Tuberculous Skull Base Osteomyelitis With Cerebral Venous Sinus Thrombosis in an Immunocompetent Adolescent: A Case Report

Abstract

Skull-base osteomyelitis is a rare yet lethal entity. It is infrequently observed among immunocompetent children and young adults, and Mycobacterium is much less common among the various bacterial and fungal etiological causes noted. We report a rare case of a 17-year immunocompetent girl who presented with complaints of head and neck pain and restricted neck movements. The analysis of her cerebrospinal fluid revealed a lymphocytic pleocytosis with elevated protein levels. Imaging studies revealed erosion of the occipital condyle and clivus and an extradural collection extending into the prevertebral and paravertebral spaces until the second cervical vertebra level. In addition to this life-threatening complication, the potential involvement of the cerebral venous sinuses is also of particular interest-a diagnosis of tubercular meningitis with skull base osteomyelitis based on the CSF and imaging findings. The drastic improvement in the initiation of anti-tubercular therapy emphasizes the need for prompt and early initiation of anti-tubercular therapy in endemic areas. The clinical picture, diagnosis, and treatment of tubercular skull-base osteomyelitis are further discussed, and pertinent literature has been reviewed.

Keywords: meningitis; skull-base osteomyelitis; thrombosis; tuberculosis; young.

Figure 1. Axial CT at the skull base reveals erosion of basisphenoid bone.

Figure 2. Post-contrast axial CT brain reveals dilated bilateral lateral ventricles with meningeal enhancement.

Figure 3. Axial MR STIR sequence reveals heterogeneously increased signal intensities in the right paravertebral space extending to the prevertebral space at the skull base.

Figure 4. Axial MR T2 wt scan reveals intermediate to increased signal intensities in the right cerebellomedullary cistern & pre medullary cisterns.

Figure 5. Axial T1 postcontrast sequence reveals thick, an irregular peripheral rim of enhancement in the right paravertebral region of the base of the skull and enhancing adjacent bone marrow of atlas vertebra representing skull base osteomyelitis with abscess formation (blue arrow). A note is made of enhancing meninges in the thecal space representing meningitis (red arrow).

Figure 6. Coronal T2 scan reveals increased signal in right paraspinal space along C2 extending into adjacent skull base.

Figure 7. Right parasagittal T2 scan reveals the same as above.

Figure 8. Coronal T1 postcontrast FS sequence shows heterogeneous enhancement.

Figure 9. Right Parasagittal postcontrast T1 FS shows central non-enhancing area s/o necrosis.

Figure 10. T2W axial section shows resolution of altered signal

Figure 11. T1W axial scan reveals resolution of altered signal