Bilateral Tuberculous Otitis Media with Cerebellar Abscess in an Immunocompromised Child
1Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Hosur Road, Near Dairy Circle, Bengaluru, Karnataka, India
Corresponding Author: Preetham S Dange, Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India, Phone: +91 9449472866, e-mail: firstname.lastname@example.org
Received on: 02 September 2021; Accepted on: 12 December 2021; Published on: 31 December 2022
Aim: Reporting a rare case of bilateral tuberculous otitis media with cerebellar abscess, its treatment and its outcome.
Background: Mycobacterial tuberculosis is a rare cause of otitis media. Nevertheless, it is more commonly encountered in immunocompromised children. Delay in diagnosis and inadequate treatment can cause intra-cranial spread. Cases of tuberculous cerebellar abscess due to otitis media in immunocompromised patients have hardly been documented in literature.
Case description: 7-year-old male child with HIV infection presented with History of ear discharge from 3 years and recent onset of cerebellar symptoms. He was diagnosed to have cerebellar abscess and was treated with twist drill aspiration and ventriculoperitoneal shunt. The child had recurrence of the abscess. Craniotomy and excision of the abscess was done. ZN staining of the pus showed Acid-fast bacilli. The child recovered with full course of anti-tubercular drugs.
Conclusion: A tuberculous cerebellar abscess has a good prognosis even in an immunocompromised child if treated adequately.
Clinical significance: Tuberculous etiology for otitis media must be suspected early in the presentation of an immunocompromised child with ear discharge especially when bilateral aggressive surgical approaches like craniotomy and excision must be considered when the disease is more wide spread such as in bilateral ear disease.
How to cite this article: Dange PS, Raj PA. Bilateral Tuberculous Otitis Media with Cerebellar Abscess in an Immunocompromised Child. Pediatr Inf Dis 2022;4(4):147-150.
Source of support: Nil
Conflict of interest: None
Keywords: Extrapulmonary tuberculosis, Tuberculous cerebellar abscess, Tuberculous otitis media.
Tuberculous otitis media is still rampant in India and other developing nations, with an incidence of 1.5 per 1,000 population; 4 per 1,000 population are bacteriologically positive in India.1 Complications of TBOM include cerebellar abscess caused by spread of tubercular bacilli from middle ear and is life-threatening. It requires prompt recognition and adequate treatment. This inadvertent complication of tuberculous otitis media is rarely reported in scientific literature. Henceforth, we report a case of cerebellar abscess in a 7-year-old HIV-infected boy with bilateral otitis media treated with surgical excision resulting in clinical and radiological cure.
History and examination: A 7-year-old male with HIV infection presented to us with intermittent seropurulent discharge in bilateral ears since 3 years. Patient was diagnosed as a case of Chronic Suppurative Otitis Media (CSOM) and was managed medically. Patient developed swaying while walking. Upon evaluation, patient was found to have cerebellar abscess on Contrast-Enhanced Computed Tomography (CECT) brain (Fig. 1). Patient underwent ventriculo-peritonial shunt (right Frazier’s point) and burr hole and aspiration of the pus.
Following surgery, patient noticed transient improvement followed by worsening of the earlier symptoms; ear discharge persisted. Swaying while walking worsened and patient also developed cough, headache, and pus discharge from the operative site. On presentation to National Institute of Mental Health and Neuro Sciences (NIMHANS), patient was conscious and oriented. He was afebrile and had no neck rigidity. Left cerebellar signs were present. Purulent discharge from the burr hole site was also noted.
Investigations: Computed Tomography (CT) temporal bone showed sclerosis in bilateral middle ear (Fig. 2). Chest X-ray Postero Anterior (PA) view revealed heterogeneous infiltrates in bilateral lung fields (Fig. 3). Magnetic Resonance Imaging (MRI) brain revealed T2 heterogeneous lesion with peripheral contrast enhancement in the left cerebellar hemisphere extending into the vermis causing compression of the fourth ventricle. Diffusion-weighted imaging showed diffusion restriction (Fig. 4).
Surgery: Patient underwent left paramedian suboccipital craniectomy and excision of the abscess. Craniectomy was created from the previous burr hole site. Cortisectomy revealed yellowish grey colored pus. Abscess wall was thick and tough. It also contained loculations at multiple places. The entire abscess wall was excised except the part that was firmly adherent to the brainstem. Dura was primarily closed.
Post-op course and follow-up: Patient recovered from the surgery well. Post-op scan was showing complete excision of the abscess (Fig. 5). Patient was discharged in a stable condition with advice to continue antitubercular drugs for 18 months.
Zeil Neilsen (ZN) staining of the pus revealed tubercle bacilli.
Histopathological examination revealed florid granulation tissue with well-formed epithelioid cell granulomas and areas of caseous necrosis. Surrounding parenchyma showed cerebritis.
Patient was followed up with imaging and clinical examination for 2 years. Patient had complete resolution of the abscess on MRI at 2 years.
Extrapulmonary tuberculosis is a common disease in India and other developing nations. In a cross-sectional study by Stani et al., the incidence of extrapulmonary tuberculosis was 6.1% which was much lower compared to reported incidences from the western world which was 15–40%.1 TBOM accounts for 0.1% of all cases and 1.7% of extrapulmonary tuberculosis in India.1 TBOM is often diagnosed late because of the rarity of occurrence and difficulty in diagnosis.2,3 The duration of illness in our present report was 3 years. In endemic countries, tuberculous otitis media is an important differential diagnosis of chronic otorrhea that is unresponsive to conventional antibacterial therapy. Rarely, if these cases are operated suspecting chronic active otitis media, otorrhea may recur and healing maybe slow and incomplete. Cough, fever, and night sweats maybe present.4 Classically, painless otorrhea and multiple perforations of the tympanic membrane were described as findings suspicious of TBOM.5 However, in a series of 13 cases published by Yaniv et al., patients with severe conductive hearing loss, abundant pale granulations, and an eroded malleus handle were more commonly diagnosed with TBOM.6 Presence of facial nerve palsy is highly suggestive of TBOM.3 Chronic ear discharge from both ears in an immunocompromised child, such as in our report should be highly suspicious of tuberculous otitis media.
The bacilli can gain entry into the middle ear through (1) Eustachian tube, (2) Blood stream, (3) Contiguously from intracranial and extracranial sites7, and (4) Genital tract of the mother with genital tuberculosis during birth (rare).8
Our patient was found to have Acid-fast bacilli (AFB) in ear discharge on ZN staining. Ordinarily, TBOM is a difficult case to diagnose. Positive culture for tubercle bacilli yields the most definitive evidence. However, AFB are found in ear discharge only in 5–35% of the cases of TBOM.2,3 For diagnosing TBOM, chest radiograph, purified protein derivative skin testing, and ZN staining of ear secretions for AFB are necessary. Surgical biopsy demonstrates chronic caseous necrosis and granuloma formation. Middle ear mucosal biopsy and aural polypectomy yielded diagnosis in only 30 and 35% of the cases, respectively.9
Most common intracranial complications of TBOM include tuberculoma, otitic hydrocephalus, and tuberculous meningitis10. Differential diagnoses of a brain abscess on radiology include pyogenic abscess, fungal abscess and tuberculoma. Tuberculous abscess can be diagnosed with MRI. Tubercular abscesses can be single or multiple, often being multiloculated. These abscesses have smooth walls with regular thickness and show ring enhancement on contrast. On Diffusion Weighted Imaging (DWI), low apparent diffusion coefficient has been found in fungal, tubercular abscesses, and pyogenic abscesses. Tuberculous brain abscesses exhibit significantly lower magnetization transfer ratios compared with those of pyogenic abscesses, with no evidence of amino acids on MR specroscopy – a spectral hallmark of the pyogenic abscess.11
Only one case of tuberculous cerebellar abscess as a complication of TBOM has been reported in literature.12 Patient was a 14-year-old girl from Thailand diagnosed to have right TBOM with right cerebellar abscess on CT scan. Presence of hydrocephalus is not commented upon. Patient was managed with right radical mastoidectomy and aspiration of the abscess along with continuation of ATT.
Our patient had hydrocephalus which was initially managed with Ventricolo Peritonial (VP) shunt followed by aspiration of the abscess and ATT. However, the abscess recurred and patient underwent suboccipital craniectomy and excision of the abscess. TBOM was managed with ATT.
Kirsch et al. reported that most of the cases with TBOM resolve with ATT and do not require surgery.3 The case reported by Peninnah Oberdorfer had a small well-defined abscess without distortion of the fourth ventricle and percutaneous aspiration was plausible.
Conversely, the abscess in our case was large with perilesional edema causing distortion of the fourth ventricle with resultant hydrocephalus. Percutaneous aspiration in this scenario must have been undertreatment and hence excision of the abscess by craniotomy was considered as a better alternative. The initial non-responsiveness of the treatment could also be related to the CD4 counts, nutrition, or other factors which cannot be conclusively proved to be responsible.
A series of tubercular cerebellar abscesses have been reported by Chakraborti et al.13 from National Institute of Mental Health and Neuro Sciences in which 10 cases of cerebellar tuberculosis were reported. Two among them had previous history of CSOM, three had pulmonary tuberculosis, two had disseminated disease, one had Pott’s spine and rest had no significant past history. Therefore, it can also be concluded that in a case of tuberculous cerebellar abscess, CSOM or pulmonary infection must be actively sought.
Despite the fact that cerebellar abscess in a case of CSOM points to the presence of pyogenic organisms, it is prudent to test for presence of AFB, especially in endemic countries. Patients with tuberculous cerebellar abscess have good outcome when recognized early and managed both medically as well as surgically. On the other hand, TBOM can be managed with ATT alone in most of the cases.2
Tuberculous otitis media, although a rare diagnosis, must be sought early in the evaluation of an immunocompromised patient with ear discharge. A tuberculous cerebellar abscess has a good prognosis even in an immunocompromised child if treated adequately.
Mycobacterial tuberculosis is a rare cause of otitis media in immunocompromised children, which can involve the brain secondarily. Antitubercular drugs with or without surgical intervention can cure the condition. Tuberculous etiology for otitis media must be suspected early in the presentation of an immunocompromised child with ear discharge especially when bilateral aggressive surgical approach like craniotomy and excision must be considered when the disease is more wide spread such as in bilateral ear disease.
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