Coexistent acute pyogenic and tubercular petrous apicitis: a diagnostic dilemma

Abstract

We report the case of a 16-year-old boy who presented to us with acute otitis media, facial weakness and retro-orbital pain. Computed tomography and magnetic resonance imaging (MRI) scans of the head and temporal bone revealed otitis media with petrous apicitis. The patient responded to broad-spectrum, parenteral antibiotics, with disappearance of facial weakness and reduction in pain. One month following the completion of treatment, the patient continued to have dull retro-orbital pain and developed ear discharge. A repeat MRI of the temporal bone revealed a persistent inflammatory lesion in the petrous apex, with a nodular, ring-enhancing lesion in the cerebellum, strongly suggestive of tuberculosis. The ear discharge stained positive for acid-fast bacilli and the patient's serum enzyme-linked immunosorbent assay for tuberculosis was reactive. The patient responded well to anti-tubercular treatment and was disease free eight months following the completion of treatment.