Clival Tuberculosis: A Case Report
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.344665
Source of Support: None, Conflict of Interest: None
Keywords: Endoscopic approach, primary clival tuberculosis
Tuberculosis (TB) is caused by Mycobacterium tuberculosis and atypical mycobacteria. The incidence of TB in India is 84 per 100,000 cases annually. Worldwide 10.4 million cases of TB are reported. Of all patients of TB, 1–2% have involvement of skeletal system. Spinal TB constitutes 50% of all cases of skeletal TB. Cranio- Vertebral Junction (CVJ) TB accounts for only 0.3–1% of all spinal TB and causes atlanto-axial dislocation (AAD). Primary tuberculoma of clivus sparing craniovertebral junction is extremely rare. Only three case reports of spheno-clival tuberculosis without involvement of cranio-vertebral junction are reported till date.,, We present a case of primary tuberculosis of clivus and our management protocol.
A 39-year-old female presented with complaints of occipital headaches, diplopia, numbness over left half of face and deviation of face to the right. The patient had no co-morbidities and had no past history of exposure to TB. On examination, she had hypoaesthesia over left half of face, associated with bilateral abductor and left facial palsies. Her routine laboratory investigations and chest radiograph were normal. There was no clinical or laboratory evidence of previous TB.
Magnetic resonance (MR) images of the brain showed a well-defined lytic lesion involving the clivus and adjacent sphenoid sinus and sella. Computerized tomography (CT) of the paransal sinuses demonstrated the lesion to be lobulated, expansile and osteolytic involving the clivus and eroding the posterior wall of sphenoid sinus and sellar floor [Figure 1]. A differential diagnosis of chordoma, chondrosarcoma, meningioma, and nasopharyngeal carcinoma were considered.
The patient underwent a transnasal endoscopic excision of the clival mass. A granulomatous mass was seen eroding the floor and medial walls of the sphenoid sinus and extending into the upper clivus. The lesion was partially excised. Intraoperative squash preparation was suggestive of chronic inflammatory mass probably of tuberculous origin. The patient made an uneventful postoperative recovery.
Histopathological examination of the clival mass showed chronic granulomatous inflammation of tuberculous origin. Multiple noncaseating epitheloid cell granulomas were noted along with occasional epitheloid cell granulomas with spotty necrosis and Langhan's giant cells, in the background of lymphocytes, plasma cells, histiocytes, and neutrophils. No evidence of mycobacterium, fungal hyphae or tumor was noted [Figure 2].
The patient was administered multidrug anti-tuberculous regimen. The patient had a gradual recovery of cranial nerve deficits in the next 6 months. Post-operative MR and CT imaging done at 12 months showed a near total resolution of the clival lesion [Figure 3].
TB involves the CVJ causing AAD. Skull involvement in tuberculosis is very rare (1% of skeletal TB). Primary tuberculoma of clivus sparing CVJ is extremely rare., Only three case reports of spheno-clival TB without involvement of CVJ are reported till date which are tabulated in [Table 1].,, The present case report is the first case to be managed endoscopically.
Usually TB has hematogenous transmission, but it can spread directly from pharyngeal lymphoid tissues. This is probably due to the downward direction of lymphatic drainage into the deep cervical nodes.,
The patient presented with headache and multiple cranial nerve involvement. The cranial neuropathies may have been due to leptomeningitis resulting in local ischemia, entrapment of the nerves in chronic inflammatory exudate or endarteritis.,
On imaging the tuberculous lesion of clivus showed heterogeneous intensity signal with multiple hypointense areas within it on T1W images and predominant isointense signal with few hyperintensities within it on T2W images. Unlike the typical ring enhancement noted in cerebral parenchyma granulomas, the clival involvement showed diffuse enhancement mimicking a tumor. A preoperative diagnosis of clival TB is difficult because of rarity of TB involvement of the clivus. Postoperative imaging showed a near total resolution of the clival lesion on completion of 1 year of anti-tuberculous therapy.
The mainstay of management of tuberculosis of spheno-clival region consists of surgical debulking, histopathological confirmation followed by long-term anti-tubercular chemotherapy. Our patient has been prescribed multidrug anti-tuberculous regimen for 2 years which includes administration of streptomycin, rifampicin, isoniazid, ethambutol, pyrazinamide along with pyridoxine. The TB granuloma resolved completely on radiology associated with resolution of neurological involvement.
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[Figure 1], [Figure 2], [Figure 3]