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SHORT COMMUNICATION
Year : 2006  |  Volume : 9  |  Issue : 4  |  Page : 227-229
 

Calvarial tuberculosis: Review of six cases


Department of Neurosurgery, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi - 110 029, India

Correspondence Address:
Karam Chand
123, Anandkunj, Vikas Puri, New Delhi - 110 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.29205

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   Abstract 

Calvarial tuberculosis is a very rare entity scantily described in literature. It forms 0.2-1.3% of the bone tuberculosis. This is a rare entity even in the endemic areas. Primary calvarial tuberculosis with no evidence of tuberculosis is still rarer of these cases. We describe six cases of calvarial tuberculosis. The relevant clinicoradiological features and management are discussed. A high index of suspicion and awareness of this condition may lead to early diagnosis.


Keywords: Calvarial, tuberculosis


How to cite this article:
Awasthy N, Chand K, Singh A. Calvarial tuberculosis: Review of six cases. Ann Indian Acad Neurol 2006;9:227-9

How to cite this URL:
Awasthy N, Chand K, Singh A. Calvarial tuberculosis: Review of six cases. Ann Indian Acad Neurol [serial online] 2006 [cited 2019 Oct 17];9:227-9. Available from: http://www.annalsofian.org/text.asp?2006/9/4/227/29205


Tuberculosis of the skull (TBS) is a rare condition. The reported incidence of TB skull is 0.2-1.3% of all cases of skeletal tuberculosis.[1] The condition is rarely seen in infancy because of the small amount of cancellous bone in the skull.[2] This scantily described condition is being reviewed with reference to six cases observed at our institution.


   Materials and Methods Top


The study was conducted at a tertiary care center in Safdarjang Hospital, in the Department of Neurosurgery. This was a retrospective study. Study included all the patients presenting to the Neurosurgery Department, over a period of four years from March 2000 to February 2004. Study-group comprised of patients from 11 to 35 years of age. The data of these patients was analyzed in terms of their clinical presentation viz presenting symptoms, clinical examination and radiological features. Outcome of these patients was evaluated with respect to the therapeutic intervention in terms of conservative versus surgical intervention and compared with the existing literature.


   Results Top


A total of six subjects were admitted as case of TB skull in the neurosurgery ward. TBS was found to be of equal frequency in males and females with male to female ratio being 1:5 [Table - 1].

Scalp swelling and discharging sinus scalp were the commonest presenting symptoms observed in three patients followed by fever (two) and cough (one). Fluctuant scalp swelling with mild tenderness and discharging scalp sinus were observed in three patients. Restriction of chest movements and crepitations in the chest were observed in one patient each. None of the patient presented with any neurological deficit. All the six patients had positive mantoux test. Lytic lesions in the scalp were demonstrated in all six cases. Parietal bone was involved in three cases, frontal bone in two cases and occipital bone in one case. Patient with the occipital bone involvement had associated lesion of the anterior arch of  Atlas More Details (case 1). Chest X-ray had definitive evidence of the Koch in only one case (case 4). There was evidence of TB dactylitis in one patient (case6). CT scan demonstrated lytic lesions of bone in all the cases and large epidural collections in three cases [Figure - 1] and[Figure - 2]. There was no involvement of the underlying brain in any of the cases. Two cases showed large epidural collection with destruction of bone, underlying brain showed no abnormal signals (case 2, 3). Definitive tissue diagnosis in the form of tuberculous grannuloma was obtained in all the cases [Figure - 3].


   Discussion Top


Calvarial tuberculosis constitutes amongst a rare disorder even amongst the communities with high incidence of TB infection. This condition constitutes 0.1-3.7% of the skeletal tuberculosis.[1],[2],[3] It was first described by Reid in 1842.[2] The paucity of data from endemic areas has been attributed to: 1) chronic indolent asymptomatic lesions, 2) decreased awareness of the entity 3) earlier diagnosis and management of the primary disease. Fifty per cent of the cases of TBS are seen in children less than 10 years of age. This condition is rarely seen in infancy because of the paucity of cancellous bone in the infants. It is observed to affect both the sexes equally; this is unlike our observation although our sample size is too small to consider the evaluation.

Most cases occur secondary to pulmonary tuberculosis, although spread from the paranasal sinuses and orbits have been implicated. We had evidence for extracranial tuberculosis in two of the six patients. One of these had pulmonary Koch (case 4), while another had other osseous involvement in the form of tubercular dactylitis (case 6).

Lymphatic spread from a primary focus explains the rarity of the calvarial tuberculosis, as the skull is deficient in lymphatic supply. After their lodgment in the cancellous and diploe rich spaces, further development depends upon the virulence of the bacilli and the host resistance. The infection causes capillary obliteration and the replacement of the bony trabeculae by granulation tissue. Duramater is resistant to their penetration, thus explaining the incidence of extradural lesions in our case, as has been the observation of other authors.[2],[3]

Trauma has been implicated as a possible cause of skeletal tuberculosis.[2],[3],[4],[5] It is postulated that the inflammation at the site of trauma may harbor or attract mycobacterium rich inflammatory cells thus initiating the lesion.

Painless fluctuant swelling forms the commonest mode of presentation. Attachment to the skin, sinus formation and discolouration constitute the late features. Systemic features of infection such as weight loss, anorexia or those of the primary site of the lesion may be accompanied. Clinical observation of the intracranial extension such as hemiparesis, focal seizures, meningitis, papilledema and superior sinus thrombosis are scantily reported.[2],[6] None of these were observed in our cases. ESR is elevated in significant number, observed in 66% of our cases and mantoux test is usually positive as was positive in all of our patients. Other authors have reported similar observation.[1],[2],[3],[4],[5],[6] Features of radiograph of the skull is variable and nonspecific. A soft, fluctuant swelling of the scalp with erosion of the bone but without reactionary bone formation, is very characteristic of skeletal tuberculosis. A button sand or bone sequestrum may be observed in a few cases. Sclerosis is uncommon and its presence may indicate secondary infection. Radiological evidence of healing may be seen after two months of chemotherapy with new bone formation from the edges. CT usually shows peripherally enhancing, low-density extradural soft tissue masses on both sides of a lytic skull lesion. CT helps in the assessment of the extent of the bone destruction, scalp swelling and the degree of intracranial involvement. MRI imaging may lead to conclusive diagnosis. Proton density and T2 weighted images show a high signal intensity soft tissue mass within the defect in the bone. This may project into subgaleal and epidural spaces.[4] A definitive diagnosis can be made by the identification of the acid-fast bacilli from the smears or biopsy specimens. Acid fast bacilli may not be demonstrable in all the cases because of severe necrosis in some specimens. However correct diagnosis may be made on circumstantial clinical evidence.

The management includes predominately anti-tubercular therapy. Surgery is indicated for the following: diagnostic purposes, for removal of epidural collections or large sequestra and for patients with discharging sinuses, intracranial extensions or large collections of the caseating material causing mass effect or increase in the intracranial pressures. During treatment, radiological evidence of repair lags behind clinical evidence of improvement. Prognosis depends upon the gravity of the associated tubercular lesions and extent of the local disease.[7] It is generally good with complete resolution of the lesion.

Calvarial tuberculosis may present with isolated scalp swelling and the evidence of systemic tuberculosis evidence may not be present in all the cases. Mantoux and ESR serve as a good marker, especially when there is high index of suspicion. The radiological findings are a very valuable supportive tool in this regard. Definitive tissue diagnosis is valuable gold standard. Treatment modality is predominantly ATT medication, which may be given as per the W.H.O protocol. Surgical intervention may be considered for large epidural symptomatic cases or when there is associated superimposed infection.

 
   References Top

1.Unuvar E, Oguz F, Sadikoglu B, Sidal M, Ones U, Tetikkurt S. Calvarial tuberculosis. J Paediatr Child Health 1999;35:221-2.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Mukherjee KK, Kaushik R, Nada R, Khosla VK, Khandelwal N, Kak VK. Calvarial tuberculosis. Surg Neurol 2002;57:195-203.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Shahat AH, Rahman NU, Obaideen AM, Ahmed I, Zahman Au A. Cranial-epidural tuberculosis presenting as a scalp swelling. Surg Neurol 2004;61:464-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Raut AA, Nagar AM, Muzumdar D, Chawla AJ, Narlawar RS, Fattepurkar S, et al . Imaging features of calvarial tuberculosis: A study of 42 cases. AJNR Am J Neuroradiol 2004;25:409-14.  Back to cited text no. 4    
5.Sencer S, Sencer A, Aydin K, Hepgul K, Poyanli A, Minareci O. Related articles, imaging in tuberculosis of the skull and skull-base: Case report. Neuroradiology 2003;45:160-3.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Jadhav RN, Palande DA. Calvarial tuberculosis. Neurosurgery 1999;45:1345-50.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Malhotra R, Dinda AK, Bhan S. Tubercular osteitis of skull. Indian Pediatr 1993;30:1119-23.  Back to cited text no. 7  [PUBMED]  


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

    Tables

[Table - 1]


This article has been cited by
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2 Chronic tuberculous retropharyngeal abscess due to vertebral tuberculosis with associated calvarial tuberculosis. A case report
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