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CASE REPORT
Year : 2022  |  Volume : 70  |  Issue : 2  |  Page : 775-777

Clival Tuberculosis: A Case Report


Department of Neurosurgery, BYL Nair Ch. Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India

Date of Submission15-Aug-2018
Date of Decision16-Nov-2019
Date of Acceptance20-Jan-2020
Date of Web Publication3-May-2022

Correspondence Address:
Dr. Trimurti D Nadkarni
Department of Neurosurgery, BYL Nair Ch. Hospital and Topiwala National Medical College, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.344665

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 » Abstract 


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. On examination she had hypoesthesia over left half of face, associated with bilateral abductor and left facial palsy. Neuroradiology showed a well-defined lytic lesion involving the clivus and adjacent sphenoid sinus and sella. The patient underwent an endoscopic transnasal decompression of the clival lesion. Intraoperative squash preparation was reported to show tuberculous granulation, which was confirmed on postoperative histology. The patient was advised anti-tubercular therapy. At 12 months follow up neuroradiology showed a near total resolution of the clival lesion. The patient had completely recovered from her cranial nerve deficits. Tuberculous involvement of spheno-clival region is rare and the authors' literature search has yielded only three previous similar case reports. A surgical decompression followed by anti-tubercular therapy is the recommended approach for management of clival tuberculosis. The relevant literature on the subject is presented.


Keywords: Endoscopic approach, primary clival tuberculosis
Key Message: TB of the spheno-clival region is a rare entity and should be included in the differential diagnosis of such cases, especially in areas where TB is endemic. Squash preparation has a very important role in such lesions as the surgical strategy can be conservative in tuberculous pathology as postoperative medical anti-TB treatment results in complete resolution of the disease. Trans-nasal endoscopy offers a minimally invasive approach for surgical management of spheno-clival tumors.


How to cite this article:
Gandhi AS, Nadkarni TD, Balasubramaniam S. Clival Tuberculosis: A Case Report. Neurol India 2022;70:775-7

How to cite this URL:
Gandhi AS, Nadkarni TD, Balasubramaniam S. Clival Tuberculosis: A Case Report. Neurol India [serial online] 2022 [cited 2022 Jun 27];70:775-7. Available from: https://www.neurologyindia.com/text.asp?2022/70/2/775/344665




Tuberculosis (TB) is caused by Mycobacterium tuberculosis and atypical mycobacteria. The incidence of TB in India is 84 per 100,000 cases annually.[1] Worldwide 10.4 million cases of TB are reported. Of all patients of TB, 1–2% have involvement of skeletal system.[2] Spinal TB constitutes 50% of all cases of skeletal TB.[3] Cranio- Vertebral Junction (CVJ) TB accounts for only 0.3–1% of all spinal TB[4] 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.[5],[6],[7] We present a case of primary tuberculosis of clivus and our management protocol.


 » Case History Top


Clinical summary

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.
Figure 1: (a) Computerized tomography (CT) of paranasal sinuses show an osteolytic lesion eroding the clivus. (b) Magnetic resonance (MR) imaging of brain and craniovertebral junction shows an enhancing mass involving the clivus and adjacent bone

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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.

Pathological findings

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].
Figure 2: Photomicrograph of clival mass showing multiple noncaseating epitheloid cell granulomas (Arrows) and occasional epitheloid cell granulomas with spotty necrosis with Langhan's Giant cells in the background of lymphocytes, plasma cells, histiocytes and neutrophils (H and E, 40X)

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Post-operative management

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].
Figure 3: (a) Post operative Computerised tomography (CT) of paranasal sinuses shows healing of inflammatory tuberculous clival lesion. (b) Post operative Magnetic resonance (MR) sagittal image shows near total resolution of the clival lesion

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 » Discussion Top


TB involves the CVJ causing AAD.[8] Skull involvement in tuberculosis is very rare (1% of skeletal TB). Primary tuberculoma of clivus sparing CVJ is extremely rare.[6],[9] Only three case reports of spheno-clival TB without involvement of CVJ are reported till date which are tabulated in [Table 1].[5],[6],[7] The present case report is the first case to be managed endoscopically.
Table 1: Literature survey of patients with Spheno-Clival tuberculosis sparing the Cranio-Vertebral Junction

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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.[6],[7]

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.[5],[10]

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.[11] 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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Chakraborthy AK. Epidemiology of tuberculosis: Current status in India. Indian J Med Res 2004;120:248-76.  Back to cited text no. 1
    
2.
Agrawal V, Patgaonkar PR, Nagariya SP. Tuberculosisi of spine. J Craniovertbr Junction Spine 2010;1:74-85.  Back to cited text no. 2
    
3.
Rasauli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Movaghar VR. Spinal tuberculosis: Diagnosis and management. Asian Spine J 2012;6:294-308.  Back to cited text no. 3
    
4.
Qureshi MA, Afzal W, Khalique AB, Pasha IF, Aebi M. Tuberculosis of the craniovertebral junction. Eur Spine J 2013;4:612-7.  Back to cited text no. 4
    
5.
Indira Devi B, Tyagi AK, Bhat DI, Santosh V. Tuberculous osteitis of clivus. Neurol India 2003;51:69-70.  Back to cited text no. 5
    
6.
Shenoy SN, Raja A. Tuberculous granuloma of the spheno-clival region. Neurol India 2004;52:129-30.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Bhavanam HS, Rajesh A, Uppin MS. Tubercular osteomyelitis of spheno-clival region presenting with lateral rectus palsy. Neurol India 2014;62:198-200.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Kanaan IU, Ellis M, Safi T, Al Kawi MZ, Coates R. Craniocervical junction tuberculosis: A rare but dangerous disease. Surg Neurol 1999;51:21-5.  Back to cited text no. 8
    
9.
Selvapandian S, Chandy MJ. Tuberculous granuloma of the clivus. Br J Neurosurg 1993;7:581-2.  Back to cited text no. 9
    
10.
Vellutini Ede A, Balsalobre L, Hermann DR, Stamm AC. The endoscopic endonasal approach for extradural and intradural clivus lesions. World Neurosurg 2014;82:S106-15.  Back to cited text no. 10
    
11.
Augier A, Zrig H, Roqueplan F, Brauner M, Dumas JL. MR and CT features of craniocervical junction tuberculosis: A report of 5 cases. J Radiol. 2008;89:585-9.  Back to cited text no. 11
    


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