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   Table of Contents      
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 269-271

Tubercular osteomyelitis as scalp swelling and alopecia areata


1 Senior Resident, Dept of TB and Respiratory diseases, LHMC, New Delhi, India
2 Dept of TB and Respiratory diseases, LHMC, New Delhi, India
3 Professor, Dept of TB and Respiratory diseases, LHMC, New Delhi, India

Date of Submission20-Feb-2022
Date of Acceptance11-Jul-2022
Date of Web Publication07-Dec-2022

Correspondence Address:
Pushpendra Verma
Assosciate Professor, Dept of TB and Respiratory diseases, LHMC, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_14_22

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  Abstract 


Tuberculosis (TB) is a well-known endemic disease in developing countries. It continues to be one of the major causes of death and disability in such countries. However, extrapulmonary TB is less common than pulmonary TB. Skeletal TB constitutes about 1% of all tubercular cases. Tubercular osteomyelitis of skull is a rare entity. The most common sites affected are the frontal and parietal bones with destruction of both the inner and outer table. We hereby report a young male presenting to us with scalp swelling in the left frontal region with loss of hair in surrounding areas and in left temporal region. NCCT head was suggestive of osteolytic lesion in frontal bone on left side with accompanying periosteal reaction, consistent with osteomyelitis. In Gene Xpert of pus drained from the swelling, Mycobacterium tuberculosis was detected. Patient was started on Antituberculous treatment, and subsequently improved.

Keywords: Alopecia areata, calvarial tuberculosis, scalp swelling, tubercular osteomyelitis


How to cite this article:
Bhatia A, Verma P, Singh AK. Tubercular osteomyelitis as scalp swelling and alopecia areata. MAMC J Med Sci 2022;8:269-71

How to cite this URL:
Bhatia A, Verma P, Singh AK. Tubercular osteomyelitis as scalp swelling and alopecia areata. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 1];8:269-71. Available from: https://www.mamcjms.in/text.asp?2022/8/3/269/362890




  Introduction Top


In developing countries, tuberculosis (TB) is one of the major health problems. Skeletal TB represents a rare form of TB, accounting for only 1% of the cases. Primary calvarial TB (osteomyelitis of skull) with no evidence of TB elsewhere is still rare, and accounts for only 0.2% to 1.3% of cases of skeletal TB. Tubercular osteomyelitis of skull is a rare entity and therefore diagnosis is not suspected. A high index of suspicion is important to recognize tubercular involvement of the skull.


  Case Report Top


An 18-year-old male, immunocompetent, nonsmoker, student by occupation, came to us with left-sided swelling on head in frontal region for 1 month. Swelling was gradually increasing in size. It was tender, red, and associated with loss of hair in frontal and temporal area [Figure 1] and [Figure 2]. On examination, swelling was 2 × 2 cm in size [Figure 2]. Fluctuation was present.
Figure 1 Loss of hair in temporal area (before starting antituberculous treatment).

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Figure 2 Swelling in frontal region (before starting antituberculous treatment).

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Patient had a low-grade fever. Patient was initially treated as a case of lipoma with alopecia areata. Non contrast computerized tomography (NCCT) of head was done, which was suggestive of osteolytic lesion in frontal bone on left side with accompanying periosteal reaction, consistent with osteomyelitis [Figure 3]. Soft-tissue thickening of scalp was seen overlying the lytic lesion. Later on, pus from swelling was sent for gram stain and culture sensitivity, Ziehl-Neelsen (ZN) stain, and Gene Xpert. Pus was negative for gram stain and ZN stain. On Gene Xpert (Cepheid), Mycobacterium tuberculosis (MTB) was detected, and it was Rifampicin sensitive from national reference lab (NRL) at Delhi. Sample was sent for Line probe assay (LPA), and it was Rifampicin as well as Isoniazid sensitive. Patient was started on Antituberculous treatment (ATT). Eventually, patient responded to the treatment. The size of swelling reduced and regrowth of hair was seen in temporal area [Figure 4].
Figure 3 NCCT of head.

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Figure 4 After completing ATT.

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  Discussion Top


TB is a common disease which can involve pulmonary and extrapulmonary organs. Most commonly, it involves lungs, but it can also involve pleura, pericardium, bones, joints, spine, and male and female genitourinary structures. Cranial and epidural TB are infrequent manifestations of extrapulmonary TB.[1] Tuberculous skull osteomyelitis usually occurs through the hematogenous spread of bacilli from primary active focus in the lungs or latent infection.[2] About 75% to 90% of patients suffering from calvarial TB are between the age group of 20 and 30 years.[3],[4] It usually involves the frontal and parietal bones due to the greater amount of cancellous bone with diploic channels in these bones.[5],[6] Skull bones are usually involved secondarily from the lung or lymph node focus. TB involving bone can present as cold abscess on the surface. Tubercular osteomyelitis of skull is a rare entity and therefore diagnosis is not suspected.


  Conclusion Top


Our patient was diagnosed as a case of calvarial TB, that is, tubercular osteomyelitis of frontal bone on the basis of NCCT head, Gene Xpert, and LPA. Patient responded well to ATT. Swelling started decreasing in size and patient was feeling symptomatically better.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms and the patient has given his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Strauss DC. Tuberculosis of the flat bones of vault of the skull. Surg Gynecol Obstet 1993;57:384-98.  Back to cited text no. 1
    
2.
Mohanty S, Rao CJ, Mukherjee KC. Tuberculosis of the skull. Int Surg 1981;66:81-3.  Back to cited text no. 2
    
3.
Jadhav RN, Palande DA. Calvarial tuberculosis. Neurosurgery 1999;45:1345-50.  Back to cited text no. 3
    
4.
Raut AA, Nagar AM, Muzumdar D et al. Imaging features of calvarial tuberculosis: a study of 42 cases. Am J Neuroradiol 2004;25:409-14.  Back to cited text no. 4
    
5.
Sundaram PK, Sayed F. Superior sagittal sinus thrombosis caused by calvarial tuberculosis: case report. Neurosurgery 2007;60:E776.  Back to cited text no. 5
    
6.
De Pape AJ. Multiple pseudo-cystic tuberculosis of bone; report of a case. J Bone Joint Surg Br 1954;36-B:637-41  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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