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.