Sternal Tuberculosis: An Uncommon Presentation

Abstract

Skeletal tuberculosis as an extrapulmonary entity is uncommon accounting for less than 7% cases [1]. Tubercular involvement of the sternum is rarer even in countries where tuberculosis is highly prevalent [2]. We herein report an unusual case of tuberculous osteomyelitis of sternum with acute presentation as a swelling over anterior chest wall.An eleven year old girl presented with one week history of chest pain and swelling over anterior chest wall. There was history of progressive weight loss and low grade intermittent fever for one month. She was BCG vaccinated and there was no history of contact with tuberculosis in the family.On examination, the child was febrile, with thin built, and weighed 35 kgs (<50th percentile). Local examination showed diffuse swelling over manubrium. The swelling was highly tender and fluctuant. There was no redness, localised rise of temperature or any venous prominence over the swelling. There was no lymphadenopathy. Systemic examination revealed dullness over bilateral lower chest with decreased breath sounds on corresponding areas. Other systems were found to be normal.Investigations revealed hemoglobin of 10.4gm/dl, erythrocyte sedimentation rate was elevated to 40 mm in 1st hour. Tuberculin test was strongly positive measuring 20 x 20 mm with negative HIV test. Chest x-ray showed bilateral pleural effusion. Computed tomography of the chest showed permeative destruction (lytic areas) of sternum along with extrapleural collection tracking all along the anterior mediastinum and encroaching on anterior clear space on sagittal views (Fig 1). Collection was extending anterior to the sternum into parities and there was evidence of mediastinal and hilar lymphadenopathy along with areas of pleural reaction (thickening in the left hemithorax) along the costal pleura (Fig 2). There was enlargement of subcarinal group of lymph nodes. Fat planes anterior to mediastinum under collection were maintained. Aspirate from swelling over manubrium sterni revealed positive culture for Mycobacterium tuberculosis and positive Zeil Neelsen staining for acid fast bacilli.The child was started on antitubercular treatment with four drugs viz isoniazid, rifampicin, ethambutol and pyrazinamide. The child showed dramatic improvement within a month of institution of treatment. The pain and swelling subsided. She was switched over to continuation phase with two drugs isoniazid and rifampicin. Abstract:Primary tubercular osteomyelitis of sternum presenting as an acute swelling over chest is an extremely rare presentation in pediatric population. We herein report such a case which was diagnosed by CT scan showing lytic lesion and aspiration revealed positive culture for Mycobacterium tuberculosis. Child improved with antitubercular treatment.Tubercular osteomyelitis, Sternum

Sternal mycobacterial infections

“…As a result, 76 articles[ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 ] were obtained, including 56 (73.7%) case reports,[ 1 3 4 5…”

“…A total of 107 (67.3%) cases were primary,[ 2 5 9 10 13 14 16 17 18 19 21 22 23 28 30 31 32 33 34 38 39 40 42 43 44 48 50 52 53 56 59 60 61 62 64 65 66 67 69 70 72 73 74 75 76 ] 33 (20.8%) were secondary,[ 6 11 12 15 20 24 25 26 29 35 37 46 47 51 55 62 64 66 67 ] and 19 (11.9%) were postoperative. [ 1 3 4 7 8 27 36 41 45 49 54 58 62 63 68 …”

“…The underlying causes for secondary sternal TB were a previous history of lung TB in 12 (36.4%)[ 15 25 55 62 66 67 73 ] (one was reactivated lung TB[ 73 ] and one was associated with lymph node TB[ 55 ]), TB contact in 10 (30.3%),[ 20 24 46 47 66 ] extrapulmonary TB in six (18.2%) including TB lymphadenitis in three[ 6 51 55 ] (cervical,[ 55 ] supraclavicular,[ 6 ] and unstated[ 51 ] in one each) and vertebral TB,[ 67 ] multifocal skeletal TB,[ 67 ] and abdominal and spinal TB[ 37 ] in one each; and Bacille de Calmette et Guérin vaccination in five (15.2%) patients. [ 11 12 26 29 35 ]…”

Conquering the conquered: sternal tuberculosis osteomyelitis with hiv infection

“…Studies by few authors have found extrasternal involvement presenting as bilateral pleural effusion or as involvement of other organs. [6][7][8][9][10][11][12][13][14][15][16] As per WHO guidelines if an individual is diagnosed to have HIV infection then it is recommended to start screening for tuberculosis before starting antiretroviral therapy and also to continue screening at regular intervals and vice versa. The various screening and surveillance tools are focused towards symptoms of cough, night sweats and weight loss.…”

“…While with the availability of gene expert it is not necessary. 16 While testing by Interferon gamma release assay also known as QuantiFERON-TB Gold there is limitation of inability to differentiate between active and latent infection. 19,20 Isolated case reports suggest estimation of vitamin D levels which were found to be low in their study but the rationale of conducting the test being unclear.…”