Tuberculous brain abscess in a patient with AIDS: case report and literature review

A rare case of central nervous system tuberculosis

Intracranial abscess is an extremely rare form of central nervous system (CNS) tuberculosis (TB). We describe a case of central nervous system tuberculous abscess in absence of human immunodeficiency virus (HIV) infection. A 82-year-old Middle Eastern male from Yemen was initially brought to the emergency room due to altered mental status and acute renal failure. Cross-sectional imaging revealed multiple ring enhancing lesions located in the left cerebellum and in bilateral frontal lobe as well as in the inferior parietal lobe on the left. The patient was placed on an empiric antibiotic regimen. Preliminary testing for infectious causes was negative. Chest radiography and CT of chest showed no positive findings. He was not on any immunosuppressive medications and human immunodeficiency virus (HIV) enzyme immunoassay (EIA) test was negative. A subsequent MRI one month later showed profound worsening of the lesions with increasing vasogenic edema and newly found mass effect impinging on the fourth ventricle. Brain biopsy showed focal exudative cerebellitis and inflamed granulation tissue consistent with formation of abscesses. The diagnosis of CNS TB was finally confirmed by positive acid-fast bacilli (AFB) cultures. The patient was started on standard tuberculosis therapy but expired due to renal failure and cardiac arrest.

Recurrent Immune Reconstitution Inflammatory Syndrome of Tuberculous Brain Infection in People Living with HIV/AIDS

HIV infection has changed the scenario of infectious disease. HIV-associated immunodeficiency resulted in a wide spectrum of new opportunistic infections. After introduction of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS) became an important challenge in management of 10% to 25% of the patients. Meta-analyses of IRIS from various reports published worldwide by Monika Muller et al described 12% IRIS incidence and 15.7% IRIS tuberculosis. Among IRIS tuberculosis, central nervous system involvement with IRIS tuberculous meningitis forms only 7%. Only 9 cases of tuberculous brain abscess is reported in patients with AIDS so far. The IRIS tuberculous brain abscess is very rare, and so far only 1 case is reported as a paradoxical reaction after ART initiation. Here, we report a case of recurrent IRIS tuberculosis meningitis and brain abscess.

Tuberculous brain abscesses: Case series and review of literature

INTRODUCTION

Tuberculous brain abscess (TBA) is a rare but serious condition. It resembles a pyogenic brain abscess clinically and radiologically and poses a problem in diagnosis and treatment. A final diagnosis is established by smear or culture demonstration of acid fast bacilli (AFB) within the abscess. Here, we report four such cases in our five-year study on brain abscesses, along with the different diagnostic modalities used.

MATERIALS AND METHODS

A total of 75 brain abscess pus specimens were collected during neurosurgery, either by burr hole or by craniotomy. These specimens were further subjected to Gram stain, Ziehl-Neelsen (ZN) stain, and conventional microbiological culture. Only those cases which showed presence of AFB on ZN stain along with the growth of Mycobacterium tuberculosis were considered as TBAs. Such TBA cases were further presented along with their In vitro Proton Magnetic Resonance (MR) Spectroscopic findings.

RESULTS

Of these four patients, three were males. Though this condition is more commonly seen in immunocompromised patients, three of the patients in this study were immunocompetent. All the four pus specimens showed presence of AFB in the ZN stain. Three of them grew M. tuberculosis as sole isolate. The fourth case was of concomitant tuberculous and pyogenic brain abscess. In vitro Proton MR spectroscopy of the pus specimens showed absence of multiple amino acids at 0.9 ppm, which was found to be hallmark of TBA. One patient died of four.

CONCLUSIONS

TBA always poses a diagnostic dilemma. ZN stain and conventional microbiological culture for Mycobacteria always help to solve this dilemma. In vitro Proton MR Spectroscopy also seems to have the diagnostic utility.

Tuberculous brain abscesses in immunocompetent patients: management and outcome

BACKGROUND

Tuberculosis (TB) remains an important public health problem in developing countries.

OBJECTIVE

To evaluate the clinical presentation, management, and long-term outcome in 6 patients with tuberculous brain abscesses (TBA), an uncommon form of central nervous system (CNS) TB.

METHODS

A search of medical records of a single referral neurological center in Mexico City from 2002 to 2007 retrieved 149 patients with CNS TB; 6 of them (4%) met Whitener's criteria for TBA and were included in this review.

RESULTS

Five of six patients had a previous history of TB. Three patients were referred to our center under antituberculous treatment (ATT) for pulmonary and lymph node TB, and two patients were receiving ATT for TB meningitis at diagnosis of TBA. All presented with symptoms of intracranial hypertension and hemiparesis. On imaging studies, 3 patients had a single, deep multiloculated lesion and another three had separated lesions, all patients underwent surgery and received long courses of ATT. One patient died after surgery and the rest recovered with moderate to severe neurological sequelae. The residual lesions in 5 patients resolved in follow-up CT or MRI studies at a mean time of 10 months.

CONCLUSIONS

Early surgery confirms the diagnosis of TBA. Some patients may require additional surgical procedures if enlargement or recurrence of the lesion occurs. No evidence of drug resistance was found in our cases, and we found only two reports of TBA with primary resistance to ATT in a selective literature review. TBA does not seem to be a consequence of drug resistance. Sequelae are common, and long-term ATT with close clinical and imaging follow-up is mandatory.

Clinicopathological study of tuberculous brain abscess

Central nervous system tuberculosis is still one of the leading causes of morbidity in the developing world, and tuberculous abscess is one of its uncommon manifesting forms. It closely mimics a pyogenic abscess clinically, radiologically, and histologically. An accurate diagnosis is imperative due to therapeutic implications. In this study, 21 cases of tuberculous abscesses encountered over a period of 13 years (1995-2007) were reviewed to study the clinical, radiological, and histopathological spectrum of the disease. The presence of palisading epithelioid cells and sheets of foamy histiocytes, enclosing a neutrophillic exudate rich in fibrin with nuclear debris, were clues as to suspicion of a tuberculous abscess. The demonstration of acid fast bacilli in the wall of the abscess or necrotic contents by microscopy or culture is essential to confirm the diagnosis of tuberculous abscess. A high index of clinical suspicion is necessary particularly in countries endemic for tuberculosis to ensure an accurate diagnosis and application of an appropriate therapy.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

Tuberculous brain abscess in AIDS patients: report of three cases and literature review

OBJECTIVE

Clinical description of tuberculous brain abscess in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

Clinical case report and review of the literature from January 1981 to January 2003 using the MEDLINE database.

RESULTS

The authors report three cases of tuberculous brain abscess in AIDS patients and review nine similar cases. The mean age was 30 years (range: 18-56 years) with seven patients being male. Five (42%) were intravenous drug users, had prior history of extra-cerebral tuberculosis, and presented alterations on chest radiograph. Tuberculin skin test was anergic in six (75%) of eight patients. Three patients of nine had a CD4+ cell count higher than 200 cells/microL, and three had a CD4+ cell count lower than 100 cells/microl. All but one patient had a brain computerized tomography scan with a single lesion. All patients received anti-tuberculous treatment and underwent surgical procedures. Most patients (75%) showed appropriate clinical responses.

CONCLUSION

Tuberculous brain abscess must be considered in the differential diagnosis of intracranial mass in AIDS patients. A careful epidemiological, clinical and laboratory evaluation may guide a diagnostic suspicion. Surgery combined with specific anti-tuberculosis treatment seems to determine a good outcome.

Cerebral tuberculomas in AIDS patients: a forgotten diagnosis?

The human immunodeficiency virus (HIV) infection epidemics increased the prevalence, multi-drug resistance and disseminated forms of tuberculosis. The central nervous system (CNS) tuberculosis has high mortality and morbidity, and it is usually divided into diffuse (meningitis) and localized (tuberculoma and abscess) forms. We report three cases of cerebral tuberculomas in AIDS patients: one with definitive diagnosis, confirmed with histopathology, and two with probable diagnosis, based on clinical information, radiological images, Mycobaterium tuberculosis isolation out of the CNS and adequate response to antituberculous treatment. Further, we discuss diagnostic, therapeutic and prognostic issues of tuberculomas, with emphasis in the distinction from cerebral tuberculous abscesses. Despite of their infrequent presentation, tuberculomas should be considered in the differential diagnosis of cerebral expansive lesions in patients with AIDS.

Chagasic meningoencephalitis: case report of a recently included AIDS-defining illness in Brazil

Recently, reactivation of Chagas disease (meningoencephalitis and/or myocarditis) was included in the list of AIDS-defining illnesses in Brazil. We report a case of a 52-year-old patient with no history of previous disease who presented acute meningoencephalitis. Direct examination of blood and cerebrospinal fluid (CSF) showed Trypanosoma cruzi. CSF culture confirmed the diagnosis. Serological assays for T. cruzi and human immunodeficiency virus (HIV) were positive. Despite treatment with benznidazol and supportive measures, the patient died 24 hours after hospital admission. In endemic areas, reactivation of Chagas disease should always be considered in the differential diagnosis of meningoencephalitis among HIV-infected patients, and its presence is indicative of AIDS.