Stereotactic aspiration in the management of a rare case of tuberculous cerebellar abscess
Hatim Belfquih, M.D, Ali Akhaddar, M.D. IFAANS
PII: S1878-8750(19)31531-1
DOI: https://doi.org/10.1016/j.wneu.2019.05.254 Reference: WNEU 12551
To appear in: World Neurosurgery Received Date: 8 December 2018 Revised Date: 30 May 2019 Accepted Date: 30 May 2019
Please cite this article as: Belfquih H, Akhaddar A, Stereotactic aspiration in the management of a rare case of tuberculous cerebellar abscess, World Neurosurgery (2019), doi: https://doi.org/10.1016/
j.wneu.2019.05.254.
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Stereotactic aspiration in the management of a rare case of tuberculous cerebellar abscess
Authors:
Hatim Belfquih, M.D., Ali Akhaddar, M.D. IFAANS
Department of Neurosurgery, Avicenne Military Hospital, Marrakech, Morocco and Mohammed V University in Rabat, Rabat, Morocco.
Corresponding Address:
Department of Neurosurgery, Avicenne Military Hospital, 40000, Marrakech, Morocco.
Email address: hatimbelfquih@gmail.com
Phone number: (212) 6.61.33.86.23.
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Stereotactic aspiration in the management of a rare case of tuberculous cerebellar abscess
Abstract:
Tuberculous brain abscess is an extremely rare form of central nervous system tuberculosis. This lesion usually occurs in the supratentorial space. Cerebellar tubercular abscesses are very rare.
Most of these cases occur in immunocompromised patients. We report an immunocompetent individual with tuberculous abscess of the cerebellum and discuss the role of stereotactic aspiration in the management of these rare lesions.
Key words:
Cerebellar abscess, Mycobacterium tuberculosis, aspiration, stereotactic surgery.
Conflicts of interest: None.
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Text:
Central nervous system (CNS) tuberculosis (TB) remains common in Morocco and other developing countries. The continued incidence of new cases of CNS TB in developing countries and the resurgence of CNS TB in developed countries is attributed to the human immunodeficiency virus (HIV) pandemic, travelling refugees, and international movement of people across borders. Tuberculous brain abscess (TBA) is a rare manifestation of CNS TB (1,2).
TBA is characterized by an encapsulated collection of pus containing viable tubercular bacilli without evidence of the classic tubercular granuloma. This must be distinguished from granuloma with central caseation and liquefaction mimicking pus (3,4). These lesions usually occur in the supratentorial space. Cerebellar tubercular abscesses are very rare (5).
A 56-year-old woman, previously healthy, was initially brought to the emergency room due to altered mental status and fever. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed hypodense multiloculated lesion in the left cerebellum with a thick enhancing capsule (Figure 1). The fourth ventricle was compressed. She had tested negative for HIV 1 and 2 by enzyme-linked immunosorbent assay (ELISA). Preliminary testing for infectious causes was negative. Chest CT scans showed no pulmonary lesion. The patient underwent an emergency stereotactic aspiration of the cyst with cystic wall biopsy (Figure 2 A, B). The cyst contained 20 ml of thick yellow pus. The cystic wall biopsy showed exudative inflammation consistent with an abscess. Bacterial cultures of the pus were negative (aerobic and anaerobic).
Ziehl-Neelsen (ZN) staining demonstrated multiple acid-fast bacilli (AFB) suggestive of
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reaction (PCR) for tuberculosis. Postoperative CT showed a small residual collection (Figure 2 C). Antitubercular therapy was instituted; the course consisted of an intensive phase of four drugs for 2 months (isoniazid, rifampicin, pyrazinamide and ethambutol) followed by a maintenance phase with two drugs for 12 months (isoniazid and rifampicin). The patient remains asymptomatic and neurologically stable 1 year after surgery. No fresh lesions were seen on follow-up CT scans.
Surgical options in this case report include aspiration through a burr hole, stereotactic aspiration and total excision of the abscess via a suboccipital approach (5). The development of a fulminant tuberculous meningitis is sometimes problematic following surgical excision of TBA (3,6). In our case, stereotactic aspiration was a safe and an useful alternative modality. If available, frameless image-guided stereotaxy would be also a favorable option in such cases. Antitubercular therapy is the mainstay of management and may need to be continued for 12 to 18 months (1,5).
The author has no conflicts of interest to declare.
No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
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Legend of Figures:
Figure 1. This 56-year-old previously healthy woman, was initially brought to the emergency
room due to altered mental status and fever. Brain CT scans with contrast injection showed a left cerebellar cystic lesion with peripheral rim enhancement (A). MRI revealed hypodense
multiloculated lesion in the left cerebellum (B, C and D) with a thick enhancing capsule after gadolinium injection (C).
Figure 2. The patient underwent an emergency stereotactic aspiration of the cyst with cystic wall
biopsy under local anesthesia. Axial cranial CT with contrast injection during preplanning stereotactic procedure (A). Intraoperative view showing the stereotactic aspiration of the cerebellar abscess (B). Ziehl-Neelsen staining demonstrated multiple acid-fast bacilli suggestive of Mycobacterium tuberculosis. This was also confirmed by Lowenstein culture and PCR for tuberculosis. Immediate postoperative CT showed a small residual collection (C).
Antituberculous chemotherapy was started for 14 months. The patient remains asymptomatic and neurologically stable 1 year after surgery. No fresh lesions were seen on follow-up CT scans.
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References
1- Roopesh Kumar VR, Gundamaneni SK, Biswas R, Madhugiri VS. Tuberculous cerebellar abscess in immunocompetent individuals. BMJ Case Rep. 2012 Oct 6;2012.
2- Parekh R, Haftka A, Porter A. A rare case of central nervous system tuberculosis. Case Rep Infect Dis. 2014;2014:186030.
3- Kumar R1, Pandey CK, Bose N, Sahay S. Tuberculous brain abscess: clinical presentation, pathophysiology and treatment (in children). Childs Nerv Syst. 2002;18:118-123.
4- Naama O, Boulahroud O, Elouennass M, Akhaddar A, Gazzaz M, Elmoustarchid B, Boucetta M. Primary tuberculous cerebellar abscess in an immunocompetent adult. Intern Med.
2010;49:875-876.
5- Akhaddar A. Surgical therapy. In: Turgut M, Akhaddar A, Turgut A., Garg R, editors.
Tuberculosis of the Central Nervous System. Switzerland: Springer International Publishing;
2017. p. 173-191. doi.org/10.1007/978-3-319-50712-5_14
6- Mohanty A1, Venkatarama SK, Vasudev MK, Khanna N, Anandh B. Role of stereotactic aspiration in the management of tuberculous brain abscess. Surg Neurol.1999;51:443-446.
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AFB : acid-fast bacilli
CNS : central nervous system CT : computed tomography
ELISA : enzyme-linked immuno sorbent assay HIV : human immunodeficiency virus MRI : magnetic resonance imaging PCR : polymerase chain reaction TB : tuberculosis
TBA : tuberculous brain abscess ZN : Ziehl-Neelsen
