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IMAGES IN NEUROLOGY
Year : 2009  |  Volume : 12  |  Issue : 3  |  Page : 195-196
 

Chronic epidural intracranial actinomycosis: A rare case


1 Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry - 605 006, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry - 605 006, India

Date of Submission09-Nov-2008
Date of Decision25-Jan-2009
Date of Acceptance05-Jul-2009
Date of Web Publication8-Oct-2009

Correspondence Address:
S K Narayan
Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.56324

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How to cite this article:
Narayan S K, Swaroop A, Jayanthi S. Chronic epidural intracranial actinomycosis: A rare case. Ann Indian Acad Neurol 2009;12:195-6

How to cite this URL:
Narayan S K, Swaroop A, Jayanthi S. Chronic epidural intracranial actinomycosis: A rare case. Ann Indian Acad Neurol [serial online] 2009 [cited 2019 May 24];12:195-6. Available from: http://www.annalsofian.org/text.asp?2009/12/3/195/56324


A 13-year-old boy presented with a healing ulcer over the vertex, a healed ulcer above the right eye [Figure 1]A, occasional fever, weight loss, diplopia, bilateral proptosis, lagophthalmos and bilateral mild facial palsy. In hospital, he developed left-sided focal seizures and symptoms and signs of raised intracranial pressure. The skull radiograph showed a thickened frontal vault, suggestive of chronic osteomyelitis [Figure 1]B. CT brain confirmed thickening of the skull vault over the right frontal region and revealed an epidural mass in the prefrontal region that was predominantly on the right side but crossed the midline and caused a mass effect, with midline shift to the left. Also present was massive white-matter edema, with effacement of the ipsilateral ventricle and enlargement of the contralateral one [Figure 1]C. A biopsy from the scalp lesion demonstrated granulation tissue, hematoxyphilic colonies, and gram positive filamentous rods, features that were diagnostic of actinomycosis [Figure 1]D. The boy recovered well withintravenous administration of crystalline penicillin and co-trimoxazole along with oral erythromycin for six weeks, followed by oral co-trimoxazole and erythromycin for six moths. The epidural mass and skull thickening, however, persisted.

Clinical features of chronic epidural lesions of the skull and spine can be subtle and treacherous. Signs, rather than the symptoms, of raised intracranial pressure often dominate. Spinal lesions may present earlier. Epidural mass lesions can be due to a variety of causes; these include (1) hematoma due to trauma, bleeding diathesis or venous sinus thrombosis; (2) malignant deposits from lymphoma, leukemia, multiple myeloma or chloroma; (3) chronic noninfectious granuloma due to sarcoidosis, eosinophilic granuloma, cholesteatoma, hypertrophic pachymeningitis, Wegener granulomatosis or cranial fascitis; (4) chronic infectious lesions, e.g., aspergillosis or tuberculosis (5); primary neoplasms like chondromas, chordoma, chondromyxoid fibroma, osteoblastoma, giant cell tumors of skull, Ewing sarcoma, congenital lipomatosis, histiocytosis and endometrial carcinoma.

Actinomycosis, a subacute or chronic granulomatous inflammatory disease, gives rise to suppuration, abscess formation and sinuses. The most common causative agent is Actinomycosis israeli, a gram-positive, acid-fast organism with some morphological resemblance to fungi. [1] Clinical forms include oro-cervico-facial (the commonest), thoracic, abdomino- pelvic, musculoskeletal and disseminated disease. The cerebral form is rare (< 5%) and may pose a diagnostic challenge, presenting as brain abscess (67%), meningitis/ meningoencephalitis (13%), actinomycetoma (7%), subdural empyema (6%) or epidural abscess (6%). Infection spreads by the hematogenous route from lung, oral cavity, abdomen or pelvis. [2],[3] Dense fibrosis, a pathological hallmark of actinomycosis, is usually minimal in a cerebral lesion, while features characteristic of the disease at anatomic sites elsewhere (such as draining sinuses and sulfur granules) are not seen with epidural lesions. Diagnosis is usually confirmed by biopsy. Penicillin and Erythromycin are effective against actinomyces while a closely related species, nocardia is sensitive to co-trimoxazole.

 
   References Top

1.M. Goodfellow. Actinomycetes In: Colle, Fraser, Marmion, Simmons, eds. Practical Medical Microbiology.14th edn India: Elsevier; 2006. p. 343-53.  Back to cited text no. 1      
2.Puzzilli F, Salvati M, Ruggeri A, Raco A, Bristot R, Bastianello S, et al. Intracranial actinomycosis in juvenile patients. Case report and review of the literature. Childs Nerv Syst 1998;14:463-6.  Back to cited text no. 2      
3.Soto-Hernαndez JL, Morales VA, Lara Giron JC, Balderrama Baρares J. Cranial epidural empyema with osteomyelitis caused by Actinomyces: CT and MRI appearance. Clin Imaging 1999;23;209-14.  Back to cited text no. 3      


    Figures

  [Figure 1]


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