Childs Nerv Syst (2010) 26:11171120
DOI 10.1007/s00381-010-1157-3
CASE REPORT
Pediatric intracranial subdural empyema caused
by Mycobacterium tuberculosisa case report
and review of literature
Anirban Deep Banerjee & Paritosh Pandey &
Sudheer Ambekar & B. A. Chandramouli
Received: 6 March 2010 / Accepted: 13 April 2010 / Published online: 2 May 2010
# Springer-Verlag 2010
Abstract
Introduction Intracranial subdural tubercular empyema is
an extremely rare entity. To our knowledge, only one such
case has been previously reported in the pediatric popula-
tion (Cayli et al. J Neurosurg 94(6):988991, 2001). We
report a case of intracranial tubercular subdural empyema in
a child, with both convexity and interhemispheric fissure
involvement.
Case material A 12-year-old boy with history of exposure
to an active case of pulmonary tuberculosis (his father)
presented to our institution with features of raised intracra-
nial pressure and fever for 1 month and altered sensorium
for 2 days. Computerized tomography (contrast enhanced)
revealed a left fronto-parietal and interhemispheric subdural
space abscess. A left fronto-parietal craniotomy was
performed and the subdural empyema was evacuated, and
adjacent calvarium was normal. ZiehlNeelsen staining
A. D. Banerjee : P. Pandey (*) : S. Ambekar :
B. A. Chandramouli
Department of Neurosurgery,
National Institute of Mental Health and Neurosciences (NIMHANS),
Bangalore 560029, India
e-mail: paritosh2000@gmail.com
A. D. Banerjee
e-mail: anirbandeepbanerjee@yahoo.com
S. Ambekar
e-mail: Sudheer19a@gmail.com
B. A. Chandramouli
e-mail: bacmouli@gmail.com
A. D. Banerjee : P. Pandey : S. Ambekar : B. A. Chandramouli
National Institute of Mental Health and Neurosciences (NIMHANS),
Bangalore, India
revealed acid-fast bacilli and the subsequent polymerase
chain reaction test was positive. Histopathological exami-
nation showed granulation tissue including scattered mul-
tinucleated giant cells and caseation. Mycobacterium
tuberculosis bacilli were the sole organisms cultured after
6 weeks. Anti-tuberculous treatment was given in appro-
priate doses for 18 months at the end of which the patient
was doing well with no deficits.
Conclusion Intracranial tubercular subdural empyema in
the pediatric age group is an extremely rare but curable
entity.
Keywords Pediatric . Intracranial . Tubercular .
Subdural space . Empyema
Introduction
Manifestations of neurotuberculosis in children constitute a
wide spectrum [2]. However, its presentation as subdural
empyema is anecdotal at best. Till date, only two cases of
intracranial tubercular subdural empyema have been
reported in English literature [1, 3], of which one was in
the pediatric age group [1]. In the latter case, a 1-year-old
boy, a known case of pulmonary tuberculosis, presented
with nausea, vomiting, and lethargy and was diagnosed to
be suffering from a right fronto-parietal subdural empyema
with no evidence of calvarial infection. He was successfully
treated with craniotomy and a 12-month course of anti-
tuberculous therapy following a positive polymerase chain
reaction test histopathological examination. We report a
unique case of pediatric intracranial subdural tubercular
empyema with both convexity and interhemispheric fissure
involvement.
1118 Childs Nerv Syst (2010) 26:11171120

Case material

History and examination A 12-year-old boy with history of

exposure to an active case of pulmonary tuberculosis (his
father) was brought to our institution with features of raised
intracranial pressure and fever for 1 month and altered
sensorium for 2 days. On admission, the boy had a
Glasgow Coma Scale score of 13, no focal deficits, and
no clinical signs of meningism. Results of routine labora-
tory studies were normal except a raised total white blood
cell count. Computerized tomography (contrast enhanced)
revealed a left fronto-parietal and interhemispheric subdural
space abscess with no evidence of calvarial involvement
(Fig. 1).

Operation A left fronto-parietal craniotomy was per-

formed. In opening the dura, a thick yellow capsule was
encountered, containing purulent material. The outer cap-
sule was totally excised, along with evacuation of the
nonfoul smelling purulent fluid. Adjacent calvarium was
normal.
Adjuvant therapy Peri-operatively, an intravenous empirical
high-dose antibiotic regimen consisting of ceftriaxone,
gentamycin, and metronidazole was given in appropriate
doses. ZiehlNeelsen staining revealed acid-fast bacilli
(Fig. 2) followed by a positive polymerase chain reaction
test. Histopathological examination revealed granulation
tissue, scattered multinucleated giant cells, and caseation
Fig. 2 ZiehlNeelsen staining revealed acid-fast bacilli
(Fig. 3). The patient was treated with a four-drug oral anti-
tubercular regime: rifampicin (15 mg/kg/day) and isoniazid
(10 mg/kg/day) for 18 months along with pyridoxine
(20 mg/day) and pyrazinamide (25 mg/kg/day) and etham-
butol (15 mg/kg/day) for 3 months. Mycobacterium
tuberculosis bacilli were the sole organisms cultured after
6 weeks.
Post-operative course The post-operative course and the
subsequent follow-up reviews were uneventful. At the end
of 18 months, the patient did not have any deficits and there
was no evidence of recurrence (Fig. 4).

Discussion

Formation of an intracranial subdural empyema is a rare

Fig. 1 Axial post-contrast CT head image showed a left fronto-
parietal and interhemispheric subdural space abscess with no evidence
of calvarial involvement
manifestation of neurotuberculosis. There are only two
reported cases of intracranial subdural empyema caused by
M. tuberculosis [1, 3], of which one has been documented
in the pediatric age group [1]. The former of these reports
describes a 59-year-old patient with a 5-year history of
pulmonary tuberculosis. CT scan revealed rim calcification
and cranial osteitis, in addition to underlying subdural pus
collection. The probable mechanism was thought to be a
hematogenous dissemination from the lungs, causing
osteitis of the cranium, which in turn had retrogradely
spread to the subdural space through diploic veins. The
patient achieved good outcome following adequate surgical
drainage and appropriate 18-month course of anti-
tubercular medications [3].
Childs Nerv Syst (2010) 26:11171120
Fig. 3 Photomicrograph (a)
showing tubercular granulation
tissue with caseation.
b Langhans giant cell (H & E
stain, 100)
The second case report elucidates about a 1-year-old
patient who was a known case of pulmonary tuberculo-
sis. The patient presented with nausea, vomiting, and
lethargy and was diagnosed to be suffering from a right
fronto-parietal subdural empyema with no evidence of
calvarial infection. The patient was successfully treated
with craniotomy evacuation and a 12-month course of
anti-tuberculous therapy following a positive polymerase
Fig. 4 Follow-up (18 months) axial post-contrast CT head image
showed no recurrence
1119
chain reaction test and concordant histopathological
examination [1].
Our patient was a 12-year-old boy with a history of
exposure to active pulmonary tuberculosis. In our case, CT
head revealed involvement of both the pariety (left fronto-
parietal region) as well as the interhemispheric fissure.
There was no clinico-radiological evidence of cranial
involvement; subsequent surgical exposure revealed the
same. The possible pathogenetic process might have been a
hematogenous dissemination of tuberculous bacilli from the
lung to the subdural space, forming perhaps, a small subpial
tuberculous granuloma, followed by rupture of this granu-
loma into the adjacent subarachnoid space. Focal rupture of
the consequently affected arachnoid possibly led to the
percolation of microorganisms into the unrestricted sub-
dural space and eventual formation of diffuse subdural
empyema. This mechanism is implicated by the interhemi-
spheric subdural pus collection as well. The dura mater and
arachnoid together might have confined the pathogenetic
process, thus preventing further involvement of the
meninges, the epidural space or the calvarium. Following
craniotomy and evacuation of the purulent collection, the
patient achieved full recovery after an 18-month course of
anti-tubercular medications.
Conclusion
Intracranial tubercular subdural empyema in the pediatric
age group is a very rare manifestation of neurotubercu-
losis. It is curable if diagnosed promptly and managed
appropriately with surgical evacuation and anti-tubercular
medications.
1120
References
1. Cayli SR, Onal C, Koak A, Onmu SH, Tekiner A (2001) An
unusual presentation of neurotuberculosis: subdural empyema.
Case report. J Neurosurg 94(6):988991
Childs Nerv Syst (2010) 26:11171120
2. Gelabert M, Castro-Gago M (1988) Hydrocephalus and tuberculous
meningitis in children: report on 26 cases. Childs Nerv Syst 4:268
270
3. van Dellen A, Nadvi SS, Nathoo N, Ramdial PK (1998)
Intracranial tuberculous subdural empyema: case report. Neurosur-
gery 43(2):370373