Calvarial Tuberculosis: E Ünüvar, F O Guz, B Sadiko Glu, M Sidal, Ü One S and S Tetikkurt

J. Paediatr.
Child Health (1999) 35, 221222
Calvarial tuberculosis
E NVAR, F OGUZ,
B SADIKOGLU,
M SIDAL, ONES and S TETIKKURT
Institute of Child Health, University of Istanbul, Istanbul, Turkey
Abstract: We report a six-year-old boy who presented with swelling of the forehead, and had calvarial tuberculosis, a rare
form of tuberculous osteitis.
Key words:
abscess; bone; calvarium; skull; tuberculosis.
Calvarial tuberculosis is a rare form of tuberculosis, which

constitutes 0.21.3% of all bone tuberculosis.1 Most cases
reported in the literature are from countries with a high incidence
of tuberculosis. The incidence of bone tuberculosis appears to
be falling.2,3 We report a patient with tuberculosis of the frontal
bone of the skull.
CASE REPORT
A six-year-old boy developed a painless frontal swelling over two
weeks. There was no major trauma history to the frontal bone
but he used to head the ball when he played football, which may
be the cause of minor trauma. His family history did not include
tuberculosis and he had been vaccinated with BCG at birth.
There was no history of contact with tuberculosis. On physical
examination his weight was 18 kg (1025th centile line) and
height was 114 cm (2550th centile line). He looked well and
was afebrile. A fluctuating mass 3 6 cm located on the frontal
bone area was seen. There was no associated erythema and
papilloedema. He had 2 2 cm anterior cervical lymphadenopathy on the right side. There were no abnormalities on neurologic examination. He had a BCG scar.
His total white blood cell count was 10.4 109 L1, his ESR
was 83 mm hour1 and skin testing with PPD (5 tuberculin units)
yielded induration of 15 mm. Chest roentgenogram was normal.
On the X-ray of the skull, areas of irregular radiolucency were
seen in the frontal region. Multiple lytic lesions were demonstrated on lateral frontal bone X-ray films. A computed tomographic (CT) scan confirmed the bone defect and showed a
subperiostal abscess with greater involvement of the inner table.
No oedema of the brain was seen (Fig. 1).
A specimen for culture (aerobic, anaerobic and for fungi) was
obtained from the abscess material. Bacteriological culture
was negative. No acid-fast bacilli were seen on smears.
LoewensteinJensen cultures were negative. Polymerase chain
reaction investigation for Mycobacterium tuberculosis and
atypical mycobacteria of a specimen obtained from the abscess
was also negative. Histopathological examination of the bone
Correspondence: Dr Emin nvar, MD, Harper Guest House Center

#403, 3737 Beaubien Blvd, Detroit, MI, USA. Fax: +00902125855604;
e-mail: emin@magnet.com.tr.
E nvar, MD, Fellow, Paediatrician. F O g uz, MD, Associate
Professor. B Sadk oglu, MD, Resident. M Sdal, MD, Professor. Ones ,
MD, Professor. S Tetikkurt, MD, Resident.
Accepted for publication 21 August 1998.
confirmed tuberculous osteomyelitis and granulomatous inflammation with Langhans giant cells. The final diagnosis was bone
tuberculosis with cold abscess, based on the positive tuberculin
test and histopathological findings. Our patient was treated with
isoniazid (15 mg kg d1), rifampicin (15 mg kg d1), pyrazinamide
(20 mg kg d1), and streptomycin (40 mg kg d1). After two
months, therapy was continued with isoniazid and rifampicin.
By the end of the second month of antituberculous therapy,
regression of the lesion and a decrease in the ESR were noted.
By the sixth month, lytic bone lesions had relatively disappeared.
Therapy was maintained for 1 year. Follow-up of the child
continues.
DISCUSSION
Calvarial tuberculosis is an uncommon form of tuberculosis
usually seen in younger patients. Of the reported cases, almost
50% are under 10 years of age and 90% under 20 years of age,
affecting both sexes equally. 1,3 It is uncommon in infants. A
summary of the reported paediatric cases in the English literature is given in Table 1.
Fig. 1 The cranial CT imaging showed an abscess formation on the

frontal bone and osteolytic lesions in internal and external tables.
E nvar et al.
222
Table 1
Reported cases of calvarial tuberculosis in paediatric age group*
Author and year

De Pape, 1954
Tirona, 1954
Cremin, 1970
Miles and Hughes, 1970

Prinsloo and Kinsten, 1977
Tata, 1978
Brown, 1980
Bhandari, 1981
Schuster, 1984
Gupta, 1989
Age (years)/
sex
History of
trauma
0,5, M
13, M
15, F
3, M
3,5, M
2,5, M
6, M
15, M
15, M
3, M
12, F
6, M
16, M
3, F
5, M
4, M
11, F
Tuberculosis
elsewhere
Systemic
Foot/Lung
Vertebra
NR
Skeletal
Lung
Lung
NR
NR
Cervical lymph nodes
Negative
Lung
Lung
Lung
Lung
Lung
Lung, dactylitis
Presentation
Frontal swelling
Frontal swelling
Seizure
Frontal swelling
Scalp swelling
Proptosis left orbit
Right orbital swelling
Right temporal swelling
Nerve paralysis
Right frontal swelling
Scalp swelling
Scalp swelling
Scalp swelling
Scalp swelling
Diabetes incipidus
Loss of apetite
Occipital swelling
Histology;
microbiology
AFB, Culture
NR
NR
NR
Pathology
NR
NR
AFB/Culture
AFB/Culture
Pathology
Pathology
NR
NR
Pathology
NR
AFB/Culture
Pathology
*Summarised from LeRoux PD et al.3

AFB, acid fast bacilli; NR, not reported.
The bacillus is thought usually to reach the calvarium by

haematogenous spread,15 although rarely by direct penetration. Some authors called attention to the role of trauma as
in other skeletal tuberculosis, but they are usually chronic minor
traumas. Frequent heading of a ball could have caused repetitive minor trauma in our case. The primary calvarial involvement region is usually the frontal and parietal bones, as they
are broad and with thick diploe.3 The settling of the bacillus in
the diploe marks the onset of acute inflammation surrounded by
fibroblasts. Granulation tissue takes place in the bone trabeculae and Langhans giant cells and epitheloid histiocytes
appear.14 Frontal bone was involved in our patient with inner
and outer table invasions. As the dura is extremely resistant
to calvarial tuberculosis, tuberculous meningitis is rare.3 With
further development the cold abscess formation appears.
Radiological findings are nonspecific. Both osteolytic and
osteoblastic features are seen. Lesions which are usually lytic
first, can normally be seen on the plain X-ray of the skull and are
helpful for the diagnosis.6,7 Osteolytic lesions were shown on the
skull X-ray and cranial CT in our case. The differential diagnosis
of tuberculosis includes pyogenic osteomyelitis, calvarial metastasis, haemangiomas, aneurysmal bone cysts, meningiomas
and hystiocytosis.1,7,8 The identification of tuberculous bacillus at
the site of lesion confirms the diagnosis.15 We could not isolate
bacillus from the lesion. However, as this is not always possible,
clinical, radiological and histopathological findings in association
with good results achieved by antituberculous therapy are
important for the diagnosis.24 Positive findings for tuberculosis in
our case were positive tuberculin test and Langhans giant cells
on pathological smear. The improvement on antituberculous
therapy that was seen after the second month is in compliance
with the report of Gupta et al.1 The mainstay of treatment is antituberculous chemotherapy. Surgical therapy is considered when
the lesion creates a mass effect, increase in intracranial pressure
or when the patient has a large collection of caseous material.1
In conclusion, if a child develops swelling of the frontal region
associated with osteolytic lesions on skull X-ray, tuberculosis
must be included in the differential diagnosis, especially in
countries with a high rate of infection.
REFERENCES
1
2
3
5
6
Gupta PK, Kolluri VRS, Chanddramouli BA, Venkatamana NK, Das

BS. Calvarial tuberculosis: a report of two cases. Neurosurgery
1989; 25: 8302.
Scoggin CH, Schwartz MI, Dixon BW, Durrance JR. Tuberculosis of
the skull. Arch. Intern. Med. 1976; 136: 11556.
LeRoux PD, Griffin GE, Marsch HT, Winn HR. Tuberculosis of the
skull a rare condition: Case report and review of the literature.
Neurosurgery 1990; 26: 8515.
Lee SH, Abramson SB. Infection of the musculoskeletal system by
M. tuberculosis. In: Rom WN, Garay S, eds. Tuberculosis. Little,
Brown and Company, New York, 1996; 62544.
Davidson PT, Horowitz I. Skeletal tuberculosis. Am. J. Med. 1970;
48: 7784.
Silverman FN, Bryde SE, Fitz CR. The skull, spine, and central
nervous system. In: Silverman FN, Kuhn JP, eds. Caffeys Pediatric
X-Ray Diagnosis. Mosby ACV, St. Louis, USA, 1993; 5765.
Schuster JD, Rakusan TA, Chonmaitree T, Box QT. Tuberculous
osteitis of the skull mimicking histiocytosis X. J. Pediatr. 1984; 105:
26971.
Tirona JP. The roentgenological and pathological aspects of tuberculosis of the skull. AJR 1954; 72: 7628.

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J. Paediatr.

Child Health (1999) 35, 221222

abscess; bone; calvarium; skull; tuberculosis.

Calvarial tuberculosis is a rare form of tuberculosis, which

Correspondence: Dr Emin nvar, MD, Harper Guest House Center

Fig. 1 The cranial CT imaging showed an abscess formation on the

Reported cases of calvarial tuberculosis in paediatric age group*

Author and year

Miles and Hughes, 1970

*Summarised from LeRoux PD et al.3

The bacillus is thought usually to reach the calvarium by

Gupta PK, Kolluri VRS, Chanddramouli BA, Venkatamana NK, Das

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