J Korean Neurosurg Soc.  2016 May;59(3):310-313. 10.3340/jkns.2016.59.3.310.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

• Kim J
• Kim C
• Ryu YJ
• Lee SJ

• KMID: 2192113
• DOI: http://doi.org/10.3340/jkns.2016.59.3.310

Abstract

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

Keyword

Empyema; Skull fracture; Trauma; Tuberculosis

MeSH Terms

Arm
Contusions
Craniotomy
Emergency Service, Hospital
Empyema
Empyema, Subdural*
Head
Hemorrhage
Humans
Maxilla
Middle Aged
Mycobacterium tuberculosis
Neurologic Examination
Orbit
Radius
Ribs
Scapula
Seizures
Skull Fractures*
Skull*
Thorax
Tuberculosis
Tuberculosis, Pulmonary
Zygoma

Figure

• 

  Fig. 1 Brain CT scan performed on the first day shows a skull fracture (A) and minimal cerebral contusion and intracranial hemorrhage (B).

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  Fig. 2 A: Preoperative brain CT scan performed on the eighteenth day shows left fronto-temporal and left occipital fluid collections. B: Preoperative axial MRI, T1-weighted gadolinium-enhanced images shows the empyema in the left occipital region.

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  Fig. 3 Photomicrograph of sections used for histopathological examination shows central caseous necrosis and palisading epithelioid cells (hematoxylin and eosin staining, original magnification ×200).

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  Fig. 4 Axial MRI performed six months after the operation, T1-weighted gadolinium-enhanced image shows complete disappearance of the left occipital empyema.

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