CAS E _RE POR T

Paediatric
calvarial

tuberculosis
s. Andronikou

FC Rad Dlag (SA)

C. Weiman
MBChB

E. Kader
MBChB

Department of PatJdiatric Radiology, University
of cape Town and Institute of Child Health,

Red Cross War Memorial Children ~ Hospital,
Rondebosch, cape Town

Co"esponding author
S. Andronikou

Department of PatJdlatric Radiology
RtJd Cross war Memorial Chlldren~ Hospital

cape Town
7700

Telephone: 021-6585442
Fax: 021-6585101

E-mail: docsaV@mweb.co.za

Abstract
Calvarial tubercu losis
is a rare presentation
of tubercu losis. We
present two cases seen
in the paediatric age
group of tuberculosis
involving the sphenoid
bone. One of the
patients was positive
for the human
immunodeficiency
virus (HIV). The
literature is reviewed
in brief.

Key words
Calvarial/ skull,
tuberculosis/ H/~ CT

Introduction
While tuberculosis (TB) is com-

mon in South Africa, it does not com-
monly affect bone. When it does, skull
involvement is rare. We present two
paediatric cases of calvarial TB with
discussion of the relevant literature.

Case 1
A three-and-a-half year-old boy

presented with a two-month history
of a slowly increasing swelling over
the right frontoparietal region of the
skull. There were no constitutional
symptoms ofTB or TB contacts. The
swelling was non-tender and was not
fluctuant. A skull X-ray (Figure la)
and a subsequent CT brain (Figures
lb and c) were performed. The diag-
nostic differential at this stage included

Figure la: Lucency involving the lateral right orbit
with lytic destruction (open arrow) of the right
greater wing of sphenoid.

20 SAJOURNAL OF RADIOLOGY. August 2000

TB, eosinophilic granuloma, neurob-
lastoma metastases and a primary
bone tumour. The ESR was raised (55
mm/hour) and the Mantoux was
strongly reactive. Chest X -ray was
suggestive of bilateral hilar adenopa-
thy. Full blood count and bone mar-
row aspirate were normal. Biopsy
demonstrated neerotising granuloma-
tous inflammation in keeping with TB.

Figure 1b: Coronal post-contrast CT of the head
demonstrates lytic destruction of the right greater
wing of sphenoid (open arrow) and lateral wall of
orbit (arrowhead) with associated soft tissue mass
extending into the temporal fossa.

Figure 1c: Axial post·contrast CT of the head
shows soft tissue swelling in the right frontopari-
etal region with contrast enhancing soft tissue on
both sides of the calvarium and in the region of
the right anterior temporal lobe.

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Paedi<ltric calvarialluberculosis

from page 20

He was commenced on three-drug
anti-TB treatment. At follow-up at
three months, the child was well and
the mass was decreasing in size.

Case 2
A 22-month-old HIV-positive boy

presented with fever and cough. He
had received four months of anti-TB
treatment for pulmonary TB, ending
six months prior to the current ad-
mission. There were no features of
meningitis but he was noted to have
marked developmental delay and a
CT brain was performed (Figures 2a
and b). CSF studies were supportive
of a diagnosis of tuberculous menin-
gitis.He was commenced on four-drug
antituberculous therapy.

Discussion
TB is endemic in developing coun-

tries and is becoming more prevalent
with the rise in human immunodefi-
ciency virus (HIV) infection. Calvarial
TB is rare, with only a few cases de-
scribed in the current literature.!"
About 0.01 % of mycobacterial infec-
tion involves the skull. It is a disease of
children, with 50% of the cases under
la years of age and 90% under 20 years
of age. It usually presents with a pain-
less scalp swelling (Case I) or a dis-
charging sinus.1 The outward expansion
of the calvarium produces Pott's puffy
tumour. 5 Lesions are usually single,
well-circumscribed and lytic with in-
volvement of the frontal or parietal
bones, and rarely in the sphenoid
(Cases 1 and 2) and occipital bones.
The calvarial lesions can penetrate
both the inner and outer table and

have an associated soft tissue compo-
nent. They rarely penetrate the dura.
There may occasionally be diffuse in-
volvement of the calvarium or a sin-
gle lytic lesion with surrounding scle-
rosis.' Most skull involvement is seen

Figure 2a: Axial post-contrast CT of the head
demonstrates extracranial enhancing soft tissue
(arrow) in the left frontotemporal region.

Figure 2b: Axial post-contrast CT of the head
shows that the focus of the enhancing tissue seen
in Figure 2a is associated with a lytic bone lesion
(arrow).

22 SAJOURNAL OF RADIOLOGY. August 2000

in children with disseminated disease.'
The differential diagnosis for a lytic le-
sion seen on the skull radiographs in-
cludes pyogenic osteomyelitis, metas-
tasis, haemangioma, aneurysmal bone
cyst, meningioma and histiocytosis.!
CT is useful to exclude a concurrent
intracranial TB component. I While
isolation of acid fast bacilli from the
lesion would be ideal, a combination
of clinical, radiological and his-
topathological findings in associa-
tion with a good response to antitu-
berculous therapy are often used for
diagnosis/ Treatment is with four-drug
anti-TB therapy for 18 months. Sur-
gery is reserved for cases of uncertain
diagnosis or for those where the sus-
pected calvarial TB, with an extradural
collection, is associated with neurologi-
cal deficits, sinus formation or a large
pocket of caseating material. 1

Conclusion
Calvarial TB is a rare manifestation

of a disease that is endemic in South
Africa and may be imaged incidentally
or because of symptomatology.
Changes in the bone will be seen on
skull radiographs, but a CT head is re-
quired to exclude intracranial TB.

References
I. Jadhav RN, Palande DA. Calvarial tuberculosis.

Neurosurgery 1999; 45 (6):1345-1350.
2. Uniivar E, Oguz F, Sidal M, Ones, 0, Tetekkurt

S. Calvarial tuberculosis. ] Paediatr Child Health
1999; 35 221-222.

3. Pelteret RM. Tuberculous osteitis of the skull.
Ann Trop Paediatr 1989; 9 (1): 40-42.

4. Echeverria J, Kaude N Multitocal tuberculous
osteomyelitis.PediatrRadioI1978; 7 (4): 238-240.

5. Cremin BJ, Jamieson DH. Imaging of skeletal
tuberculosis. In: Cremin BJ, Jamieson DH,
Childhood tuberculosis: Modern imaging and
clinical concepts. Berlin: Springer. 1995: 99-106.