Case Report

SPINAL INTRAMEDULLARY TUBERCULAR ABSCESS

M.F. Hoda1, R. Prasad2, V.P. Singh1, P. Maurya1, K. Singh3 and V. Sharma4
(Original received on 21.5.2005; Revised version received on 23.8.2005; Accepted on 30.8.2005)

Summary: Spinal intramedullary tubercular abscess is an extremely rare entity. Only few cases are reported in literature.
A Nine-year-old girl presented with pain in gluteal region and progressive paraparesis. Her chest-X-ray revealed a
primary focus suggesting pulmonary Koch’s & MRI lumbosacral spine showed a ring enhancing hypointese lesion in
T1w and hyperintense in T2w at L2 to L3 suggestive of epidermoid or tubercular abscess, which was confirmed at
operation and subsequently by AFB staining and culture. Mycobacterium tuberculosis was seen in both staining and
culture of pus. Patient improved after 2 months of ATT. [Indian J Tuberc 2005; 52:211-214]

Key words: Intramedullary tuberculosis, spinal cord, tubercular abscess.

INTRODUCTION loss below L2 dermatome on both sides (left > right).

Intramedullary spinal tubercular abscess is
least common among various forms of spinal
tuberculosis. Only 9 cases have been reported in the
literature till now1-4. These lesions particularly diagnosed
as a case of space occupying lesion of neoplastic origin
leading to neurosurgical intervention later turned out
to be a tubercular lesion5. We are reporting a 9-year
old girl with progressive paraparesis secondary to
intramedullary tubercular abscess.
CLINICAL RECORD
A 9-year old HIV seronegative girl presented
with pain in gluteal region for last 5 months, gradually
progressive weakness of both lower limbs preceding
2 months and increased frequency of micturation
leading to occasional incontinence for last 7 days.
There was no prior history of fever, trauma and
cough but there was history of loss of appetite and
weight loss for last 2 months.
The general physical examination was
unremarkable and her weight was 22kg.
Neurological examination revealed decreased power
at both ankle (Dorsiflexion 3/5, planter flexion 4/5)
and knee (flexion 4/5, extension 4+/5). Bilateral knee
and ankle reflexes were diminished and planter
reflexes were bilaterally flexor with 10-15% sensory
1. Senior Resident 2. Junior Resident 3. Lecturer 4.Reader & Head
Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi
Correspondence: Dr. M.F. Hoda, C/o Dr. Vivek Sharma, Reader and, Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu
University, Varanasi-221 005. Tel No. 91-542-2367389; Fax 91-542-2367568; E-mail: neurosurgery_bhu@yahoo.co.in
There was no spinal deformity or tenderness. Both
upper limbs were normal and there were no meningeal
signs. Rest of systemic examination was normal.
Haemogram was within normal limits while
chest X-ray (PA view) showed lobulated
homogeneous opacity suggesting pulmonary Koch’s
(Fig 1). Mantoux test was equivocal (6mm×9mm).
X-ray dorsolumbar spine was normal. MRI
dorsolumbar spine revealed hypointense
intramedullary lesion on T1w and hyperintense on
T2w with peripheral ring enhancement on contrast
extending from L1 to L3 with obliteration of CSF
space (Figs. 2, 3 & 4). Provisional diagnosis of
epidermoid was considered and patient was planned
for surgery. She underwent laminotomy extending
from L1 to L3. Peroperatively the epidural space was
normal with increased vascularity over the dura and
cord with loss of epidural flat. After opening the
dura by a vertical small incision over the midline on
dorsal aspect of cord, frank creamy pus came out.
The pus was not encapsulated and no caseation or
granulation tissue was present. After complete
evacuation of pus the cord became laxed and CSF
circulation maintained. Pus was sent for gram
staining, AFB staining, culture and sensitivity for both
pyogenic and tubercular infection which revealed
Mycobacterium tuberculosis on both staining and
culture examination. In the immediate postoperative

Indian Journal of Tuberculosis

212 M. F. HODA ET AL
Fig.1 X-ray chest PA view showing lobulated,
homogeneous opacity in right upper lobe
suggestive of active tuberculosis
Fig. 2: GdDTPA MRI lumbosacral spine (sagittal
view) showing intense peripheral ring
enhancement.
Indian Journal of Tuberculosis
Fig. 3: GdDTPA MRI lumbosacral spine (coronal
view) showing intense peripheral ring
enhancement
period, patient did not show any improvement or
deterioration and she was put on ATT (4 drugs)
Isoniazid 100 mg/day, Rifampicin 200 mg/day,
Pyrazinamide 500 mg/day and Ethambutol 400 mg/
day for two months then Isoniazid 100 mg/day and
Rifampicin 200 mg/day for next four months. After
two months of follow up, her power and urinary
incontinence improved to near normal.
DISCUSSION
The commonest form of central nervous
system tuberculosis is meningitis while tuberculoma
is unusual. The spinal cord involvement is extremely
rare and ratio reported of intramedullary spinal to
intracranial tuberculoma is 1:426-9. Intramedullary
tuberculosis is almost always secondary to
pulmonary tuberculosis with rare exception as
extrapulmonary form10,11. Tubercular abscess in
 INTRAMEDULLARY ABSCESS
Fig. 4: T2 weighted image of MRI lumbosacral
spine (sagittal view) showing hyperintense
intramedullary lesion with a hypointense
rim superiorly as well as inferiorly
intramedullary region is rarely reported in literature.
Out of 77 case reports of intramedullary abscess
since the original case documented by Har,
Mycobacterium tuberculosis has been demonstrated
in only four cases 4,12. Intramedullary tubercular
abscess may be diagnosed by presence of acid-fast
bacilli within the tissue or by positive culture.
MR imaging provides detailed, valuable
information about intramedullary lesions and,
therefore, is useful in determining the pathology. Like
present case, MRI in these cases shows signal
changes within the cord with expansion of the cord.
These are ring lesions typical of abscess with
GdDTPA ring enhancement. However, MRI findings
are indistinguisible from intramedullary tuberculoma
in many cases 13 . In late stage, the centre of
intramedullary tuberculoma becomes hyperintense
213
on T2 weighted image with development of liquefied
caseation14. The solid part of granuloma may appear
hypo-hyperintense corresponding to the phase and
condition, and make MRI appearance of
intramedullary tuberculoma similar to intramedullary
tubercular abscess. Like in the present case, majority
of the patients present with signs and symptoms of
spinal cord compression with minimal symptoms of
tubercular toxemia, hence the high index of suspicion
is a must to diagnose these cases as tubercular
abscess preoperatively and MRI along with other
supportive investigation for primary lesion in the chest
may be helpful.
Medical therapy is now curative for
intramedullary tuberculosis 15,16. Medial therapy
without surgical management may be appropriate for
established cases of tuberculosis. In endemic
regions, intramedullary spinal lesions in patients with
evidence of tuberculosis elsewhere, could be of
tuberculous etiology, and these lesions usually have
a good response to medical treatment and if diagnosed
early would avoid unnecessary surgical intervention5.
As with the present case, the diagnosis was doubtful
even after MRI and patient was having progressive
neurological deficit with bladder involvement. Hence
urgent surgical decompression was done to establish
the diagnosis as well as to decompress the tumor.
To conclude, if the diagnosis is doubtful
or the patient does not respond to medical
management, surgery should be done for a
definite histological diagnosis. However, optimal
medical therapy even after surgery is necessary
for 6 months or more to achieve best neurological
outcome17. On the other hand, for intramedullary
abscess, surgical evacuation of pus with
appropriate medical treatment offers a
favourable prognosis even in cases with severe
neurological deficits18.
REFERENCES
1. Tanriverdi T et al. Atypical intradural spinal tuberculosis:
report of three cases. Spinal Cord 2003; 41: 403-409.
2. Tacconi L et al. Intramedullary spinal cord abscess: case
report. Neurosurgery 1995; 37: 817-819.
3. Bindira D, Chandra S, Mongia S, Chandramouli BA, Sastry
KV, Shankar SK. Spinal intramedullary tuberculoma and
Indian Journal of Tuberculosis
214 M. F. HODA ET AL

abscess: a rare cause of paraparesis. Neurol India 2002; 50:
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4. Ditullio MV. Intramedullary spinal cord abscess: a case report
with review of 53 previously described cases. Surg Neurol
1997; 7: 351-354.
5. Agrawal A, Joshi R, Badole CM, Gangane N, Dwivedi S.
Intramedullary diffuse tubercular lesion resembling glioma.
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6. Lin TH. Intramedullary tuberculoma of the spinal cord. J
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13. Shen WC, Cheng TY, Lee SK et al. Disseminated tuberculomas
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15. Garg G, Singh S. Intramedullary spinal tuberculoma. Br J
Neurosurg 2002; 16: 75-76.
16. Rao GP. Spinal intramedullary tuberculous lesion: medical
management. Report of four cases. J Neurosurg 2000;
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17. Torii H, Takahashi T, Shimizu H, Watanabe M, Tominaga
T. Intramedullary spinal tuberculoma. Neurol Med Chir
(Tokyo) 2004; 44: 266-268.
18. Hanci M, Carioglu AC, Uzan M, Islak C et al. Intramedullary
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769.

ESSAY COMPETITION FOR MEDICAL STUDENTS-2005

The Tuberculosis Association of India awards every year a cash

prize of Rs. 500/- to a final year medical student in India for an original
essay on tuberculosis. The subject selected for the year 2005 competition is
‘MDR TB’. The essay should be written in English, typed double spaced,
on foolscap size paper and should not exceed 15 pages (approximately
3,000 words, including tables, diagrams, etc.). Four copies of the typescript
should be forwarded through the Dean or Principal of a College/University
to reach the Secretary-General, Tuberculosis Association of India, 3 Red
Cross Road, New Delhi-110 001, before 31st December 2005 along with
a certificate that the author is a final year medical student.

Indian Journal of Tuberculosis