|Year : 2015 | Volume
| Issue : 3 | Page : 395-397
Tubercular brain and liver abscesses in an immunocompetent young male
Nikhil Gupta1, Ajinkya Sonambekar1, Akanksha Swadi2, Nikhil Nair3
1 Department of Medicine, University College of Medical Sciences, Dilshad Garden, Delhi, India
2 Department of Radio-Diagnosis, B J Medical College, Pune, India
3 Department of Radio-Diagnosis, Lady Hardinge Medical College, Delhi, India
|Date of Web Publication||15-May-2015|
Department of Medicine, UCMS, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Brain abscess is a very rare form of central nervous system tuberculosis. It is particularly uncommon in immunocompetant individuals. Tubercular brain abscess along with liver abscess is a rare phenomenon especially in an immunocompetent patient. We hereby report this rare presentation in a young immunocompetant male patient. Recognizing this rare clinical entity early is essential, as timely institution of antitubercular therapy can save the life.
Keywords: Immunocompetent, liver abscess, tubercular brain abscess
|How to cite this article:|
Gupta N, Sonambekar A, Swadi A, Nair N. Tubercular brain and liver abscesses in an immunocompetent young male. Med J DY Patil Univ 2015;8:395-7
| Introduction|| |
Central nervous tuberculosis (TB) may manifest in the form of meningitis, tuberculomas or very rarely as tubercular abscess. A tubercular abscess in an immunocompetant individual is particularly rare. Diagnosis is based upon demonstration of tubercular bacilli in the pus aspirate by culture or acid-fast bacilli (AFB). Treatment consists principally of antitubercular therapy (ATT) and drainage of pus, in cases of singular abscess. We report a case of multiple tubercular brain abscess (TBA) along with liver abscess in an immunocompetent young male. In this case, confirmation of tubercular etiology was done by aspiration of liver abscess and its positive AFB staining and culture. Brain abscess was not tapped due to the characteristic magnetic resonance imaging (MRI) picture and multiple lesions. Treatment was initiated with the first line antitubercular drugs and other conservative management. The patient responded clinically and is now symptom free, and continues to remain on follow-up.
| Case Report|| |
A 30-year-old male patient presented to the medical emergency with a history of low grade fever, decreased appetite, fatigue, and nausea for last 1 month, right hypochondriac pain for 3 weeks and single episode of convulsion, followed by loss of consciousness 4 h back. There was no history of headache, weakness of any part of body, trauma, visual or ear complaints. There was no significant past or family history. There was also no history of any high-risk behavior or drug abuse.
On examination, the patient was drowsy with postictal confusion. His Glasgow coma scale score was E1M5V3, and was hemodynamically stable. General physical examination did not reveal any abnormality. There was no neck rigidity; Kernig's and Brudizinski's sign being negative. Bilateral plantars were up-going, with no focal neurological deficit or cranial nerve abnormality. Fundus examination was normal. Per-abdominal examination revealed mild hepatomegaly. The rest of systemic examination was normal.
On investigations, complete hemogram was normal, except for a high erythrocyte sedimentation rate of 30; liver and kidney function tests were normal. Serum calcium was 8.5 mg/dl. Montoux test was positive. HIV test was negative. Chest X-ray was normal. MRI revealed multiple ring enhancing lesions scattered in the supra and infra tentorial brain parenchyma [Figure 1] involving left frontal lobe [Figure 2], right paracentral lobule and both cerebellar hemispheres associated with marked surrounding edema in the left frontal lobule. Areas of focal acute infarct were noted in left frontal lobe white matter. A brain biopsy was performed and the contents were positive for AFB by Ziehl - Neelsen (ZN))-staining. Culture growth was positive for mycobacterium TB. TB polymerase chain reaction was also positive.
|Figure 1: Magnetic resonance imaging showing ring enhancing lesions scattered in brain parenchyma|
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|Figure 2: Magnetic resonance imaging revealing ring enhancing lesion in left frontal lobe|
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Ultrasonography abdomen was suggestive of multiple liver abscesses. Liver abscess aspirate was positive for AFB by ZN-staining and culture growth revealed Mycobacterium TB. With a clinical impression of disseminated TB, standard first line ATT was instituted with other conservative management. Patient became fully conscious and was discharged after 15 days of hospital stay. Patient has completed the intensive phase of ATT and is now on continuation phase.
| Discussion|| |
Tubercular abscess closely mimics pyogenic abscess. Whitener, in 1978, had reviewed world literature on TBA and concluded that this disease process is more common in the third or fourth decade of life, and in around 35% of the cases, the abscess were multiple. They were predominantly supratentorial in location.  Tubercular abscess are rare, even in countries where TB is endemic.  In our case, the patient was a 30-year-old male. He was immunocompetant, without any history of Koch's in the past. Kaushik, et al. in their study have reported a case of TBA in a young immunocompromised male.  Vidal et al. have also reported a similar case.  Narang, et al. have reported multiple abscesses in a child in 2010.  Cardenas reviewed six such cases in immunocompetant individuals in 2010. 
Tubercular etiology of liver abscess in our case was confirmed by ZN-staining and culture. Since brain abscesses were multiple, and MRI was very much suggestive of tubercular etiology, they were not tapped. Magnetic resonance spectroscopy, though can help in distinction of tubercular and pyogenic abscesses,  it was not done in our case due to patient unaffordability.
Patient responded to the first line ATT and other conservative treatment.
| Conclusion|| |
Tubercular brain abscess along with liver abscess are a rare clinical entity in an immunocompetent person. Etiological diagnosis can be established by pus aspiration from easily accessible sites. Hence, screening for evidence of TB in other organ systems should be actively sought in cases of suspected brain abscesses. Early diagnosis and prompt institution of antitubercular treatment in such cases can save life.
| References|| |
Whitener DR. Tuberculous brain abscess. Report of a case and review of the literature. Arch Neurol 1978;35:148-55.
Bottieau E, Noë A, Florence E, Colebunders R. Multiple tuberculous brain abscesses in an HIV-infected patient successfully treated with HAART and antituberculous treatment. Infection 2003;31:118-20.
Kaushik K, Karade S, Kumar S, Kapila K. Tuberculous brain abscess in a patient with HIV infection. Indian J Tuberc 2007;54:196-8.
Vidal JE, Cimerman S, da Silva PR, Sztajnbok J, Coelho JF, Lins DL. Tuberculous brain abscess in a patient with AIDS: Case report and literature review. Rev Inst Med Trop Sao Paulo 2003;45:111-4.
Narang M, Gomber S, Upreti L, Dua S. Multiple intracranial tubercular abscesses in a child. Kathmandu Univ Med J (KUMJ) 2010;8:244-6.
Cárdenas G, Soto-Hernández JL, Orozco RV, Silva EG, Revuelta R, Amador JL. Tuberculous brain abscesses in immunocompetent patients: Management and outcome. Neurosurgery 2010;67:1081-7.
Gupta RK, Vatsal DK, Husain N, Chawla S, Prasad KN, Roy R, et al
. Differentiation of tuberculous from pyogenic brain abscesses with in vivo
proton MR spectroscopy and magnetization transfer MR imaging. AJNR Am J Neuroradiol 2001;22:1503-9.
[Figure 1], [Figure 2]