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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 120-122

Primary calvarial tubercular osteomyelitic abscess presenting as scalp swelling—a rare case


1 Department of Pulmonary Medicine, Max Super Speciality Hospital, Vaishali, Ghaziabad, India
2 Department of Neurosurgery, Max Super Speciality Hospital, Vaishali, Ghaziabad, India

Date of Submission12-Apr-2022
Date of Decision18-Aug-2022
Date of Acceptance27-Sep-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Ankit Bhatia
Department of Pulmonary Medicine, Max Super Speciality Hospital, Vaishali, Ghaziabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_12_22

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  Abstract 


Abstract
Tuberculosis (TB) is a well-known endemic problem in India. Skeletal tuberculosis constitutes about 1% incidence of all cases of tuberculosis, however, tuberculosis involving the skull bones is very uncommon even in endemic areas like India. The frontal and the parietal bones are the most commonly involved bones. We, hereby, report a young male presenting to us with scalp swelling in the left temporal region after a small trauma. The radiology revealed an abscess within the left right temporal bone and an associated bony defect. A temporal craniotomy was done and Gene-Xpert as well as Mycobacterium culture confirmed tubercular pathology. There was no reoccurrence on antitubercular therapy.

Keywords: Calvarial tuberculosis, skull tuberculosis, tuberculosis


How to cite this article:
Bhatia A, Joshi S, Tayal N, Vaish M. Primary calvarial tubercular osteomyelitic abscess presenting as scalp swelling—a rare case. J Assoc Chest Physicians 2022;10:120-2

How to cite this URL:
Bhatia A, Joshi S, Tayal N, Vaish M. Primary calvarial tubercular osteomyelitic abscess presenting as scalp swelling—a rare case. J Assoc Chest Physicians [serial online] 2022 [cited 2023 Jan 28];10:120-2. Available from: https://www.jacpjournal.org/text.asp?2022/10/2/120/364437




  Introduction Top


Skull bone tuberculosis or calvarial tuberculosis constitutes 0.2% to 1.3% of all cases of skeletal tuberculosis and hence a diagnosis is not suspected in most cases.[1] There can be hematogenous seeding or foci from the lung or lymph node, however, a primary focus is not identified in many cases leading to hesitation in diagnosis. Needle aspiration and biopsy of these cases usually confirm the diagnosis. Surgery and standard antitubercular treatment are the standard treatment. We, hereby, present a case highlighting all these aspects of calvarial tuberculosis.


  Case Report Top


A 19-year-old male presented with the complaints of a painless slowly growing swelling in the left temporal region with headache. There was a history of mild trauma 2 months back when he was hit on the head with a cupboard while walking. There was a history of pain since then along with increasing swelling over local part. On local examination, there was a boggy, non-pulsatile, non-mobile swelling over the temporal scalp lesion of size 2 × 2 cm in size. MR revealed a T1 hypointense and T2 hypertense well-defined lesion situated between the scalp and the extradural area [Figure 1]. His chest X-ray done was unremarkable. A left temporal craniotomy with drainage was done by neurosurgery team and debridement of granulation tissue was done. Histopathological examination granulomatous inflammation with necrosis; involving soft tissue and bone, acid fast stain negative, Gene X-pert positive, while Mycobacterium species was isolated after 30 days incubation period. The postoperative period was uneventful. Antitubercular (ATT) treatment with the combination of rifampicin, isoniazid, ethambutol, and pyrazinamide for 1 year. Repeat MRI did not show any recurrence [Figure 2].
Figure 1 MR- T1 hypointense and T2 hypertense well-defined lesion situated between the scalp and the extradural area.

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Figure 2 Repeat MR- resolution of lesion.

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  Discussion Top


Skull bone tuberculosis was first reported by Reid in 1842, while Volkman gave it the term “Calvarial Tuberculosis” in 1880.[2] Children of less than 10 years of age are most commonly affected and 90% cases involved are less than 20 years of age. Male–female ratio involvement is 2:1, and trauma is usually a predisposing factor. Most common presentations are painless swelling of scalp area and discharging sinuses, however, seizures and motor deficits can occur in few cases.[3]

Isolated calvarial tuberculosis is, however, very rare, and it mostly arises with metastasis of primary lesion through hematogenous spread usually secondary to pulmonary tuberculosis, although our patient had a normal chest X-ray and no respiratory symptoms. Our patient presented with painless swelling of the scalp with a small history of trauma.

The frontal and parietal bones are the most commonly involved bones which has been attributed to the presence of relatively more cancellous bone elements compared to other bones of the skull vault. Intracranial spread is very rarely known to occur as the dura acts as a strong barrier to intracranial spread.[4]

There can be three types of radiological findings in Calvarial tuberculosis—commonly seen is the circumscribed lytic type, with small circumscribed punched out lesions; the diffuse type, in which widespread involvement of diploe is seen along with inner table destruction and epidural granulations. The third type is the circumscribed sclerotic type.[5] Computerised tomography (CT) and magnetic resonance imaging (MRI) help in detecting intraparenchymal pathologies and extradural lesions. Though MRI has higher sensitivity, especially with soft tissue lesions. CT scan although non-specific, may reveal an irregular bony defect which is seen wider at the inner table, a diffuse hypodense lesion with enhancing margins, and a well circumscribed enhancing lesion.[1] There can be other pathologies which mimic such presentations which include bacterial osteomyelitis, metastases, eosinophilic granulomas, hemangiomas, meningiomas, aneurysmal bone cysts, neuroblastomas, and syphilis. Acid fast stain and culture for mycobacterium tuberculosis are diagnostic but may not be positive in every case.

Histopathology which reveals epitheloid granulomas, langhans type giant cells, and caseation necrosis are considered diagnostic. Surgery is usually indicated for large sized extradural collections leading to neurological deficits, large pockets of caseating material with associated sinus formation, fulminant superadded infections, cosmetic issues, and for confirmation of diagnosis if it remains uncertain. The management of Calvarial tuberculosis includes both surgical curettage and antitubercular therapy (ATT), having good prognosis.[5] ATT has been recommended for 18 to 24 months but 1-year course has also been found adequate. Our patient has completed 12 months of follow up and a repeat MRI has not shown any recurrence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh P, Dutta V. Tubercular osteomyelitis of skull: a case report. Med J Armed Forces India 2006;62:288-90.  Back to cited text no. 1
    
2.
Raut AA, Nagar AM, Muzumdar D 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. 2
    
3.
Rajmohan BP, Anto D, Alappat JP. Calvarial tuberculosis. Neurol India 2004;52:278-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mukherjee KK, Kaushik R, Nada R. Calvarial tuberculosis. Surg Neurol 2002;57:195-203.  Back to cited text no. 4
    
5.
Choo YH, Seo Y, Choi J. Calvarial tuberculosis presenting with skin defect in an elderly patient. World Neurosurg 2020;140:267-70.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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