Discussion
Tuberculosis continues to be a significant public health concern in India, with millions of cases each year. However, tubercular brain abscesses are very uncommon in tuberculosis. This instance highlights the need to consider TBA in patients with neurological symptoms, particularly in areas with a high incidence of tuberculosis. [6]
While only few cases have been documented in global medical literature to meet the specific criteria established by Whitener. [7] The reason why abscesses develop instead of the more common tuberculoma, which make up about 20% of intracranial space-occupying lesions in patients, is unclear. Various factors, including the body’s immune status, the amount of the infectious agent, the characteristics of the affected tissue, and the anti-tuberculosis treatment, may influence the type of tissue reaction. [5,7] It typically arises from the spread of Mycobacterium tuberculosis through the bloodstream from another location, though it can also spread through the lymphatic system from the cervical lymph nodes. The walls of the abscess generally lack epithelioid and giant cells, which are common in tuberculomas, and if such cells are present, they do not form organized follicles. [8] The abscess wall is composed of a necrotic inner surface and a fibrous outer surface associated with an inflammatory reaction. [8,9] TBA is usually caused by the hematogenous spread of mycobacterium tuberculosis from a primary focus in the lungs.
In literature review, we found that the clinical presentations of tubercular brain abscess are variable, depending on the size and location of the abscess. Common symptoms include headache, fever, seizures, and focal neurological deficit. [3] Previously published case reports include cerebral TBA at various location within brain parenchyma in HIV patients. [1,10-13] Hydrocephalus can also be present in cases of TBA [14], however in our case it is not present. This case also emphasizes an uncommon and serious form of central nervous system tuberculosis in HIV patient: tubercular brain abscess (TBA) with signs of meningitis. This patient, a 45-year-old male farmer from Gujarat, India, experienced headache, fever and vomiting since several days. Examination indicates meningeal irritation, but no focal neurological deficits were found which is usually present in significant number of patients CNS tuberculosis. [15] The Glasgow Coma Scale (GCS) score of 15 indicated the patient was fully conscious at the time of presentation.
The diagnostic modalities for TBA is commonly includes, blood investigations, brain imaging by CT-scan or MRI and AFB on stain, culture or PCR. [16] In our case we have confirmed TBA through various investigative methods. On blood tests neutrophils were significantly high with raised inflammatory markers (CRP & ESR) . Cerebrospinal fluid (CSF) analysis revealed an increased number of cells with a predominance of lymphocytes, elevated protein levels, reduced glucose levels and AFB smear detected mycobacterium tuberculosis bacilli, which are indicative of tuberculous meningitis. A chest X-ray revealed primary tuberculosis infection in the right lung. Importantly, brain NCCT findings are suggestive of brain abscess.
The mainstay of treatment of TBA is surgical management as well as ATT. In this patient both surgical and medical approaches have been used. The abscess was aspirated by stereotactic aspiration. After the aspiration, the patient began anti-tuberculous therapy (ATT), which is essential for treating tuberculous abscesses (TBA). Following the surgery and initiation of ATT, the patient’s symptoms improved markedly, leading to their discharge after two weeks with instructions to continue ATT for six months. The patient fully recovered, demonstrating the effectiveness of prompt and vigorous treatment in these situations.
While the prognosis of TBA is generally favorable with prompt diagnosis and treatment, it can be complicated by factors such as HIV infection, malnutrition, and other immunosuppressive conditions. The patient in this case has HIV, which likely contributed to worsening of tuberculosis. However, the presence of pleural thickening and calcification suggests a chronic or reactivated tuberculosis infection, which could have posed additional challenges if not managed appropriately.
This case report of a tubercular brain abscess in a middle-aged farmer from Gujarat, India, highlights the diagnostic and therapeutic challenges associated with this rare manifestation of tuberculosis. It emphasizes the need for a high index of suspicion, thorough diagnostic workup, and aggressive treatment to ensure favorable outcomes. Public health measures to control tuberculosis and improve nutritional and immune status among the population are critical in preventing such severe complications.