Dovepress Tuberculous brain abscess with Gerstmann’s syndrome Figure 2 (A) hematoxylin and eosin stain showing necrotic tissue with neutrophilic infiltration (original magnification × 400). (B) Ziehl–Neelsen stain demonstrating acid-fast bacilli (original magnification × 400). on the right side gradually recovered (from grade 3 to 0 out of 5) after aspiration of the abscess and antituberculous che- motherapy. Dexamethasone was continued during admission and then changed to an oral formulation after one month. Dexamethasone was suspected to be helpful for the cerebral edema causing his focal neurologic signs. The patient was transferred to our physical medicine and rehabilitation ward for further rehabilitation. Initially, upon arrival for rehabilitation, he could only walk with the use of a walker. Severe left-right confusion, right-sided apraxia, dyscalculia, and dysgraphia were noted. He needed moderate assistance in most activities of daily living. His functional independence measure score was 65. The patient was diagnosed as having a tuberculous brain abscess in the left parietal lobe with Gerstmann’s syndrome and right-sided apraxia. Physical therapy, occupational therapy, and speech therapy were arranged. In addition, to regain somatic sensa- tion and motor control of the right side of his body, training was focused on the right-left confusion and apraxia. The sensory rehabilitation program addressed various perception deficits and impairment of hand-eye coordination. The motor training program included limb and trunk motion, posture, and balance training, which finally progressed to ambula- tion training. Speech therapy included writing and cognitive training. After antituberculous chemotherapy and rehabilita- tion, the patient was able to walk without assistance and had almost recovered normalcy at four months. His left-right confusion, right-sided apraxia, dyscalculia, and dysgraphia improved significantly. He continued to receive antituberculous chemotherapy for a total of 18 months. We repeated the chest x-ray several times Neuropsychiatric Disease and Treatment 2012:8 over the course of 12 months and all were normal. Subsequent magnetic resonance imaging showed that the previous brain abscess had almost completely resolved. Discussion The pathogens commonly found in brain abscesses are Staphylococcus aureus, Streptococcus viridans, anaerobes, and Gram-negative bacilli.9 M. tuberculosis is a rare pathogen in brain abscesses and is often seen in immunocompromised hosts. With the advent of acquired immune deficiency syn- drome, more cases have been diagnosed, but very few have been reported in immunocompetent patients negative for human immunodeficiency virus. A previous case report and a review of the treatment of tuberculous brain abscess have shown that a combination of microsurgery and antituberculous chemotherapy seemed to be a better treatment method.11,12 There has been no report on how rehabilitation programs affect the prognosis or whether rehabilitation programs are beneficial to patients with tuberculous brain abscess who have already received surgery and antituberculous chemotherapy. Gerstmann’s syndrome is characterized by dyscalculia or acalculia (impaired ability or inability to calculate), dys- graphia or agraphia (impaired or inability to write), finger anomia (inability to name individual fingers, such as the index finger or thumb), and right-left confusion (inability to dis- tinguish which side is right or left).13 Gerstmann’s syndrome is associated with lesions or dysfunction of the left angular gyrus in the parietal lobe.14 Our patient had a tuberculous brain abscess in the left parietal lobe. This condition led to Gerstmann’s syndrome and right-sided apraxia. Gerstmann’s submit your manuscript | www.dovepress.com Dovepress 219