Calvarial Tuberculosis: Shifting Paradigm from Surgical to Conservative Approach

Background  Tuberculosis (TB) is an endemic disease in developing countries like India. However, incidence of calvarial TB is very low and it presents in varied forms posing a diagnostic dilemma and delay in management. Objective  This article reports a case series of 15 patients with varied presentations of calvarial TB from a tertiary care superspeciality center of Haryana state in India. Materials and Methods  Study is a retrospective analysis of 15 patients with calvarial TB treated between 2018 and 2021 in a tertiary care hospital. Clinical features, radiological findings, surgical and medical management, and outcomes were reviewed. Results  Of the 15 patients, 9 were males and age ranged between 12 and 45 years. Mean duration of symptoms was 2.9 months (range 1-5 months). The most common presenting symptoms were scalp swelling, discharging sinus, and pain. Four patients were treatment defaulters of pulmonary TB and two patients were found human immunodeficiency virus positive. Brain imaging showed peripherally enhancing extradural collection with bone erosions in most cases. Eleven patients were managed conservatively with fine-needle aspiration cytology (FNAC) or local debridement/sinus excision. Four patients were managed surgically with drainage of collection, excision of necrotic bone, followed by antitubercular therapy. One patient needed cerebrospinal fluid diversion for associated hydrocephalous with tubercular meningitis which could not recover and succumbed. Conclusion  Calvarial TB is a rare occurrence of common prevalent diseases. Conservative management with FNAC and sinus excision followed by antitubercular treatment are the mainstay of treatment. Surgery should be reserved for extensive lesion or lesion with mass effect.