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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 278-279

Calvarial tuberculosis presenting as multiple osteolytic soft tissue lesions


1 Department of Radiology, St. Johnís Medical College, Bengaluru, Karnataka, India
2 Department of Anatomy, St. Johnís Medical College, Bengaluru, Karnataka, India
3 Department of Pathology, St. Johnís Medical College, Bengaluru, Karnataka, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Reddy Ravikanth
St. Johnís Medical College, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_36_17

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  Abstract 

Primary tuberculosis (TB) of the skull is a very rare entity scantily described in literature with 0.2%–1.3% of cases. The different radiological forms of calvarial TB described are - circumscribed lesions of the sclerotic and lytic type and diffuse TB of the cranium. Treatment for skull TB includes antituberculous therapy along with appropriate surgical intervention. Here, we present a case of calvarial TB presenting as multiple osteolytic soft tissue lesions.

Keywords: Button sequestrum, calvarial tuberculosis, multiple myeloma, osteolytic lesions


How to cite this article:
Ravikanth R, Mathew S, Selvam RP. Calvarial tuberculosis presenting as multiple osteolytic soft tissue lesions. CHRISMED J Health Res 2017;4:278-9

How to cite this URL:
Ravikanth R, Mathew S, Selvam RP. Calvarial tuberculosis presenting as multiple osteolytic soft tissue lesions. CHRISMED J Health Res [serial online] 2017 [cited 2020 Apr 6];4:278-9. Available from: http://www.cjhr.org/text.asp?2017/4/4/278/216471


  Introduction Top


Skeletal tuberculosis (TB) accounts for 1% of all TB infections. Primary TB of the skull is a very rare entity. A solitary discrete round or oval punched out osteolytic defect with minimal surrounding sclerosis in the frontoparietal bones is the most common presentation of skull TB. When multiple, they appear serpiginous with geographical defects suggesting extensive bone loss. TB may present as a subgaleal swelling (Pott's puffy tumor) with a discharging sinus when the outer table is involved.[1] Involvement of the inner table is associated with formation of underlying extradural granulation tissue. Here, we present a case of calvarial TB presenting as multiple osteolytic soft tissue lesions.


  Case Report Top


An 18-year-old boy of Asian ethnicity presented in the outpatient department of our hospital with multiple painless, discharging sinuses over the scalp. The patient had a history of low-grade fever with intermittent discharge of cheesy material from the sinuses. On examination, the sinus was found to be attached to the underlying calvarium. The investigations revealed hemoglobin 9 gm%, erythrocyte sedimentation rate 24 mm in the first hour (Wintrobe's method), total lymphocyte count 4500 cells/mm 3 with polymorphs 72% and lymphocytes 28%. The Mantoux test was positive with induration of 14 mm × 18 mm. Plain radiographs of the skull [Figure 1]a and [Figure 1]b and computed tomography scan of head [Figure 2] revealed large circumscribed lytic lesions with sclerotic margins, destroying both inner and outer tables of the calvariun with adjacent subgaleal soft tissue. Polymerase chain reaction was positive for TB, and direct smear was positive for acid-fast bacillus. Histopathology of tissue bone aggregates showed multiple granulomas composed of epithelioid cells, Langerhans giant cells, and lymphocytes with casseous necrosis consistent with TB. Anti-TB treatment was initiated and the discharging sinuses were healed in 3 weeks.
Figure 1: (a) Frontal radiograph of the skull showing multiple lytic lesions with a sclerotic margin. (b) Lateral radiograph of the skull showing large circumscribed lytic lesions involving the calvarium

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Figure 2: Axial computed tomography of the head with a bone window showing left frontoparietal calvarial defects destroying both inner and outer tables with adjacent subgaleal soft tissue and a characteristic button sequestrum in the right parietal bone

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  Discussion Top


TB is endemic in developing countries and more prevalent in the rural communities. TB primarily affects people in their most productive years of life with important socioeconomic consequences for the household and the disease is even more common among the marginalized sections of the community. Skeletal TB accounts for 1% of all TB infections.[2] Primary TB of the skull is very rare with 0.2%–1.3% of cases.[3] This rarity may be because of paucity of lymphatics in the calvarial bone. Pathogenesis involves lodging of bacilli in the diploic spaces of skull bones through hematogenous spread from the extracalvarial focus.[4] Multiple discharging sinuses with osteolytic lesions and characteristic button sequestra.[5] Multiple myeloma, osteomyelitis of the skull and secondary metastases should be considered as differentials. Skull vault TB remains an extremely unsual site for skeletal TB due to the little cancellous nature of the flat bones of the skull.[6]

The different radiological forms of calvarial TB described are - circumscribed lesions of the sclerotic and lytic type and diffuse TB of the cranium.[7] Although the bony involvement maybe variable, calvarial TB often presents with painful scalp swellings, subgaleal collections, discharging sinuses, and variable amount of extradural granulation tissue. Isolated skull bone involvement is rare.[8]

Treatment for skull TB includes antituberculous therapy along with appropriate surgical intervention. An urgent surgical intervention is indicated in the presence of large extradural collections causing mass effect and neurological deficits. The presence of large collections of pus in the subgaleal plane and sinus formation necessitates thorough debridement and excision of the sequestrum along with the infected granulation tissue. Associated secondary infection needs treatment with appropriate antibiotics. Finally, an excision biopsy of the lesion would be indicated. Surgical treatment should always be followed by adequate antituberculous therapy, considering the indolent nature of infection.[9]


  Conclusion Top


The differential diagnosis of multiple osteolytic lesions of the skull would include metastases, multiple myeloma, histiocytosis and pyogenic, fungal, or tuberculous osteomyelitis. In developing countries, a high index of suspicion is important to recognize tuberculous involvement of the skull.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jadhav RN, Palande DA. Calvarial tuberculosis. Neurosurgery 1999;45:1345-9.  Back to cited text no. 1
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2.
Rajmohan BP, Dominic A, Alappat JP. Calvarial tuberculosis. Neurol India 2004;52:278-9.  Back to cited text no. 2
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3.
LeRoux PD, Griffin GE, Marsh HT, Winn HR. Tuberculosis of the skull – A rare condition: Case report and review of the literature. Neurosurgery 1990;26:851-5.  Back to cited text no. 3
[PUBMED]    
4.
Mukherjee KK, Kaushik R, Nada R, Khosla VK, Khandelwal N, Kak VK. Calvarial tuberculosis. Surg Neurol 2002;57:195-203.  Back to cited text no. 4
[PUBMED]    
5.
Barton CJ. Tubercolosis of the vault of the skull. Br J Radiol 1961;34:286-90.  Back to cited text no. 5
[PUBMED]    
6.
Tirona JP. The roentgenological and pathological aspects of tuberculosis of the skull. Am J Roentgenol Radium Ther Nucl Med 1954;72:762-8.  Back to cited text no. 6
[PUBMED]    
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7. Patankar T, Varma R, Krishnan A, Prasad S, Desai K, Castillo M. Radiographic findings in tuberculosis of the calvarium. Neuroradiology 2000;42:518-21.  Back to cited text no. 7
    
8.
Al-Wohaibi M, Russel NA, Omojola M, Al-Feriyan A. Tuberculosis of the skull. J Neurosurg 2000;92:1065.  Back to cited text no. 8
    
9.
Raut AA, Nagar AM, Muzumdar D, Chawla AJ, Narlawar RS, Fattepurkar S, 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. 9
    


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