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Year : 2000  |  Volume : 48  |  Issue : 1  |  Page : 91-2

Tuberculous osteomyelitis of the bone flap following craniotomy for a glioma.






How to cite this article:
Biniwale S N, Rajshekhar V. Tuberculous osteomyelitis of the bone flap following craniotomy for a glioma. Neurol India 2000;48:91


How to cite this URL:
Biniwale S N, Rajshekhar V. Tuberculous osteomyelitis of the bone flap following craniotomy for a glioma. Neurol India [serial online] 2000 [cited 2019 Sep 18];48:91. Available from: http://www.neurologyindia.com/text.asp?2000/48/1/91/1461



We report a patient in whom there was tuberculous osteomyelitis of the bone flap following craniotomy and radiation therapy for a glioma. This report emphasises the fact that while treating osteomyelitis of bone flap following craniotomy, possibility of tuberculosis should be considered especially in our country.
A 34 year old man presented with history suggestive of left contraversive seizures. Computerised tomography (CT) of brain revealed a right frontal mass lesion. He was a diabetic and was on oral antidiabetic agents. His routine hematological and biochemical investigations were normal. The chest Xray was normal. He was subjected to right frontal craniotony and CT guided stereotactic volumetric excision of the tumour. The bone was normal. A free bone flap was used and replaced. The biopsy was reported as astrocytoma grade II. The postoperative period was uneventful and there were no neurological deficits. He underwent radiotherapy postoperatively.
Nine months after surgery he noticed purulent discharge from the wound which did not subside with regular dressings and antibiotics. On examination, a sinus discharging pus was found in the anterior part of the wound. The neurological examination was normal. X-ray of the skull showed areas of osteolysis suggestive of osteomyelitis [Figure - 1]. Hence it was decided to remove the bone flap. He underwent the procedure and during surgery a subcutaneous pocket containing about 5 ml of creamy yellow pus was found along with exuberant extradural granulation tissue. The surrounding bone was normal. The osteomyelitic bone was sent for histopathological examination and the pus and granulation tissue were sent for routine, fungal and AFB cultures. The biopsy was reported as tuberculous osteomyelitis. The routine, AFB and fungal cultures showed no growth of micro-organisms. The patient was started on antituberculous treatment. On follow up, there was minimal occassional discharge from the posterior part of wound after one year of therapy. The antituberculous therapy was being continued. In the past five years, in our department, 26 patients were diagnosed to have postoperative cranial osteomyelitis and were subjected to removal of the bone flap. Thirteen of them had received radiotherapy following excision of the lesion. Sixteen cases were reported to have chronic non specific osteomyelitis and three to have acute nonspecific osteomyelitis. However, tuberculous involvement was not noted in any of these specimens.
Tuberculosis of the skull is a rare entity with occurrence of 1 in 10,000 cases of tuberculosis. Skeletal tuberculosis accounts for 1 to 3% of all cases of tuberculosis[1] and skull tuberculosis accounts for only 1% of all skeletal tuberculosis. Young persons are commonly involved, with 80% patients being less than 20 years of age and 50% being less than 10 years of age.[2] Skull involvement is believed to be haematogenous in origin and is rare. This is probably due to paucity of lymphatics in the skull. The role of local trauma has also been mentioned by some authors.[3]
The origin of the infection in this case is difficult to determine. The two possible routes could be haematogenous or a direct inoculation during surgery. As tuberculosis is endemic in our country, either of these routes could have been possible. Furthermore, being a diabetic patient he might have been predisposed to tuberculous infection. It is important to consider tuberculosis as a cause of postoperative osteomyelitis, as its treatment is quite distinct from pyogenic osteomyelitis which is the commonest cause of postoperative osteomyelitis. Hence, all bone flaps which are removed for suspected osteomyelitis should be sent for the histopathological examination and for AFB and fungal cultures, in addition to routine cultures.

 

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1.Tuli S: Epidemiology and Prevalance: Tuberculosis of the skeletal system: Jaypee brothers, New Delhi. 1993; 1.   Back to cited text no. 1    
2.Schuster J, Rakasun T, Chonmaitree T et al: Tuberculous osteitis of skull mimicking histiocytosis X. J Pediatr 1984; 105: 269-271.   Back to cited text no. 2    
3.Weir W, Murleedharan M: Tuberculosis arising at the site of primary injury: 8 case histories. J Infect 1983; 7: 63-64.   Back to cited text no. 3    

 

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Online since 20th March '04
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