A van Dellen1, S S Nadvi, N Nathoo, P K Ramdial. 1. Department of Neurosurgery, University of Natal Medical School and Wentworth Hospital, Durban, South Africa.
Abstract
OBJECTIVE AND IMPORTANCE: Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema. CLINICAL PRESENTATION: A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling. INTERVENTION: The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy. CONCLUSION: The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.
OBJECTIVE AND IMPORTANCE: Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema. CLINICAL PRESENTATION: A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling. INTERVENTION: The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy. CONCLUSION: The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.