Tuberculous brain abscess

Case report

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✓ An abscess was removed from the left occipital region in a 73-year-old woman with no previous history of tuberculosis. The patient later died from aspiration bronchopneumonia. Autopsy revealed a basilar tuberculous meningitis and miliary tuberculosis in the peritracheal lymphatic glands, the liver, the spleen, and in isolated areas of the lungs. No chronic tuberculous foci were noted in any area. Including this case, only 18 instances of tuberculous abscess have been reported.

Tuberculous meningitis is the most frequent form of bacillary localization in the central nervous system (CNS). Tuberculomas of the CNS constitute 25% of the lesions occupying the brain in African and Asian countries,6,7,15,18 in contrast to approximately 1% in the United States and in European countries.17 Tuberculous abscess of the brain is rare, and the pathogenesis is not completely clear. Adams,1 in 1896, was probably the first to refer to this clinical entity. Thiébaut and Philippides20 pointed out the necessity of distinguishing tuberculous abscess of the brain from tuberculomas, which have a liquefied center. However, there are few reports of cerebral tuberculous abscesses that have been properly verified. In a series of 201 tuberculomas, Arseni2 encountered only one that contained pus. Higazi11 described a similar lesion but gave very few data. Dastur and Desai7 found eight lesions with pus or a pus-like substance among 107 tuberculomas, but no exact data were given about their characteristics. Mathai and Chandy13 found one case among 143 tuberculomas. Sinh, et al.,18 found three such lesions among 70 tuberculomas, but in two of the three cases no attempt was made to look for the tubercle bacillus. More recently, Bannister3 described a case of tuberculous brain abscess with identification of tubercle bacilli in the pus. Dinakar and Rao10 reported another case with identification of the bacillus by histological study.

Whitener21 presented another case of tuberculous cerebral abscess, and made an exhaustive search of the world literature, finding 57 cases designated as tuberculous cerebral abscess, but only 16 fulfilled his rigid criteria based on the microscopic, histological, and bacteriological aspects. He discussed the theories of the pathogenesis and made a clinical analysis of the previous 16 cases.

This paper presents the autopsy findings of a new case of tuberculous cerebral abscess in a woman without previous history of tuberculosis. The abscess was excised, and a miliary dissemination to other parts of the body was discovered later at autopsy.

Case Report

This 73-year-old woman noted the onset of dizziness, frontoparietal headaches, and ringing in the ears in early December, 1975. Ten days later, she presented with a mild right hemiparesis, and slight mental confusion.

Examination. General physical examination was normal. The neurological examination demonstrated mental confusion alternating with psychomotor agitation and aphasia. She had Grade II papilledema, and right hemiparesis, predominantly of the right arm, with a positive right Babinski sign. There were no meningeal signs. Blood count showed 10,000 leukocytes, 70% segmented polymorphonuclear leukocytes, 28% lymphocytes, and 2% band forms. Bleeding, coagulation, and prothrombin times were normal. The sedimentation rate was not determined on admission. Urinalysis was normal. The electroencephalogram showed a focal lesion in the left rolandic-temporal cortex.

Skull films were normal and the admission chest film did not demonstrate any pathology. A radionuclide brain scan showed a pathological accumulation of radioactive material in the left occipital region. Echoencephalography revealed a 5-mm deviation of the midline to the right. Left carotid angiogram demonstrated a forward displacement of the pericallosal and the Sylvian groups (Fig. 1). There was also a left-to-right displacement of the thalamostriate veins. Three days after admission, the patient was transferred to the neurosurgical service because of progressive neurological deterioration.

Fig. 1.
Fig. 1.

Left carotid angiogram, anteroposterior (left) and lateral (right) views, showing the arterial displacement of the anterior cerebral artery and of the Sylvian group.

Operation. On January 11, 1976, a left parieto-occipital craniotomy was performed. The parietal and occipital convolutions appeared pale and distended, and yellowish pus was aspirated through a subcortical puncture and sent to the laboratory. The cortex was opened and the abscess capsule, which measured 3 × 1 × 2 cm, was excised en bloc. Culture of the pus proved the presence of Mycobacterium tuberculosis hominis, sensitive to rifampicine (rifamycin), isonicotinic acid hydrazide (INH), and ethambutol.

Pathological Examination. Histological examination of the capsule demonstrated an internal necrotic zone with polymorphonuclear leukocytes. Outside this zone there was a granular reaction, rich in macrophages, of which some had foamy cytoplasm and others had an epithelioid appearance, with a tendency to form clumps. There were a few giant cells of the Langhans type, abundant lymphocytes, and a few plasmatic cells. These cell types were preferentially arranged in the adventitia of the vessels and in the area around them. The Ziehl-Neelsen stain showed acid-fast bacilli, some of which had been phagocytized by the foamy cytoplasmic macrophages. In the external zone, there was a glial reaction (Fig. 2).

Fig. 2
Fig. 2

Photomicrographs of the abscess. Left: The cavity of the abscess and inner wall. H & E, × 200 Right: View of the abscess wall showing a zone of polymorphonuclear leukocytes within the necrosis surrounded by a layer of histiocytes. There is no tuberculous granular tissue. H & E, × 500.

Postoperative Course. The patient's hemiparesis, aphasia, and level of consciousness improved after the operation. She was treated with rifampicine, INH, and ethambutol. On January 30, 1976, she experienced fever, a decreased level of consciousness, and a worsening of the right hemiparesis. There was no neck rigidity. Two cerebrospinal fluid (CSF) studies demonstrated glucose levels of 30 and 37 mg/100 ml; total protein content of 166 and 174 mg/100 ml; and 30 and 60 white cells, respectively. Cultures of the CSF were negative. The blood count showed 7500 white cells, 57% polymorphonuclear cells, 10% band forms, 30% lymphocytes, and 3% monocytes. Sedimentation rate was 48 mm in the 1st hour. Blood urea nitrogen and blood glucose were normal, and a chest film showed no evidence of active tuberculosis.

A repeat left carotid angiogram demonstrated signs of a space-occupying mass at the previous site. On February 13, 1976, the original flap was re-elevated and a zone of the right occipital lobe with areas of gliosis mixed with pockets of pus was excised. The histological and bacteriological studies were identical to those of the earlier specimen. The patient did not improve after the operation and died 10 days later from aspiration bronchopneumonia.

Postmortem Examination. The autopsy showed a basal acute meningitis with a large quantity of bacilli. Foci of pus and large zones of gliosis were seen at the operative site. In the rest of the parenchyma, multiple cortical foci of recent necrosis were found secondary to intravascular coagulation. In addition, there were foci of suppurative aspiration bronchopneumonia, thrombotic microangiopathy in glomerular capillaries, isolated miliary tubercles in the lungs, and disseminated tubercles in the lymphatic ganglia of the hilar portion of the lungs, in the liver, and in the spleen.

Discussion
Diagnosis of Tuberculous Abscess

This patient represents a case of tuberculous abscess diagnosed after surgery using strict criteria. In this patient, there had been no previous tuberculous involvement, and there was neither clinical nor radiological evidence of active tuberculosis. At postmortem examination an acute dissemination was discovered, but no chronic tuberculous foci were found. These findings led us to believe that the two operations had provoked the hematogenous dissemination which caused the recurrence of miliary tuberculosis. Tubercle bacilli can be carried to the brain by blood from the lungs;16 however, in this case there was neither clinical nor radiological evidence of any pulmonary lesion.

Bannister3 proposed that, in the absence of active tuberculous foci elsewhere in the body, the presence of small, inactive, calcified lesions in the lungs could act as a source of infection for a tuberculous cerebral abscess. Rab, et al.,14 reported a similar case that appeared 1 year after the miliary pulmonary tuberculosis was healed. Whitener21 established the following rigid anatomical, histological, and bacteriological criteria which served as a basis for the selection of his 16 cases: 1) macroscopic evidence of a cavity with pus in the center; 2) the existence of an inflammatory reaction in the wall of the abscess, composed predominantly of granular vascular tissue with acute and chronic inflammatory cells, especially polymorphonuclear leukocytes; and 3) positive culture of Mycobacterium tuberculosis or demonstration of acid-fast bacilli in the pus or in the wall of the abscess.

The signs and symptoms of cerebral abscess in the 18 cases reported to date are as follows: focal neurological deficit, 71%; headache, 47%; fever, 46%; seizures, 35%; mental alterations, 24%; and neck rigidity, 17%. The period between onset and presentation ranges between 1 and 4 weeks.21 Our patient met most of these guidelines; however, she did not have fever, rigidity of the neck, or seizures. In agreement with the findings of Whitener,21 the glucose in the CSF was low in our patient, there were few cells, and the cultures were negative on two occasions.

We would like to stress the following points: 1) In the differential diagnosis of purulent abscess, it is important to test for tuberculosis in other parts of the body; 2) tuberculomas appear at earlier ages than do tuberculous abscesses, they have a slower evolution, and in those cases the glucose in the CSF remains within normal limits;17 3) neck rigidity and the decrease of glucose in the CSF are regular and notable findings in tuberculous meningitis;19 4) the patient's reaction to tubercular infection depends on the state of individual immunity, on the extension of the tubercular infection, on the type of tissue infected, and on the medical treatment given;9 5) the patient's nutritional status is important: deficiencies of vitamins A, D, and C increase the severity of the tuberculous infection.12

Pathogenesis, Treatment, and Prognosis

The inoculation of a large number of bacilli in a hypersensitive individual provokes an exaggerated exudative phase with massive caseation. The softening of the caseous material with an influx of polymorphonuclear leukocytes can form pure pus.4,16 Dannenberg and Sugimoto5 proved the participation of certain enzymes (proteinases, nucleases, and lipases) in the liquefaction of the caseous material. Whitener21 sought an explanation for the rare histological features presented by the tuberculous focus with infiltration of polymorphonuclear leukocytes, and thought that the formation of pus and the great multiplication of tubercle bacilli might be a possible pathogenic theory.

The treatment of tuberculous cerebral abscess should include the excision of the abscess and antituberculous chemotherapy. Therapy must begin as soon as the diagnosis is made, with a combination of ethambutol, INH, and rifampicine, because these drugs cross the blood-brain barrier readily. This treatment should be given for 1 to 2 years. Recurrences of the cerebral abscesses have been reported upon termination and even during administration of the medication.8,21

The preoperative diagnosis of cerebral tuberculous abscess presents difficulties, because its clinical and radiological manifestations are similar to those of purulent cerebral abscesses and tuberculomas. The recent incorporation of computerized tomography diminishes the possibility of error to a certain extent. A correct preoperative diagnosis and administration of specific chemotherapy can reduce the high mortality, which is around 40% even with chemotherapy. Evidence of tuberculosis, such as positive cultures from the CSF or positive radiological findings, along with a positive family history, could assist an early diagnosis.

References

  • 1.

    Adams SS: Tubercular abscess of the brain. Arch Pediatr 13:6076091896Adams SS: Tubercular abscess of the brain. Arch Pediatr 13:

  • 2.

    Arseni C: Two hundred and one cases of intracranial tuberculoma surgically treated. J Neurol Neurosurg Psychiatry 21:3083101958Arseni C: Two hundred and one cases of intracranial tuberculoma surgically treated. J Neurol Neurosurg Psychiatry 21:

  • 3.

    Bannister CM: A tuberculous abscess of the brain. Case report. J Neurosurg 33:2032061970Bannister CM: A tuberculous abscess of the brain. Case report. J Neurosurg 33:

  • 4.

    Canetti G: The Tubercle Bacillus in the Pulmonary Lesion of Man; Histobacteriology and its Bearing on the Therapy of Pulmonary Tuberculosis. New York: Springer1955226 ppCanetti G: The Tubercle Bacillus in the Pulmonary Lesion of Man; Histobacteriology and its Bearing on the Therapy of Pulmonary Tuberculosis.

  • 5.

    Dannenberg AM JrSugimoto M: Liquefaction of caseous foci in tuberculosis. Am Rev Respir Dis 113:2572591976Am Rev Respir Dis 113:

  • 6.

    Dastur DKIyer CGS: Pathological analysis of 450 intra-cranial space-occupying lesions. Indian J Cancer 3:1051151966Indian J Cancer 3:

  • 7.

    Dastur HMDesai AD: A comparative study of brain tuberculomas and gliomas based upon 107 case records of each. Brain 88:3753961965Brain 88:

  • 8.

    Descuns PGarré HPascalis G: Abcès froids miliaries du cerveau de cervelet et du tronc cérébral chez un tuberculeux traité par antibiotiques. Rev Otoneuroophtalmol 28:2502551956Rev Otoneuroophtalmol 28:

  • 9.

    Des Prez RM: Diseases due to mycobacteria. Section 227: Tuberculosis. Section 236: Tuberculous meningitisBeeson PBMcDermott W (eds): Textbook of Medicineed 14. Philadelphia: WB Saunders19751393405

  • 10.

    Dinakar IRao SB: Tuberculous abscess of the cerebellum. Int Surg 55:2772791971Int Surg 55:

  • 11.

    Higazi I: Tuberculoma of the brain. A clinical and angiographic study. J Neurosurg 20:3783861963Higazi I: Tuberculoma of the brain. A clinical and angiographic study. J Neurosurg 20:

  • 12.

    Jose DGGood RA: Immune resistance and malnutrition. Lancet 1:3141972 (Letter)Lancet 1:

  • 13.

    Mathai KVChandy J: Tuberculous infections of the nervous system. Clin Neurosurg 14:1451771967Clin Neurosurg 14:

  • 14.

    Rab SMBhatti IHGhani ATuberculous brain abscess. Case report. J Neurosurg 43:4904941975J Neurosurg 43:

  • 15.

    Ramamurthi BVaradarajan MG: Diagnosis of tuberculomas of the brain. Clinical and radiological correlation. J Neurosurg 18:171961J Neurosurg 18:

  • 16.

    Rich AR: The Pathogenesis of Tuberculosised 2. Springfield, Ill: Charles C Thomas1951Rich AR:

  • 17.

    Sibley WAO'Brien JL: Intracranial tuberculomas. A review of clinical features and treatment. Neurology 6:1571651956Neurology 6:

  • 18.

    Sinh GPandya SKDastur DK: Pathogenesis of unusual intracranial tuberculomas and tuberculous spaceoccupying lesions. J Neurosurg 29:1491591968J Neurosurg 29:

  • 19.

    Tahernia AC: Tuberculous meningitis. Modern diagnosis, treatment and prognosis, as exemplified in 38 cases in southern Iran. Clin Pediatr 6:1731771967Clin Pediatr 6:

  • 20.

    Thiébaut FPhilippides D: Tubercules de l'encephale en forme d'abces. Neurochirurgie 6:3773781960Neurochirurgie 6:

  • 21.

    Whitener DR: Tuberculous brain abscess. Report of a case and review of the literature. Arch Neurol 35:1481551978Whitener DR: Tuberculous brain abscess. Report of a case and review of the literature. Arch Neurol 35:

Article Information

Address reprint requests to: C. Vázquez Herrero, M.D., Colegio Mayor “Cesar Carlos,” Calle Ramon Menendez Pidal s/n, Cuidad Universitaria, Madrid 3, Spain.

© AANS, except where prohibited by US copyright law."

Headings

Figures

  • View in gallery

    Left carotid angiogram, anteroposterior (left) and lateral (right) views, showing the arterial displacement of the anterior cerebral artery and of the Sylvian group.

  • View in gallery

    Photomicrographs of the abscess. Left: The cavity of the abscess and inner wall. H & E, × 200 Right: View of the abscess wall showing a zone of polymorphonuclear leukocytes within the necrosis surrounded by a layer of histiocytes. There is no tuberculous granular tissue. H & E, × 500.

References

1.

Adams SS: Tubercular abscess of the brain. Arch Pediatr 13:6076091896Adams SS: Tubercular abscess of the brain. Arch Pediatr 13:

2.

Arseni C: Two hundred and one cases of intracranial tuberculoma surgically treated. J Neurol Neurosurg Psychiatry 21:3083101958Arseni C: Two hundred and one cases of intracranial tuberculoma surgically treated. J Neurol Neurosurg Psychiatry 21:

3.

Bannister CM: A tuberculous abscess of the brain. Case report. J Neurosurg 33:2032061970Bannister CM: A tuberculous abscess of the brain. Case report. J Neurosurg 33:

4.

Canetti G: The Tubercle Bacillus in the Pulmonary Lesion of Man; Histobacteriology and its Bearing on the Therapy of Pulmonary Tuberculosis. New York: Springer1955226 ppCanetti G: The Tubercle Bacillus in the Pulmonary Lesion of Man; Histobacteriology and its Bearing on the Therapy of Pulmonary Tuberculosis.

5.

Dannenberg AM JrSugimoto M: Liquefaction of caseous foci in tuberculosis. Am Rev Respir Dis 113:2572591976Am Rev Respir Dis 113:

6.

Dastur DKIyer CGS: Pathological analysis of 450 intra-cranial space-occupying lesions. Indian J Cancer 3:1051151966Indian J Cancer 3:

7.

Dastur HMDesai AD: A comparative study of brain tuberculomas and gliomas based upon 107 case records of each. Brain 88:3753961965Brain 88:

8.

Descuns PGarré HPascalis G: Abcès froids miliaries du cerveau de cervelet et du tronc cérébral chez un tuberculeux traité par antibiotiques. Rev Otoneuroophtalmol 28:2502551956Rev Otoneuroophtalmol 28:

9.

Des Prez RM: Diseases due to mycobacteria. Section 227: Tuberculosis. Section 236: Tuberculous meningitisBeeson PBMcDermott W (eds): Textbook of Medicineed 14. Philadelphia: WB Saunders19751393405

10.

Dinakar IRao SB: Tuberculous abscess of the cerebellum. Int Surg 55:2772791971Int Surg 55:

11.

Higazi I: Tuberculoma of the brain. A clinical and angiographic study. J Neurosurg 20:3783861963Higazi I: Tuberculoma of the brain. A clinical and angiographic study. J Neurosurg 20:

12.

Jose DGGood RA: Immune resistance and malnutrition. Lancet 1:3141972 (Letter)Lancet 1:

13.

Mathai KVChandy J: Tuberculous infections of the nervous system. Clin Neurosurg 14:1451771967Clin Neurosurg 14:

14.

Rab SMBhatti IHGhani ATuberculous brain abscess. Case report. J Neurosurg 43:4904941975J Neurosurg 43:

15.

Ramamurthi BVaradarajan MG: Diagnosis of tuberculomas of the brain. Clinical and radiological correlation. J Neurosurg 18:171961J Neurosurg 18:

16.

Rich AR: The Pathogenesis of Tuberculosised 2. Springfield, Ill: Charles C Thomas1951Rich AR:

17.

Sibley WAO'Brien JL: Intracranial tuberculomas. A review of clinical features and treatment. Neurology 6:1571651956Neurology 6:

18.

Sinh GPandya SKDastur DK: Pathogenesis of unusual intracranial tuberculomas and tuberculous spaceoccupying lesions. J Neurosurg 29:1491591968J Neurosurg 29:

19.

Tahernia AC: Tuberculous meningitis. Modern diagnosis, treatment and prognosis, as exemplified in 38 cases in southern Iran. Clin Pediatr 6:1731771967Clin Pediatr 6:

20.

Thiébaut FPhilippides D: Tubercules de l'encephale en forme d'abces. Neurochirurgie 6:3773781960Neurochirurgie 6:

21.

Whitener DR: Tuberculous brain abscess. Report of a case and review of the literature. Arch Neurol 35:1481551978Whitener DR: Tuberculous brain abscess. Report of a case and review of the literature. Arch Neurol 35:

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