Rev. Inst. Med. trop. S. Paulo
45(2):111-114, March-April, 2003

TUBERCULOUS BRAIN ABSCESS IN A PATIENT WITH AIDS:
CASE REPORT AND LITERATURE REVIEW

José E. VIDAL, Sérgio CIMERMAN, Paula R. Marques da SILVA, Jaques SZTAJNBOK, João F.G.S. COELHO & Diogo L.M. LINS

SUMMARY
Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the
case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A
brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected
and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly
positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the
differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment
are the mainstay in the management of these uncommon lesions.
KEYWORDS: Tuberculous abscess; Brain abscess; Acquired immunodeficiency syndrome.

INTRODUCTION
Human immunodeficiency virus (HIV) infection and acquired
immunodeficiency syndrome (AIDS) are the major known risk factors
to develop tuberculosis in individuals previously infected with
Mycobacterium tuberculosis24. HIV epidemic rendered tuberculosis more
prevalent and increased the indices of mortality, multidrug resistance,
and extrapulmonary and disseminated forms16,27,28.
Central nervous system (CNS) is involved in 10-20% of the cases
where HIV infection coexists with tuberculosis. The main clinical
syndrome is tuberculous meningitis. Focal tuberculous lesions are
infrequent and may appear as tuberculomas and more rarely as
abscesses35.
We report a case of brain tuberculous abscess in an AIDS patient
and review of the literature.
CASE REPORT
A 34-year-old woman was admitted to our service in September
2002 because of holocranial headache and generalized tonic-clonic
seizures. She had a history of intravenous drug use, chronic hepatitis C,
oral candidiasis, and toxoplasmic encephalitis. She had refused any
prophylactic or antiretroviral therapies. Neurological examination on
presentation was unremarkable, without any focal abnormalities.
Laboratory revealed moderate anemia (hemoglobin of 10 g/dL), with

leukopenia (white blood cell count of 1900 cells/mm3), and lymphopenia
(260 cells/mm3). Chest radiograph was normal. His tuberculin skin test,
using purified protein derivative (PPD) was negative. Toxoplasma IgG
was higher than 250 UI (ELISA method). The absolute CD4+ count
was 55 cells/µL, and HIV-RNA level was 160,000 copies/mL.
Brain computed tomography (CT) scan showed a hypodense frontal
lesion with significant associated edema (Fig. 1A). She underwent
trepanation on the same day, draining 10 ml of pus. The Ziehl-Neelsen
stain showed abundant acid-fast bacilli (AFB). After one week, the general
status improved and a new CT scan showed a decrease in the lesion size
(Fig. 1B). She was discharged to home with isoniazid, rifampicin,
pyrazinamide, zidovudine, lamivudine, and efavirenz. Besides that, she
received primary prophylaxis for Pneumocystis carinii pneumonia and
secondary prophylaxis for toxoplasmic encephalitis.
DISCUSSION
Tuberculous brain abscesses are infrequently described in the world
literature. Before the AIDS era, WHITENER33 reviewed from 1886 to
1978 only 17 cases with etiological diagnosis, and established diagnosis
criteria of cerebral tuberculous abscess. In these patients were not reported
any information about preexisting conditions or non-infectious diseases.
In the AIDS era, we reviewed the literature from 1981 to 2002 using
the MEDLINE database (National Library of Medicine, Bethesda, MD).
The key words used were tuberculous brain abscess, cerebral abscess

Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brazil.
Correspondence to: Dr. José E. Vidal, Rua Capote Valente 668, Apto. 96, 05409-002 São Paulo, SP, Brazil. Telephone number: (55.11) 95888756; (55.11) 30853319; Fax number: (55.11)
30883602. E-mail: jbermudez@emilioribas.sp.gov.br

VIDAL, J.E.; CIMERMAN, S.; SILVA, P.R.M.; SZTAJNBOK, J.; COELHO, J.F.G.S. & LINS, D.L.M. - Tuberculous brain abscess in a patient with AIDS: case report and literature review.
Rev. Inst. Med. trop. S. Paulo, 45(2):111-114, 2003.

The histopathologic features of tuberculous abscess are different from
those of tuberculomas and the definitive diagnosis depends on the
following criteria: macroscopic evidence of pus in the abscess cavity,
microscopic evidence of acute inflammatory alterations in the abscess
walls, and the presence of AFB or M. tuberculosis growth on culture30,33.
Tuberculous abscesses are generally single lesions11,12,13,17,29,31, larger than
tuberculomas2 and also evolve more rapidly32. The exact pathogenesis
mechanisms leading to formation of abscess are unknown. It is
hypothesized that after the initial hematogenic dissemination of the
bacilli34, there would be brain areas of cerebritis that go on to meningitis
or tuberculomas. The abscesses would come from caseous necrosis and
liquefaction of these tuberculomas10 .
In AIDS era, tuberculous brain abscess usually is a subacute illness
and the most frequent clinical manifestations are seizures 12,17,31,
consciousness alterations 11,29,31 , paresis 12,14,17 , fever 11,13,17 , and
headache11,17,31. Other findings are paresthesias12,17, cerebelar signs11,31,
facial palsy 31, and intracranial hypertension 11. Before AIDS era,
WHITENER33 reported that patients with tuberculous brain abscess
usually had an acute illness, and the most common finding were focal
neurological deficit (71%), headache (47%), fever (46%), seizures (35%)
and consciousness alterations (24%).
Our case is in accordance with other reports of AIDS patients,
specially in what concerns the lack of a previous occurrence of
tuberculosis11,12,13,17,31, history of use of intravenous drugs12,29,31, and
normal chest radiographs11-13,17,29,31. Formerly, WHITENER33 reported
that patients with tuberculous brain abscess frequently presented
epidemiological, historical or laboratory evidence of extracranial
tuberculosis, but chest radiographs consistent with tuberculosis were
uncommon.
Only four of eight cases found in the literature performed serology
for T. gondii11-13,17. All these patients had detectable IgG antibodies. It is
known that 3-6% of patients with toxoplasmic encephalitis have negatives
results of serological tests26, so that a negative serology points to another
etiologic possibilities. The positive serology in our case was justified by
the previous episode of CNS toxoplasmosis.

Fig. 1 - Pre-trepanation contrast CT scan showing a large lesion with ring-enhancing in the
right frontal area (A). Post-trepanation CT scan (B) demonstrate a marked diminution in the
size, residual enhancement and a moderate degree of edema at the site of the lesion.

and acquired immunodeficiency syndrome. We also searched manually
in journals, and cases with incomplete clinical or microbiologic
information were excluded. In accordance with WHITENER‘s criteria33,
we found 8 cases of tuberculous brain abscesses in HIV-infected patients:
three in the USA12,13,14, three in Spain29,31, one in France11 and one in
Brazil 17 . One of these cases was associated with toxoplasmic
encephalitis13. Interestingly, we excluded three cases previously reported
as tuberculous abscesses 31. However, histopathology information
corresponded to tuberculomas6.
112

The major causes of intracranial focal lesions coexist with low CD4+
values, typically below 100 cells/µL26. CD4+ values for tuberculous
abscesses without other CNS infections are reported to be between 112270 cells/µL12,31. This important finding for the diagnostic reasoning
would be misleading in our case since her CD4+ cell count was 55 cells/
µL. This finding and the history of toxoplasmic encephalitis and the
lack of secondary prophylaxis for this opportunistic infection could have
retarded the diagnostic trepanation, and consequently delayed the
treatment.
Tomographic alterations of the tuberculous abscesses may be similar
to those ones related to other causes of expansive lesions in AIDS
patients32: a hyperdense ring, hypodense center, and marked contrast
enhancement. The presence of single lesions, a thick capsule, ring
enhancement, and a lobular contour, make the diagnosis of tuberculous
abscess more likely 12,17,22,25,31,32. On the other hand, toxoplasmic
encephalitis lesions in general are multiple, their capsules are not thick
and are not multilobulated.

VIDAL, J.E.; CIMERMAN, S.; SILVA, P.R.M.; SZTAJNBOK, J.; COELHO, J.F.G.S. & LINS, D.L.M. - Tuberculous brain abscess in a patient with AIDS: case report and literature review.
Rev. Inst. Med. trop. S. Paulo, 45(2):111-114, 2003.

The differential diagnosis of tuberculous abscesses is wide, including
toxoplasmic encephalitis (the most frequent cause of intracranial mass
in AIDS patients) and CNS primary lymphoma19,21,23,26. Moreover, other
rare causes have been described such as tuberculoma18, cryptococcal
abscess and cryptococcoma21, non-tuberculous mycobacteria abscess15,
pyogenic abscess12, syphilitic gumma23, aspergilloma20, Chagas disease9,
and intracranial mass due to cytomegalovirus5.
The AIDS patients with focal brain lesions, presence of IgG antibodies
against T. gondii and CD4+ cell count below 200 cells/µL should receive antiToxoplasma treatment. If after two weeks of treatment there are no clinical or
tomographic improvement, a stereotaxic brain biopsy is needed22. However,
as reported in a case of “cytomegaloviroma”5, a high index of suspicion may
justify earlier surgical approaches. In accordance with this suggestion, our
patient underwent a trepanation on the first hospital day.
The availability of imaging techniques such as Thallium-201 singlephoton emission CT (SPECT)19, positron emission tomography (PET)26,
spectroscopic magnetic resonance imaging7 and molecular techniques
(polymerase chain reaction in cerebrospinal fluid)3,26 may add to the
diagnostic strategy. These tools allow “minimally invasive” approach,
decrease the number of brain biopsies, and increase the number of in
vivo diagnosis3,4,8,19,26. However, until larger validation studies are
completed, brain biopsy will continue the only definitive diagnosis
modality26.
Biopsy and early treatment of tuberculous brain abscess in AIDS
patients, allowed a good outcome in the majority of the reported
cases11,12,14,17,31. No one of these patients had another associated CNS
disease, and all deaths observed were linked to other causes than the
abscesses themselves13,29,31. Interestingly, before AIDS era, WHITENER33
reported survival in all cases that received antituberculous chemotherapy
and underwent surgical treatment.
Considering the present case, tuberculous brain abscess, in spite of
its rarity, must be included in the differential diagnosis of focal lesions
in AIDS patients. A high index of suspicion may define an earlier surgical
excision or stereotaxic biopsy, which are considered to be the gold
standard for the diagnosis and treatment of tuberculous brain abscess.
RESUMO
Abscesso tuberculoso cerebral em paciente com aids: relato de
caso e revisão da literatura
Os abscessos tuberculosos cerebrais em pacientes com aids são raros,
existindo apenas 8 casos publicados. Os autores relatam o caso de uma
paciente de 34 anos com aids e antecedente de toxoplasmose cerebral,
que foi admitida por cefaléia e convulsões. A tomografia computadorizada
de crânio evidenciou lesão frontal única, grande, com realce anular e
efeito expansivo. Diante da suspeita de abscesso cerebral foi submetida
a trepanação, drenando material purulento e demonstrando presença de
abundantes bacilos ácido-álcool resistentes. Abordagem cirúrgica e
clínica oportuna determinaram uma boa evolução. Os abscessos
tuberculosos devem ser considerados no diagnóstico diferencial das
massas intracranianas em pacientes com aids. Excisão cirúrgica ou
aspiração por estereotaxia e tuberculostáticos constituem as bases do
tratamento destas lesões incomuns.

ACKNOWLEDGEMENTS
The authors thank Adrián V. Hernández, MD, MSc., for his comments
and assistance in preparation of the manuscript.
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Received: 02 December 2002
Accepted: 03 February 2003