Acetazolamide – an almost forgotten therapeutical option in tuberculous communicating hydrocephalus

Aims: Solitary tuberculous brain abscess is a rare clinical entity in childhood in Germany. Tuberculostatic therapy is well defined. Therapeutic options for complicating communicating hydrocephalus consist in general in neurosurgical intervention with ventriculo-peritoneal shunting. Medical options, like the formerly often mentioned Acetazolamide (AZM) are nowadays less frequently reported.

Case report: We report on a case of a 13-year old girl, who presented with visual disturbances and papilledema. MRI showed internal hydrocephalus due to an intracranial cerebellar mass of unknown origin with beginning compression of the brainstem. After neurosurgical intervention with extirpation and short time external ventricular drainage a tuberculous brain abscess without meningitis was diagnosed. Postoperatively ventricular drainage could be suspended. The patient was started on tuberculostatic therapy. She remained without central nervous problems during the following two month, when a progressive papilledema due to communicating hydrocephalus was diagnosed. Based on therapeutic options in tuberculous meningitis the patient was started on AZM in an effort to avoid surgical therapy. Regression of papilledema was observed during the following months. The initial dose of 2×125mg was subsequently reduced during a period of 9 month of AZM-therapy. Only acral paresthesia as side effect were noted on the starting dose.

After ending the tuberculostatic therapy (12 months) and AZM (9 months) the patient still remains clinically stable without progression of hydrocephalus. Ventriculo-peritoneal shunting was not necessary.

Discussion: Radiological, infectiological findings as therapeutical options of tuberculous brain abscess are demonstrated. Acetazolamide as a still valuable conservative option in complicating communicating hydrocephalus after tuberculous brain abscess is discussed.