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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 2  |  Page : 198-200

Tubercular osteomyelitis of spheno-clival region presenting with lateral rectus palsy


1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
2 Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India

Date of Submission03-Feb-2014
Date of Decision08-Feb-2014
Date of Acceptance09-Apr-2014
Date of Web Publication14-May-2014

Correspondence Address:
Alugolu Rajesh
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.132400

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How to cite this article:
Bhavanam HS, Rajesh A, Uppin MS. Tubercular osteomyelitis of spheno-clival region presenting with lateral rectus palsy. Neurol India 2014;62:198-200

How to cite this URL:
Bhavanam HS, Rajesh A, Uppin MS. Tubercular osteomyelitis of spheno-clival region presenting with lateral rectus palsy. Neurol India [serial online] 2014 [cited 2021 Feb 27];62:198-200. Available from: https://www.neurologyindia.com/text.asp?2014/62/2/198/132400


Sir,

Sphenoclival tuberculosis without involvement of cranio-vertebral junction is quite rare and only two cases have been reported. [1],[2] Herein, we report the third case.

A 20-year-old male presented with headache, double vision, vomiting and evening rise of temperature of one month duration. Neurologic examination revealed only left sixth nerve palsy and normal ocular fundii. Brain computer tomography (CT) showed lesion in the sphenoid sinus with clivus destruction and minimal heterogenous contrast enhancement and intact cranio-vertebral junction [Figure 1]a-d. Magnetic resonance imaging (MRI) showed heterogeneous lesion involving the sphenoid sinus, posterior ethmoids and the clivus, isointense on T1W, and iso to hyperintense on T2W images. Contrast imaging could not be done because of affordablity [Figure 2]. Working diagnosis was clival chordoma. His pre-surgical evaluation was unremarkable. Microscopic transnasal exploration revealed sphenoid cavity filled with a yellowish, soft-to-firm cheesy lesion entering into the clivus. Frozen section revealed granulomatous lesion. The floor of the sphenoid and the clivus was drilled using high- speed drill till the dura. Sixth nerve function improved to normalcy by tenth postoperative day. Histological examination showed evidence of caseating necrosis with well-formed granulomas, epitheloid cells, and both Langhan's and foreign body giant cells. There was no growth of Mycobacterium tuberculosis on  BACTEC- 460 Tb system (Becton Dickinson, USA) using the 12 B vials, till 6 weeks of incubation Mantoux test, performed in the postoperative period was 16 mm at 72 hrs. Sputum for acid-fast bacilli (AFB) was negative. Patient was started on anti-tubercular drugs for a total duration of 18 months. Computed tomography (CT) scan at 18 months showed complete resolution of the lesion with bony defect in the clivus [Figure 3].
Figure 1: CT scan of skull base (a- axial; b and c- bone windows; d-f- contrast) show a lesion in the sphenoid sinus and clivus with heterogenous enhancement on contrast

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Figure 2: MRI brain (a-T1W axial, b- T2W axial, c- T1W sagittal) shows a heterogenous lesion destroying the clivus and extending into the sphenoid sinus

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Figure 3: CT scan at the end of 18 months showing complete clearance with bony reformation

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Isolated tuberculosis of spheno-clival region is very rare; with most cases occurring along with cranio-vertebral junction. [3],[4] This presentation probably related to the downward direction of lymphatic drainage into the deep cervical nodes, probably assisted by the gravity too. However, the pattern of involvement and non-involvement of paranasal sinuses is of interest. We hypothesize that site of origin and spread of tuberculosis in clivus depend on the site of involvement, wherein the disease process starting above the sphenoclival syndesmosis will the paranasal sinus; whereas in others, the cranio-vertebral junction is involved. Radiological diagnosis of tuberculosis is difficult aided by detection of primary elsewhere in the body, with definitive diagnosis depending on culture of organism. [5] Main stay of management of tuberculosis of spheno-clival region consists of surgical debulking followed by long term anti-tubercular chemotherapy. [6]

Tuberculosis of skull base should be a differential diagnosis for spheno-clival region lesions in endemic zones.

 
  References Top

1.Selvapandian S, Chandy MJ. Tuberculous granuloma of the clivus. Br J Neurosurg 1993;7:581-2.  Back to cited text no. 1
    
2.Shenoy SN, Raja A. Tuberculous granuloma of the spheno-clival region. Neurol India 2004;52:129-30.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Witcombe JB, Cremin BJ. Tuberculous erosion of the sphenoid bone. Br J Radiol 1978;51:347-50.  Back to cited text no. 3
[PUBMED]    
4.Turel MK, Rajshekhar V. Sphenoid sinus tuberculosis: A rare cause of visual dysfunction in an adolescent girl. Neurol India 2013;61:179-80.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Sencer S, Sencer A, Aydin K, Hepgul K, Poyanli A, Minareci O. Imaging in tuberculosis of the skull and skull-base: Case report. Neuroradiology 2003;45:160-3.  Back to cited text no. 5
    
6.Indira Devi B, Tyagi AK, Bhat DI, Santosh V. Tuberculous osteitis of clivus. Neurol India 2003;51:69-70.  Back to cited text no. 6
    


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