Unusual presentation of more common disease/injury

CASE REPORT

Clinicoradiological improvement of intracranial
tubercular abscess with medical management alone
Rajendra Singh Jain, Rahul Handa, Kadam Nagpal, Swayam Prakash
Department of Neurology, SMS
Medical College, Jaipur,
Rajasthan, India
Correspondence to
Professor Rajendra Singh Jain,
drrsjain@yahoo.com
Accepted 21 March 2014

SUMMARY
Tubercular abscess is a rare presentation of central
nervous system tuberculosis (TB), which commonly
presents as tuberculoma or meningitis. Most of the
published cases of tubercular brain abscess have been
dealt with by surgical treatment along with medical
management. We here report a case of intracranial
tubercular abscess in a 17-year-old girl presenting with
fever, headache and right hemiparesis who showed
significant clinicoradiological improvement with medical
management alone. Thus, in a country like India where
TB is highly endemic, TB should be considered as a
possible aetiology for any intracranial lesion with
radiological appearance suggestive of an abscess and
surgical treatment can be kept as an option in case of
neurological deficits, hydrocephalus or treatment failure.

BACKGROUND
Tuberculosis (TB) has always been a major health
problem in developing countries like India but HIV
pandemic has led to resurgence of this disease in
developed countries.1 2 Tubercular abscess is a rare
presentation of central nervous system (CNS) TB,
which commonly presents as tuberculoma or meningitis.1 Treatment of tubercular abscess includes
antitubercular chemotherapy and surgical excision.2
Most of the published cases of tubercular brain
abscess have been dealt with by surgical treatment
along with medical management.1 2 We here report
a case of intracranial tubercular abscess in a young
girl presenting with fever, headache and right hemiparesis who showed significant clinicoradiological
improvement with medical management alone.

limbs and extensor right plantar response. Neck
rigidity and Kernig’s sign were positive.

INVESTIGATIONS
Laboratory results showed normal complete haemogram, liver function and renal function tests and
normal chest X-ray. Erythrocyte sedimentation rate
was 80 mm/h; cerebrospinal fluid (CSF) examination revealed 120 white cells (90% lymphocytes),
raised proteins (240 mg%) and decreased sugar
(20 mg%) with positive PCR for Mycobacterium
tuberculosis. CSF India ink examination for cryptococcal antigen was negative. Her ELISA for HIV
infection was non-reactive. Contrast-enhanced MRI
of the brain showed a large, thin ring-enhancing
lesion in the left frontal lobe, with core being
hypointense on T1-weighted and hyperintense on
T2-weighted images suggestive of an abscess
(figure 1A–C). Since the patient had neurological
deficit, neurosurgical opinion was sought, but considering the location of lesion, open surgery was
considered too risky for which the patient’s attendants did not give consent and facility for stereotactic biopsy was not available in our medical college
hospital. A consensus opinion was formed with the
neurosurgeon and medical management including
steroids was preferred with close watch on any clinicoradiological deterioration. It was decided that
open surgery be performed if further clinicoradiological deterioration occurred.

DIFFERENTIAL DIAGNOSIS
▸ Tuberculoma
▸ Pyogenic abscess
▸ Fungal abscess

CASE PRESENTATION

To cite: Jain RS, Handa R,
Nagpal K, et al. BMJ Case
Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2013203497

A 17-year-old girl presented with mild-to-moderate
grade intermittent fever and moderate, continuous
throbbing headache in the left frontotemporal
region, associated with vomiting since 1 month
along with progressive weakness of right half of the
body including face 5 days prior to admission.
There was also a history of significant weight loss
during the past 1 month. There was no history of
ear discharge or any history suggestive of sinusitis.
On examination the patient was conscious and well
oriented with normal general physical examination.
Respiratory, cardiovascular and gastrointestinal
system
examinations
were
unremarkable.
Neurological examination revealed Glasgow Coma
Scale of 15/15, upper motor neuron left facial
weakness. Her motor examination revealed spasticity along with a power of 2/5 (Medical Research
Council (MRC) grade) in the right upper and lower

Jain RS, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203497

TREATMENT
The patient was managed conservatively with fivedrug antitubercular therapy including isoniazid
(300 mg/day), rifampicin (450 mg/day), ethambutol
(800 mg/day), pyrazinamide (1500 mg/day) and
injectable streptomycin (0.75 g/day intramuscularly)
for 3 months followed by isoniazid and rifampicin
for a total of 18 months. A short course of injectable followed by oral steroid was also given in a
tapering dose over initial 2 months.

OUTCOME AND FOLLOW-UP
The patient on follow-up showed significant
improvement in neurological deficits with resolution
of signs of meningitis and improvement in motor
power from MRC grade 2/5 to 4/5 in the right half
of body after receiving 3 months of treatment.
Periodic MRI of the brain started showing
1

Unusual presentation of more common disease/injury

Figure 1 (A) T1-weighted axial MRI showing a hypointense mass lesion with hyperintense rim in the left frontal lobe (arrow). (B) T2-weighted
axial MRI showing the hyperintense mass lesion with hypointense rim in the left frontal lobe (arrow). (C) Post contrast T1-weighted axial MRI
showing the well-circumscribed thin ring-enhancing mass lesion in the left frontal lobe (arrow).

improvement after 2 months of treatment with complete resolution of lesion at 5 months of treatment (figure 2A–C).

DISCUSSION
CNS TB comprises nearly 10% of total patients of TB.3 CNS
infection usually occurs secondary to haematogenous spread of
tubercular bacilli from lungs.2
Tuberculoma and tubercular abscess can be differentiated
pathologically by the presence of epithelioid granulomatous
reaction with giant cells in case of tuberculoma, whereas vascular granulation tissue with acute and chronic inflammatory cells
favours tubercular abscess.3 MRI is an important non-invasive
investigation which helps us to differentiate between tuberculoma and tubercular abscess. Tuberculoma usually presents as
T2-weighted hypointensity whereas the core of TB abscess
appears hyperintense on a T2-weighted image.4 Our patient’s
MRI showed ring-enhanced lesion with T2 hyperintense core.
Tubercular abscess should also be differentiated from pyogenic
abscess. As the PCR for TB was positive in CSF, it helped us to
differentiate between tubercular and pyogenic abscess. MRI of a
fungal abscess usually shows projections which are isointense to

hypointense on T2-weighted and isointense on T1-weighted
images which were not seen in our patient.5
Although biopsy is the gold standard for definitive diagnosis of
TB abscess, it may not be essential in an area where TB is endemic.6
7
Our patient was not biopsy proven as any invasive intervention
was considered too risky due to location of the lesion, but being a
resident of an endemic area and CSF PCR positive for TB, a diagnosis of intracranial tubercular abscess was made and the patient was
advised antitubercular treatment. Lumbar puncture was performed
to look for corroborative evidence for the aetiology of brain
abscess. In a study by Wasay et al8 more than 80% of patients with
tuberculoma had abnormal CSF. PCR for the diagnosis of tuberculous meningitis had an overall sensitivity of 56% and a specificity of
98% in a meta-analysis done by Pai et al9
Radical excision was the standard approach before the availability of chemotherapy, but with the use of highly active and
freely available antitubercular drugs, surgical treatment is now
limited to patients with treatment failure or intracranial hypertension.6 10–13
To conclude, in a country like India where tuberculosis is
highly endemic, TB should be considered as a strong possibility
in case of any intracranial lesion with radiological appearance

Figure 2 (A) T1-weighted axial MRI 5 months after starting antitubercular treatment showing near-complete resolution of the lesion. (B)
T2-weighted axial MRI 5 months after starting antitubercular treatment showing near-complete resolution of the lesion. (C) Post contrast
T1-weighted axial MRI 5 months after starting antitubercular treatment showing near-complete resolution of the lesion (arrow).
2

Jain RS, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203497

Unusual presentation of more common disease/injury
suggestive of an abscess, and surgical treatment can be kept as
an option in case of neurological deficits, hydrocephalus or
treatment failure.

Learning points
▸ Tuberculosis should be considered as a strong possibility in
case of any intracranial lesion with radiological appearance
suggestive of an abscess, particularly in an endemic area.
▸ Biopsy of the abscess is although the gold standard for
diagnosis, it is not mandatory.
▸ Intracranial tubercular abscess may respond well to medical
management alone.
▸ Surgical treatment of intracranial tubercular abscess can be
kept as an option in case of neurological deficits,
hydrocephalus or treatment failure.

REFERENCES
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2

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5

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7
8
9

10
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Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

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Gupta V, Chhina D, Kaushal RK, et al. Tuberculous brain abscess—case report.
Asian Pac J Trop Dis 2012;2:419–20.
Roopesh Kumar VR, Gundamaneni SK, Biswas R, et al. Tuberculous cerebellar
abscess in immunocompetent individuals. BMJ Case Rep 2012;2012: pii:
bcr2012006984.
Whitener DR. Tuberculous brain abscess. Arch Neurol 1978;35:148–55.
Pui MH, Memon WA. Magnetic resonance imaging findings in tuberculous
meningoencephalitis. Can Assoc Radiol J 2001;52:43–9.
Luthra G, Parihar A, Nath K, et al. Comparative evaluation of fungal, tubercular,
and pyogenic brain abscesses with conventional and diffusion MR imaging and
proton MR spectroscopy. AJNR Am J Neuroradiol 2007;28:1332–8.
Bouchama A, al-Kawi MZ, Kanan I, et al. Brain biopsy in tuberculoma: the risks
and benefits. Neurosurgery 1991;28:405–9.
Abdul-Ghaffar NU, El-Sonbaty MR, Rahman NA. Intracranial tuberculomas. Int J
Tuberc Lung Dis 1998;2:413–18.
Wasay M, Moolani MK, Zaheer J, et al. Prognostic indicators in patients with
intracranial tuberculoma: a review of 102 cases. J Pak Med Assoc 2004;54:83–7.
Pai M, Flores LL, Pai N, et al. Diagnostic accuracy of nucleic acid amplification tests
for tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis
2003;3:633–43.
Arseni C. Two hundred and one cases of intracranial tuberculoma treated surgically.
J Neurol Neurosurg Psychiatry 1958;21:308–11.
Del Brutto OH, Mosquera A. Brainstem tuberculoma mimicking glioma: the role of
antituberculous drugs as a diagnostic tool. Neurology 1999;52:210–11.
Rajeswari R, Sivasubramanian S, Balambal R, et al. A controlled clinical trial of
short-course chemotherapy for tuberculoma of the brain. Tuber Lung Dis
1995;76:311–17.
Gropper MR, Schulder M, Sharan AD, et al. Central nervous system tuberculosis:
medical management and surgical indications. Surg Neurol 1995;44:378–84.

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Jain RS, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203497

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