There was mild pain in the region with the movement of jaw. There was no history of trauma or any of previous surgery. On examination the patient was of average built without any disability. Locally the swelling was present on the right temporo-frontal region and measured 3.2 × 4.1 cm in size. The swelling was non tender, fluctuant and non-pulsatile. There was no discoloration of the overlying skin. Systemic examination was non-contributory. Investigations revealed hemoglobin 12 g%, erythrocyte sedimentation rate (ESR) 50 mm fall in 1st hour, total lymphocytic count (TLC) 8600/cm, differential lymphocyte count P54, L40, M02, E4. Urine examination did not show any abnormality. Plain x-ray skull was conducted as initial work up. The radiograph had revealed soft tissue swelling with an osteolytic lesion on the inferior aspect of the coronal suture on right side (Figures 2a and 2b).

Further work up was done by sonographic examination. It revealed collection underneath the thickened scalp with intracranial communication (Figures 3a and 3b).

There were multiple prominent dural veins seen in colour flow imaging (Figures 4a and 4b).

CECT was done which had revealed the greater anatomic details with epidural collection. This had shown enhancing capsular wall with a few septations (Figures 5a-5c).

MRI was also done to see the soft tissue details and the brain parenchyma with standard protocol sequences (Figures 6a-6d).

The working diagnosis was kept as Pott’s puffy tumor as per the clinical setting and the radiological investigations. Fine needle aspiration confirmed the diagnosis as that of tuberculosis origin aetiology. No surgical intervention was contemplated because of the morphology of the lesion and corresponding FNA cytology. Patient had been put on anti-tuberculosis therapy (ATT) and had been called for the follow up after four weeks.

DISCUSSION

Tuberculous osteitis of the skull is a very rare phenomenon and it becomes more in rarity when present as Pott’s puffy tumor [3,4]. These accounts for just 1% of skeletal tuberculosis. This is common in developing countries because of the poor socioeconomic status and malnutrition [5]. Other factor which plays a great aetiopathological role is immunodeficiency syndromes. The first case of skull tuberculosis was reported in 1942 [6]. In 1981, scientists had reviewed 220 cases of skull tuberculosis. Mohanty et al. [7] also reported 40 cases of calvarial tuberculosis in 1981. The pediatric group is affected the most and majority of all fall below 20 years of age. There may or may not be the discharging sinus which communicates to the underlying abscess. Soft tissue swelling is because of underlying cold abscess [8]. The skull lytic lesion can be confused with either multiple myeloma or metastatic disease. The parietal bone is the most affected bone. Sutural junctions are the still rarest as was in our present case. The superficial scalp swelling can also be evaluated by USG and color flow imaging (CFI) [9]. The surrounding vascularity and the communication can be evaluated by this modality. The lytic lesion seen in plain radiography requires further evaluation by CECT and MRI studies [10]. CECT shows a well-defined defect with the bone destruction and intracranial involvement of brain parenchyma [11,12]. The extradural collection is seen with thick enhancing capsular tissue. There may or may not be the combination of underlying abscess with the discharging sinus. Scintigraphy is superior to CT scan for diagnosis and delineation of the lesion [13]. There should be meticulous approach for the management .Surgical opinion is must for the intracranial complications and sinus pathology. There may be requirement of the sinus drainage as per the involvement. Anti-tuberculous therapy may be started as early as possible to avoid further drainage to the intradural structures [14].

CONCLUSION

Calvarial tuberculosis is rare in presenting as Pott’s puffy tumors. This requires thorough worked up by the cross sectional modalities like CT and MRI. The scalp swelling may be misleading because of not causing many symptoms. It is important to know the intracranial extension of the collection or the pathological process which is very essential in surgical management point of view. Scalp swelling with bone destruction is less likely to cause any intracranial manifestations.

ACKNOWLEDGEMENT

We are extremely thankful to Miss Sadaf Jaffar BRIT student, Faculty of Allied Health Sciences for helping us in diagnostic support. We are also thankful to Mr. Prahlad Singh, Mr. Kasif and Mr. Anil Kumar radiographers of SGT Hospital for carrying out general radiography and CT.

CONSENT OF THE PATIENT

Written consent of the patient was taken.

CONFLICT OF INTEREST

There is no conflict of interest.

ETHICAL ISSUE

Nil