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Tuberculous
abscess (TA) of the brain is a very rare entity and is characterized
by encapsulated collection of pus without evidence of classical granulomas.
With the advent of AIDS, more cases are being diagnosed, but very few
have been reported in immunocompetent individuals. We present a case
of TA occurring in a 27-year-old immunocompetent, HIV negative patient.
At autopsy, the brain showed multiple encapsulated necrotic areas, 0.5
to 2 cm in diameter, which showed only caseous necrosis with total absence
of granulomatous reaction. AFB stain showed plenty of tubercle bacilli
and confirmed the diagnosis of tuberculous abscess. TA has to be differentiated
from the more commonly occurring tuberculomas. Most cases of tuberculomas
respond to multidrug therapy, while the definitive treatment in TA is
surgical excision with a complete course of antitubercular drug therapy. |
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INTRODUCTION |
The
most severe form of TB is that involving the central nervous system
(CNS). Mycobacterium tuberculosis affects the brain in various forms.
Tuberculous abscess is a very uncommon manifestation of CNS tuberculosis.1
The rarity and importance of identifying this entity prompted this case
report. We present a case of tuberculous abscess of the brain in a 27-year-old,
HIV negative, immunocompetent patient. |
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CASE
REPORT |
At
autopsy, the brain weighed 1.2 kg and was oedematous with tonsillar
prominence. The meninges were hazy. On cut sections of the brain, there
were multiple encapsulated necrotic areas 0.5 - 2 cm in diameter in
the cerebrum and cerebellum.
Microscopy revealed large areas of caseous necrosis surrounded by fibrous
wall with total absence of granulomatous reaction (Fig. 1). On AFB staining
large number of acid-fast bacilli were demonstrated (Fig. 2). Hence,
the diagnosis of TA was confirmed. There was no evidence of tuberculosis
in any other organs. |
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DISCUSSION |
 
Tuberculosis remains a serious health problem throughout the world causing
three million deaths per year and is currently estimated that 30% of
the world population is infected.1
The most severe form of tuberculosis is that involving the CNS. Epidural,
subdural abscesses, tuberculous meningitis, tuberculomas and tuberculous
abscess (TA) are the various manifestations of tuberculous involvement
of the CNS.
TAs of the brain are exceptionally rare.1 This entity was first described
by Evans and Rand in the early 1930s. Since then there have been few
isolated case reports of TAs.2-4 However, with the advent of HIV infection,
the incidence of TAs is on the rise.1 Very few cases of TA in immunocompetent
individuals have been reported in literature.5,6 In our case the patient
was HIV negative and immunocompetent.
In 1978, Whitener proposed the following criteria for establishing the
diagnosis of TA brain.7 |
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DISCUSSION |
IGoldenhars
syndrome is often used synonymously with “Oculo-Auriculo vertebral
spectrum” is a rare disorder that is present at birth.2 This disorders
is characterized by a wide spectrum of symptoms and physical features
that may vary greatly in range and severity from case to case.3 Approximately
10 to 33 per cent of affected individuals have such malformation on
both sides of the body with one side typically affected more than the
other. It is inherited as autosomal dominant or autosomal recessive.4
Some suggests that there may be interaction of many genes possibly in
combination with environmental factors. In our case the patient had
both eyes upper lid coloboma, for which rearranging of available tissue
or Z-plasty was suggested. Removal of limbal dermoid of both eyes was
also suggested to enable the patient to close his eyes. The indifferent
presentation without vertebral, auricular and systemic features made
this case to be reported.
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CONCLUSION |
Isolated
colonic tuberculosis perforation being the rarest form of intestinal
tuberculosis poses great difficulty in diagnosis. High index of suspicion,
supported by radiological investigation, exploratory laparotomy and
histopathological examination of tissue biopsy can only lead to a definitive
diagnosis of this rare condition. Surgical treatment involves either
primary suturing or stomas followed by Antituberculosis Chemotherapy. |
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REFERENCES |
| 1. |
Korlin
R, Jue K, Jacohsen U, et al. Oculoauriculovertebral dysplasia.
J Paediatric 1963; 63 : 991 |
| 2. |
Pantos RW, Sugar JM. Excision of limbal desmoids. Ophthalmic Surg
1991; 22 : 85-9. |
| 3. |
Sugas HS. The oculoauriculo vertebral dysplasia syndrome of Goldenhar.
Am J Ophthalmol 1966; 62 : 678-82 |
| 4. |
Shields JA, Shields Ch Depottes, surgical management of conjunctival
tumours. Arch Ophthalmol 1997; 115 : 505-15. |
| 5. |
Sherman RP, Roofman J, Ha Point JS. Dermoids clinical presentation
a management. Br J Ophthal 1984; 68 : 642-52. |
| 6. |
Ziauras
E, Farbew MCC. Diamond CCA pedunculated lipodermoid in auriculovertebral
dysplasia. Arch Ophthal 1990; 108 : 2032-33. |
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HYDRALAZINE
IS NOT THE BEST ANTIHYPERTENSIVE IN PREGNANCY
Hydralazine is less effective than nifedipine or isradipine
for treating severe hypertension in pregnancy. In a meta-analysis
of randomised controlled trials published in 1966-2002, Magee
and colleagues analysed data from 21 trials that included
893 women with severe hypertension in pregnancy. Although
not robust enough to guide clinical practice, the results
do not support the use of hydralazine
BMJ 2003; 327 : 955
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