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Show ORIGINAL CONTRIBUTION Orbital Tuberculosis with Abscess Deepak Aggarwal, MD, Ashish Suri, MD, and Ashok K. Mahapatra, MD The authors present a case of progressive unilateral propto-sis caused by tuberculous osteoperiostitis of the orbital walls and sphenoid bone with extraconal orbital and extradural intracranial cold abscess formation. The patient responded well to surgical evacuation and antituberculous medical therapy. ( JNeuro- Ophthalmol 2002; 22: 208- 210) Orbital tuberculosis is a rare entity that may involve the soft tissues as well as the bones forming the orbit ( 1- 3). Differentiating it from a neoplastic process may be difficult, and the true diagnosis may reveal itself only on the operating table. Our case exemplifies the pitfalls associated with dependence on radiology for diagnosis. CASE REPORT A 7- year- old girl was brought for treatment of progressive painless proptosis in the OS for 3 years. She experienced diplopia on looking to the left side. On examination, she was afebrile and well- nourished, and had a visual acuity of 20/ 20 bilaterally. A mass was palpable in the superolateral aspect of the left orbit, causing slight proptosis, and a nonpulsatile and compressible mass of the supraorbital region extended to the left lower eyelid. The overlying skin was healthy, and there were no signs of inflammation. Restriction of abduction was present in the left eye. The fundus was bilaterally normal, and the results of the general and neurologic examination were otherwise normal. Laboratory investigations revealed a hemoglobin of 11 gm/ dl and an erythrocyte sedimentation rate of 40. A chest radiograph was normal. Contrast- enhanced computed tomography of the head and orbits revealed a soft tissue lesion in the superolateral part of the left orbit with extension into the temporal fossa extradurally. Erosion and destruction of the roof and lateral orbital wall, as well as the greater and lesser wings of sphenoid bone, were also seen ( Fig. 1). Contrast- enhanced magnetic resonance imaging of the orbits showed a homogenously enhancing extradural mass lesion with an enhancing dural tail along the left Department of Neurosurgery, C. N. Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Address correspondence to Ashish Suri, MD, 34 Ganga Apartments, Alaknanda, New Delhi 110029, India; E- mail: suri@ bol. net. in sphenoid bone and extraconal left orbit displacing the eyeball inferomedially ( Fig. 2). After imaging, a differential diagnosis of a benign neoplasm ( meningioma or a primary osseous tumor) involving the lateral sphenoid wing and orbit was made. The patient was taken for surgery. When the left frontotemporal skin flap was reflected from the supraorbital margin, thick straw- colored fluid flowed out. A burr hole was made, and the fluid was evacuated from the extradural sphenoidal and basitemporal region. The lateral wall of the orbit and the sphenoid were found to be eroded by the disease process. The dura was thickened and covered with granulation tissue. The granulation tissue was scraped, and the diseased bone was nibbled. After evacuation of pus, the orbital and eyelid swelling resolved almost immediately. The pus contained lymphocytes and acid- fast bacilli, and when cultured grew Mycobacterium tuberculosis. Cultures for aerobic, anaerobic, and fungal microorganisma were sterile. Frozen- section and definitive histopathologic examination of the involved bone showed granulomatous inflammation consistent with tuberculosis. The patient was given antituberculous therapy and is currently asymptomatic after 6 months of follow- up. DISCUSSION Tuberculosis of the orbit is extremely rare, even in places where tuberculosis is endemic. An extensive literature search revealed that fewer than 35 cases of orbital tuberculosis have been reported to date ( 1- 22). Of these, the majority ( 4- 20) were tuberculomas, and only two involved " cold abscess" formation within the orbit ( 21). A cold abscess, as the name suggests, is a purulent collection lacking signs of acute inflammation, such as brawny induration, edema, ortenderness ( 21,23). Characterized by liquefaction of the central caseous necrosis, cold abscesses are usually tuberculous, although rare instances of association with brucellosis, nocardiosis, actinomycosis, or trichophyton infection have been reported ( 23- 27). The disease may involve the soft tissues, lacrimal gland, periosteum, or bones of the orbital wall ( 3). Sphenoidal extension is rarer still; only two cases have been reported ( 1,2). There is no description of intracranial extension from orbital tuberculosis. Our patient had tubercular ^ 208. POL10.1097/ 01. WNO. 0000028869.9267Q. 97 . J. Neuro- Ophthalmol. Vol. 22, No. 3,2Q02 , Copyright © Lip pincott Williams & Wifkins. Unauthorized reproduction of this article is prohibited. ORBITAL TUBERCULOSIS WITH ABSCESS JNeuro- Ophthalmol, Vol. 22, No. 3, 2002 FIG. 1. ( A) Contrast- enhanced computed tomographic scan of the head, showing an enhancing lesion in the superolateral part of the left orbit with extension into the temporal fossa extradurally. ( B) Computed tomographic scan of bone windows, showing erosion and destruction of the roof and lateral orbital wall, as well as the greater and lesser wings of sphenoid bone. osteoperiostitis of the orbital roof as well as the lateral wall of the orbit, with involvement of the greater and lesser wings of the sphenoid bone associated with cold abscess in the extradural region. Orbital tuberculosis is more commonly seen in children ( 2), girls being more susceptible then boys ( 2), and is usually unilateral ( 22). For unknown reasons, the left orbit has been found to have a higher propensity of involvement than the right orbit ( 2). The primary tuberculous focus is commonly pulmonary, but extrapulmonary sites, such as cervical lymphade-nopathy or abdominal disease, may be present ( 2). The disease reaches the intraorbital space either by contiguity from the paranasal sinuses or through the bloodstream ( 11). Involvement of the lateral wall of the orbit implies a hematogenous source ( 11). There has usually been evidence of disseminated tuberculosis in previously reported cases ( 7,9). Although our patient was not investigated extensively Copyright © Lippincott Williams & Wilkins. Un for primary tuberculosis of the abdomen, she did not have evidence of pulmonary tuberculosis or lymphadenopathy. We could not ascertain the origin of the tuberculoma in the present case. FIG. 2. Enhanced magnetic resonance imaging scans of the brain in axial ( A), sagittal ( B), and coronal ( C) projections, showing a homogenously enhancing extradural or-bitocranial mass ( black arrow) with an enhancing dural tail ( white arrow) along the left sphenoid bone. reproduction of this article is prohibited. JNeuro- Ophthalmol, Vol. 22, No. 3, 2002 Aggarwal et al. The recommended treatment of orbital tuberculoma is wide surgical removal of all diseased tissue, combined with antituberculous chemotherapy for 18 months ( 2,4). Some authors have used antituberculous therapy alone as the primary therapy, with excellent results ( 1,10- 12,16). However, in the presence of a cold abscess, surgical evacuation of the pus ( by simple aspiration and drainage or wide surgical removal) should be combined with antituberculous medical therapy. REFERENCES 1. Van Effenterre G, Van Effenterre R, Lopez A, et al. [ A case of tuberculoma of the orbit with sphenoidal origin]. 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