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| CASE REPORT |
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| Year : 2020 | Volume
: 5
| Issue : 2 | Page : 216-218 |
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A rare case of calvarial tuberculosis
Binoy Damodar Thavara, Bijukrishnan Rajagopalawarrier
Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| Date of Submission | 15-Apr-2020 |
| Date of Decision | 22-Jun-2020 |
| Date of Acceptance | 16-Jul-2020 |
| Date of Web Publication | 18-Dec-2020 |
Correspondence Address:
Dr. Binoy Damodar Thavara
Department of Neurosurgery, Government Medical College, Thrissur - 680 596, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/bjhs.bjhs_61_19
Calvarial tuberculosis (TB) is a rare entity forming 0.2%–1.3% of skeletal TB. The authors report a case of 45-year-old male presented with a history of fall under the influence of alcohol. Two cut lacerated wounds were noted in the right frontotemporal region. Computed tomography (CT) showed right frontal hematoma with brain edema. The patient underwent right frontal craniotomy and evacuation of the hematoma. Scalp wounds were healed. After 3 months, the patient presented with a pus discharging sinus from one of the previous cut lacerated wound. No growth was found in the pus culture. It was treated with dressing and antibiotics. Due to the persistence of the pus, CT scan was taken after 7 months, which showed osteomyelitis of right frontal bone. Right frontal osteomyelitic bone, along with overlying subgaleal tissue, was excised. Histopathological examination of the bone showed focal inflammatory cell infiltration. Overlying tissue on hematoxylin and eosin stain showed caseating epithelioid cell granuloma surrounded by lymphocytes and Langhans multinucleate giant cell suggestive of TB. The patient recovered after 1 year of treatment with antitubercular treatment. In country like India, TB can present in any atypical locations. Persistent pus discharge from the scalp following surgery or trauma should raise the suspicion of TB. Persistent pus discharge not responding to conventional therapy should be investigated for TB. All the excised osteomyelitic skull bone should be sent for histopathological examination.
Keywords: Antitubercular treatment, calvarial tuberculosis, computed tomography
How to cite this article:
Thavara BD, Rajagopalawarrier B. A rare case of calvarial tuberculosis. BLDE Univ J Health Sci 2020;5:216-8 |
Calvarial tuberculosis (TB) is a rare entity forming 0.2%–1.3% of skeletal TB.[1] Only a few case series of skull TB have been reported. Diyora et al., reported a case series of 11 patients with calvarial TB. The most common presenting features were scalp swelling, discharging sinus, and pain. Computed tomography (CT) scan of the head showed punched out the bony defect, with a peripherally enhancing extradural collection in most of the cases. Ten patients underwent surgical excision. A high index of suspicion of TB is required for early diagnosis of calvarial TB. Surgery and antituberculous therapy remain the main treatment.[2]
The authors report a rare case of calvarial TB, which was developed following craniotomy for head injury.
| Case Report | |  |
A 45-year-old male presented with a history of fall under the influence of alcohol. On examination, Glasgow Coma Scale (GCS) was E4V4M6 (E-Eye, V-Vocal, M-Motor) with left hemiparesis of Medical Research Council Grade 4. Two cut lacerated wounds were noted in the right frontotemporal region. CT scan showed right frontal hematoma with brain edema [Figure 1]. There was no history of TB or contact with TB. The chest X-ray and ultrasound abdomen were normal. The patient underwent right frontal craniotomy and evacuation of hematoma. Two cut lacerated scalp wounds were sutured. The patient recovered in the postoperative period with normal GCS and grade 5 power of all limbs. Scalp wounds were healed. After 3 months, the patient presented with one pus discharging sinus from one of the previous cut lacerated wound [Figure 2]. No bacterial growth was found in the pus culture. It was treated with dressing and antibiotics. Due to the persistence of the pus, CT scan was taken after 7 months. CT scan showed osteomyelitis of the right frontal bone [Figure 3]. Chest X-ray was normal. There was no lymphadenopathy. The patient underwent surgery, and right frontal osteomyelitic bone along with overlying subgaleal tissue was excised. Wound was closed in layers. The surgical scar healed well.
Histopathological examination of the bone showed focal inflammatory cell infiltration. Overlying tissue on hematoxylin and eosin (H and E) stain showed caseating epithelioid cell granuloma surrounded by lymphocytes and Langhans multinucleate giant cell suggestive of TB [Figure 4]. Gomori's Methenamine silver stain and Periodic Acid–Schiff stain showed no organisms. The patient recovered after 1 year of treatment with antitubercular treatment (ATT). | Figure 1: Computed tomography showing right frontal hematoma with brain edema
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 | Figure 3: Computed tomography scan showing osteomyelitis of the right frontal bone
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| Discussion | | |
Calvarial TB is a rare manifestation of TB. Sridharan and Balasubramania described a case of a 20-year-old female patient presented with headache and persistent discharging sinus from the left frontal scalp. There was no history of trauma. CT scan showed a biconvex left frontal hypodense extradural lesion and osteolytic overlying bone with soft tissue swelling of the scalp. The patient underwent surgical excision of the involved part. Histopathological examination confirmed the diagnosis of TB. Calvarial TB should be included in the differential diagnosis of the osteolytic lesions of the skull with discharging sinus. A high degree of suspicion is warranted in managing such cases.[3]
Homagain et al., described a 28-year-old male presented with a history of headache and progressively increasing swelling over the right frontal region of the skull. There was no history of trauma or weight loss. CT scan showed erosion of right frontal bone with the extra-axial collection and soft tissue swelling in the adjacent scalp. The patient underwent surgery. The underlying bone was soft with multiple pores and pus exudation from bone underneath. The pus was drained from extradural and subgaleal space. Histopathological examination was consistent with TB. The patient recovered after treatment with ATT. Calvarial TB can often be misdiagnosed as infectious osteomyelitis if culture and histopathological examination are not performed. A high degree of suspicion is required for prompt diagnosis and management.[4]
Primary calvarial TB though rare, continues to be seen in neurosurgical practice. Datta et al. presented three cases of calvarial TB. All the cases occurred de novo in young, otherwise healthy individuals, hailing from good socioeconomic backgrounds and without any history or contact history with TB patients. The first case presented with a spontaneous painless swelling on her left forehead. CT head suggested the possibility of a subacute to chronic osteomyelitis of the frontal bone with an associated extradural and a subcutaneous soft tissue component. She was taken up for surgery, and the biopsy of the debrided tissues revealed chronic granulomatous lesion suggestive of TB. The second case presented with a boggy, fluctuant swelling on the right occipital region. Magnetic resonance imaging (MRI) Brain showed a collection in the right parieto-occipital region with focal erosion in the outer cortex. The patient underwent surgery. Pus and granulation tissue showed no growth of organisms. Gene XPERT mycobacterium tuberculosis (MTB) was positive for MTB. The histopathological examination reported it as chronic inflammatory tissue with the presence of epitheloid granulomas. Third case presented with slowly growing swelling in the left temporoparietal region over 2 months. There was no history of any trauma, fever, or weight loss. CT and MRI brain revealed focal bone destruction of the parietal bone with overlying subcutaneous and subjacent epidural collections. He was taken up for surgery. Histopathology revealed epithelioid granulomas. Gene XPERT MTB was positive for MTB. They concluded that a high index of suspicion and prompt management is required as the threat of serious intracranial complications does exist. Combined treatment with surgery and long-term ATT helps to cure the disease.[5]
In our case patient was not having a history of TB or contact with TB. The patient had two lacerated scalp wounds along with head injury. TB was developed at the site of surgery. TB bacilli were inoculated either during surgery or through the lacerated wound. Immunosuppressed status due to chronic alcoholism had contributed to TB. The patient recovered after starting ATT.
| Conclusion | | |
In country like India, TB can present in any atypical location. Persistent pus discharge from the scalp following surgery or trauma should raise the suspicion of TB. Persistent pus discharge, which is not responding to conventional therapy, should be investigated for TB. All the excised osteomyelitic skull bone should be sent for histopathological examination.
Informed consent
The authors certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal their identity.
Acknowledgments
This study is conducted with the help of Departments of Neurosurgery and Pathology of Government Medical College, Thrissur, Kerala, India.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Singh P, Goyal A, Tanwar A, Sharma S. Unusual presentation of calvarial tuberculosis masquerading as a cutaneous neoplasm: Diagnosis by fine needle aspiration cytology. Ann Trop Med Public Health 2013;6:347-9.  [Full text] |
| 2. | Diyora B, Kumar R, Modgi R, Sharma A. Calvarial tuberculosis: A report of eleven patients. Neurol India 2009;57:607-12. [ PUBMED] [Full text] |
| 3. | Sridharan S, Balasubramanian D. Primary calvarial tuberculosis. Surg Neurol Int 2017;8:126. [Full text] |
| 4. | Homagain S, Shrestha S, Sah S, Sedain G. Calvarial tuberculosis: A diagnostic quandary: A case report. JNMA J Nepal Med Assoc 2019;57:198-201. |
| 5. | Datta SGS, Bhatnagar V, Pan S, Mehta R, Sharma C. Primary calvarial tuberculosis: A report of three cases. Br J Neurosurg 2019;33:196-201. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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