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CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 266-269
 

Intracranial tubercular subdural empyema: A case report and review of literature


Department of Neurosurgery, Institute of Human Behavior & Allied Sciences (IHBAS), Dilshad Garden, Delhi, India

Date of Submission09-Sep-2018
Date of Decision18-Nov-2019
Date of Acceptance03-Jul-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Vinod K S Gautam
102, Academic Block, IHBAS, Dilshad Garden, Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpn.JPN_134_18

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   Abstract 

Tuberculosis (TB) is a major health problem in developing countries. Approximately 1 million children became ill with TB in year 2016. Neurotuberculosis is associated with high mortality and morbidity. Intracranial tubercular subdural empyema is extremely rare in pediatric population. Authors report a case of 13-year-old male child who had presented with recurrent seizures and features of raised intracranial pressure. Neuroradiology of skull revealed intracranial subdural empyema. He was managed effectively with burr hole evacuation of the pus, postoperative neuroradiological assessment, and prompt empirical antitubercular therapy. Authors propose that high index of suspicion, neuroradiology, and prompt therapeutic interventions are necessary for good prognosis of this rare yet curable disease.


Keywords: Neurotuberculosis, intracranial subdural empyema, seizures


How to cite this article:
Gautam VK, Upadhyay S. Intracranial tubercular subdural empyema: A case report and review of literature. J Pediatr Neurosci 2020;15:266-9

How to cite this URL:
Gautam VK, Upadhyay S. Intracranial tubercular subdural empyema: A case report and review of literature. J Pediatr Neurosci [serial online] 2020 [cited 2020 Nov 24];15:266-9. Available from: https://www.pediatricneurosciences.com/text.asp?2020/15/3/266/300038





   Introduction Top


Intracranial tuberculous subdural empyema is extremely rare manifestation of central nervous system tuberculosis (CNS TB) in pediatric population.[1] Only few cases have been reported in English literature.[1],[2],[3],[4] Timely diagnosis and early initiation of treatment are crucial to reduce mortality and morbidity associated with CNS TB in children. The early diagnosis of intracranial TB is challenging due to nonspecific clinical features and difficulty in getting pus or granulation tissue for microbiological or histopathological diagnosis of TB.[5] We describe one child with multiple intracranial extraaxial pus collections in subdural space in anterior interhemispheric fissure and in frontoparietal convexity who was effectively treated with surgery and anti-tuberculous therapy (ATT).


   Case History Top


A 13-year-old boy presented in emergency of our institute with seizures, headache, vomiting, altered sensorium, and weakness of right upper and lower limbs. He had three episodes of generalized tonic-clonic seizures (GTCS) in the last 1 month, fever, headache, vomiting, and weakness of right half of body for the last 7 days. On examination, pallor was present and he was febrile, drowsy, irritable, and with right hemiparesis.

Neuroimaging revealed left frontal convexity and anterior hemispheric fissure subdural space collection. Computerized tomography (CT) scan of skull with contrast left frontal interhemispheric parasagittal subdural hypodensity in anterior falx reion with periesional edema and effacement of sulci and gyri in anterior frontal region with peripheral enhancing lesion in the left frontoparietal region [Figure 1]A and [Figure 1]B. Magnetic resonance imaging (MRI) of the brain with contrast also suggested multiple intracranial extraaxial subdural collections with peripheral enhancement and associated edema and mass effect. Maxillary sinus of the right side showed hypointense collection with enhancing mucosa [Figure 1]C.
Figure 1: (A and B) CT scan of brain with contrast showing intracranial multiple extraaxial hypodense collections with peripheral enhancement with edema with gyral enhancement and mass effect. (C) MRI of the brain with contrast (T1 axial) image showing anterior interhemisheric parasagittal extraaxial hypointense collection with peripheral enhancement

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Provisional diagnosis of intracranial multiple pyogenic subdural empyema was made as patient had high-grade fever, history of frequent episodes of sinusitis, no history of tubercular contact, no past history of pulmonary Koch’s, and normal chest roentgenogram. Blood counts showed a polymorphonuclear leukocytosis and CT and MRI of the brain showed evidence of associated maxillary sinusitis.

Antiepileptic and cerebral decongestants were started in appropriate dosages. A left frontal burr hole was made and dural was opened under general anesthesia. Subdural pus was evacuated [Figure 2].
Figure 2: Perioperative image showing flow of pus from the burr hole

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Approximately 50mL of thick pus came out under pressure. Pus was sent for Ziehl-Neelsen staining (ZN stain), India ink preparation, gram staining, and culture. ZN stain did not reveal acid-fast bacilli. The pus did not grow any microorganism on Gram stain or culture. Initially, a broad-spectrum injectable antibiotic (ceftriaxone) and one aminoglycoside (amikacin) were given along with other symptomatic and supportive measures, but the patient did not show any significant clinical improvement.

So, the patient was again assessed with CT scan of the brain which showed persistence of the subdural empyema and associated brain edema [Figure 3].
Figure 3: Postoperative CT scan of skull showing anterior interhemispheric subdural collection with perilesional edema

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As the patient had already received broad-spectrum antibiotic and did not show significant clinical and neuroradiological improvement, the possibility of tubercular empyema was strongly considered. So, injections ceftriaxone and amikacin were stopped and empirical ATT comprising of streptomycin, isoniazid, rifampicin, and ethambutol, in appropriate dosages, was started. Unfortunately in the majority of CNS TB cases the surgical samples do not reveal any evidence of tubercular bacilli in CSF, pus, and granulation tissue of other pathological sample. It was a judicious decision to start empirical ATT without waiting for the results of Mantoux and gene expert and Mycobacterium culture. The patient improved significantly after starting of empirical ATT. Subsequent CT scan of the brain did not show any residual lesion [Figure 4]. It is further emphasized that although culture is considered the gold standard for the diagnosis of TB, but in CNS TB the clinical presentation and neuroradiology are becoming an important guide for starting empirical ATT and subsequently close observation of the patient for response to ATT.
Figure 4: CT scan of the skull with contrast showing burr hole site and no residual lesion in interhemispheric fissure and frontal convexity

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At the end of 2 months of the intensive phase of ATT course, the child was well with no evidence of any intracranial pathology.


   Discussion Top


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.[6] Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas.[3] Tuberculous brain abscess and subdural empyema are extremely rare manifestations of central nervous system tuberculosis.[4] Subdural empyema or collection of pus in the subdural space is mostly pyogenic.[4] Intracranial tubercular subdural empyema is very rare in pediatric population.[1],[2],[3],[4]

Various diagnostic modalities and treatment options are available for managing CNS TB. But, the 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.[5]

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 neuroradiology 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 multidrug-resistant (MDR) CNS TB cases, stereotaxy or ultrasonogram (USG) or CT-guided biopsy helps in obtaining the pathological sample and drug sensitivity.[5]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Banerjee AD, Pandey P, Ambekar S, Chandramouli BA Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis: a case report and review of literature. Child Nerv System 2010;26:117-20.  Back to cited text no. 1
    
2.
Cayli SR, Onal C, Koçak A, Onmuş SH, Tekiner A An unusual presentation of neurotuberculosis: subdural empyema. Case report. J Neurosurg 2001;94:988-91.  Back to cited text no. 2
    
3.
van Dellen A, Nadvi SS, Nathoo N, Ramdial PK Intracranial tuberculous subdural empyema: case report. Neurosurgery 1998;43:370-3.  Back to cited text no. 3
    
4.
Vijayakumar B, Sarin K, Mohan G Tuberculous brain abscess and subdural empyema in an immunocompetent child: significance of AFB staining in aspirated pus. Ann Indian Acad Neurol 2012;15:130-3.  Back to cited text no. 4
    
5.
Gautam VKS, Khurana S, Singh R Diagnostic and therapeutic challenges in the surgical management of CNS tuberculosis. Int J Med Health Sci 2013;2:161-9.  Back to cited text no. 5
    
6.
Global tuberculosis report 2017. WHO. Available from: http://www.who.int. [Last accessed on 2018 Jul 8].  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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