. J Mahatma Gandhi Inst Med Sci [serial online] 2015 [cited 2017 Dec 10];20:77-8. Available from: http://www.jmgims.co.in/text.asp?2015/20/1/77/151750


  Introduction Top


Tubercular abscess of the brain are rare lesions and usually occur in the supratentorial compartment in immune-compromised hosts. [1],[2] Tuberculous cerebellar abscess is a rare extra pulmonary manifestations of tuberculosis with only few reported cases in the literature. [2],[3],[4] We report an uncommon case of otogenic tubercular cerebellar abscess and review the literature.


  Case Report Top


The present case report is about an 11-year-old boy presented with the history of headache and vomiting of 10 days duration. There was a history of low grade fever and headache 1 month back and also with a history of purulent discharge from right ear of 4 year duration. For the same, he was treated with many courses of antibiotics for which details were not available. He was operated patent ductus arteriosus at the age of 1 year. In addition, he was diagnosed with cerebellar tonsillar herniation and atlantoaxial dislocation. His general and systemic examination was unremarkable. The child was afebrile. The child was conscious, alert and oriented to time, place and person. There was mild neck rigidity. Pupils were bilateral equal and reacting to light. Motor and sensory examination was normal. There were no cerebellar signs. Right ear examination revealed that right tympanic membrane was erythematous and bulging with continuous, non-foul smelling, yellowish, muco-purulent discharge. His blood investigations were normal. Blood culture was sterile. Malaria smears and human immunodeficiency virus serology were negative. A computed tomography (CT) scan showed a well-defined cystic lesion in right cerebellar hemisphere and it was enhancing in a ring like manner after contrast administration without much mass effect or peri-lesional edema [Figure 1]. There was associated mild ventriculomegaly. As the patient did not respond to the conservative management and had features of raised intracranial pressure he was planned for surgery. A right retro-mastoid suboccipital craniectomy was performed. There was thick-walled well-defined cystic lesion containing non-foul smelling yellowish purulent material. The lesion could be excised totally. Ziehl-Neelsen staining showed presence of acid fast bacilli (AFB) in pus. The patient made good recovery from anesthesia and received broad-spectrum antibiotics in immediate post-operative period. Histopatholgoical examination was suggestive of tubercular abscess [Figure 2]. The patient was started on anti-tubercular treatment and doing well at follow-up.
Figure 1: Computed tomography scan brain plain and contrast images showing ring enhancing lesion involving right cerebellar hemisphere, with minimal mass effect and peri-lesion edema

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Figure 2: (Left) granular necrotic material on the right side with adjacent fibrocollagenous tissue showing the langhans giant cells, epithelioid cells and lymphocytes (H and E, ×400) and (right) langhans giant cells admixed with lymphocytes and necrotic material (H and E, ×400)

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  Discussion Top


Tuberculoma formation is the most frequent manifestation of parenchymal central nervous system (CNS) tuberculosis. [5],[6] The tissue reaction to AFB depends on the host immunity, the inoculum size of the bacteria, the specific tissue infected and whether the patient received chemotherapy. [5],[6] The pathogenesis of tuberculous brain abscess is similar to other forms of CNS tuberculosis. [2],[3],[4] Tuberculous brain abscess characterized by a focal collection of pus containing AFB and surrounded by a dense capsule of vascular granulation tissue containing acute and chronic inflammatory cells; and presence of tubercular bacilli in the pus. [6] Clinically patients with cerebellar tubercular abscess present with fever, headache, alteration of consciousness, seizure, [6] cerebellar signs [7] and or with hydrocephalus. [4] Our patient had mild ventriculomegaly, but did not require shunt placement. Both CT and magnetic resonance imaging (MRI) can detect intracranial abscesses; however, these studies cannot easily differentiate between tuberculous and pyogenic abscesses. [8] Findings on CT scans are assumed to be characteristic of tuberculous abscesses if there is a thick-walled lesion with surrounding edema, and pyogenic, if abscess walls is relatively thin. [9] Recently, MRI has been used for better tissue characterization in CNS tuberculosis. [10] The gold standard of diagnosis remains on demonstration of innumerable tubercle bacilli in aspirated pus. [11] However, the absence of tubercle bacilli does not necessarily imply the absence of a tuberculous brain abscess. [4],[12] The mainstay of management of tubercular abscess is total surgical excision as it will confirm the diagnosis, will minimize the morbidity and shorten the hospital stay. [4],[12] It is to be followed by adequate doses of anti-tubercular chemotherapy. [4],[11],[12]

 
  References Top

1.
Chattopadhyay P, Kundu AK. Tuberculous brain abscess - A diagnostic and therapeutic challenge. J Assoc Physicians India 2006;54:829-30.  Back to cited text no. 1
[PUBMED]    
2.
Wanjari K, Baradkar VP, Nataraj G, Kumar S. A rare case of tubercular cerebellar abscess. Indian J Med Microbiol 2009;27:363-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Roopesh Kumar VR, Gundamaneni SK, Biswas R, Madhugiri VS. Tuberculous cerebellar abscess in immunocompetent individuals. BMJ Case Rep 2012;2012:???.  Back to cited text no. 3
    
4.
Agrawal D, Suri A, Mahapatra AK. Primary excision of pediatric posterior fossa abscesses - Towards zero mortality? A series of nine cases and review. Pediatr Neurosurg 2003;38:63-7.  Back to cited text no. 4
    
5.
Agrawal A, Kakani A, Mahajan SN, Vagha SJ, Acharya S. Paradoxical manifestation of cerebellar tuberculoma. Infect Dis Clin Pract 2011;19:72-4.  Back to cited text no. 5
    
6.
Oberdorfer P, Kongthavonsakul K, Intachumpoo J, Odell S. A 14-year-old girl with tuberculous otitis media and brain abscess. BMJ Case Rep 2012;2012.  Back to cited text no. 6
    
7.
Sreelatha P, Shyam P, Asadharan P. A rare case of primary tuberculous cerebellar abscess-in an immuno competent patient. Natl J Basic Med Sci 2012;2:381-3.  Back to cited text no. 7
    
8.
Inbasekaran V, Natarajan M. Tuberculous brain abscess. J Indian Med Assoc 1991;89:207, 209.  Back to cited text no. 8
    
9.
Haimes AB, Zimmerman RD, Morgello S, Weingarten K, Becker RD, Jennis R, et al. MR imaging of brain abscesses. AJR Am J Roentgenol 1989;152:1073-85.  Back to cited text no. 9
    
10.
Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007;28:1332-8.  Back to cited text no. 10
    
11.
Gupta V, Chhina D, Kaushal R, Gupta R. Tuberculous brain abscess - Case report. Asian Pac J Trop Dis 2012;2:419-20.  Back to cited text no. 11
    
12.
Babu VV, Ananda K, Vasanthakumar GR. A convenient method for the synthesis of C-protected esters of BOC-/Z-alpha, alpha-dialkylamino acids by the mixed carboxylic carbonic anhydride method. Protein Pept Lett 2002;9:345-8.  Back to cited text no. 12
    


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