About the Journal | Editorial Board | Instructions to Contributors | Submission & Review | Advertise with Us | Subscribe to E- Alerts
Sitemap | Feedback
Advanced search
Journal of Case Reports
Sternal Tuberculosis: An Uncommon Presentation

carbamazepin tegretol

carbamazepin und tramadol link carbamazepin 100
Manish Narang1, Archana Dwivedi1, Shiva Narang2, Gopesh Mehrotra3
Department of Pediatrics1, Medicine2 and Radiodiagnosis3
University College of Medical Sciences and GTB Hospital,
Delhi, India.

buy cialis viagra

Trusted buy cialis from an anline pharmacy pills.Here he can easly buy cheap buy cialis viagra. Here you can easly buy cialis online cheap.

ca50ae61-900c-46f9-b2bf-706e88d17ac6

Corresponding Author:
Dr. Manish Narang
Email: manish_2710@yahoo.com
Mobile: 9811036569

pros cons buying levitra online

Trusted generic levitra brand pills. Here you can easly buy levitra online cheap.Here you can easly buy cheap cheap canada generic levitra.

f8886167-f33c-4d8a-9f0a-1f7b4be6ba3a

Received: 05-OCT-2011 Accepted: 25-OCT-2011 Published Online: 30-OCT-2011
DOI: http://dx.doi.org/10.17659/01.2011.0003
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.

viagra online consultation

Here you can easly order viagra without prescription usa cheap. Trusted viagra online apotheke tablets.Here he could easly order cheap viagra without prescription.

aca632ea-ee6d-4333-b2c0-87c968c6f5bd

Keywords : Tubercular osteomyelitis, Sternum
6go6ckt5b8|3000F7576AC3|Tab_Articles|Fulltext|0xf1ff2416010000001500000001000700
6go6ckt5b5idvals|118
6go6ckt5b5idcol1|ID
6go6ckt5b5|2000F757Tab_Articles|Fulltext

Introduction

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.

Case Report

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.

Fig.1: Sagittal MPR showing destruction of sternum with fluid collection obliterating the anterior clear space in chest and lying in contact with anterior mediastinal structure

Fig.2: NCCT showing lytic destruction of sternum, costal end of ribs along with extrapleural thick collection within soft tissue.

Discussion

Tuberculous involvement of the sternum is rare presentation of extrapulmonary tuberculosis[3]. The diagnosis is often delayed because osseous tuberculosis is a paucibacillary lesion and smears are often negative.  Localised pain, fever and weight loss are common modes of presentation. Our patient presented with a painful swelling over anterior chest wall as initial manifestation of sternal tuberculosis.
There are few reports of tuberculosis infection of sternum. Out of 20 cases of sternal osteomyelitis reviewed by McLellan et al, only 2 were children
[4]. The earliest age at presentation has been 9 months, described in a Japanese infant[5]. Ray et al described sternal involvement in a case of disseminated tuberculosis in a child[6]. Tuberculosis of sternum may complicate thalassemia and HIV [7,8]. Spontaneous fracture of sternum with tuberculous infection has been reported [9].

Tubercular sternal osteomyelitis is usually caused by reactivation of latent loci formed during hematogenous or lymphatic dissemination of primary tuberculosis. In our case extrasternal involvement was suggested by presence of bilateral pleural effusion. Unlike pyogenic sternal infections characterized by more rapid and fulminant course, tubercular sternal osteomyelitis might present with sternal pain, painful swelling, cold abscess and parasternal sinus.

The gold standard for diagnosis of osseous tuberculosis is culture of Mycobacterium tuberculosis which was positive in our case. Our case also had positive Zeil Neelsen staining for acid fast bacilli but this does not differentiate between tuberculous and non tuberculous mycobacteria[10,11]. The advent of DNA detection via PCR has improved the diagnostic accuracy for exclusion of non tuberculous mycobacteria. The extent of bony lesion and degree of soft tissue involvement may be defined better by CT scan. MRI is helpful in differentiating between abscess and granulation tissue.

There is still no consensus on the optimal therapy of chest wall tuberculosis. Some experts favour a surgical treatment others argue that combination antitubercular chemotherapy should be the mainstay of treatment. Current recommendations for the treatment of sternal tuberculosis include a two month initial phase of isoniazid, rifampicin, ethambutol, pyrazinamide followed by a six to twelve months regimen of isoniazid and rifampicin. Our patient is responding well to medical treatment. However, close follow up is needed in these patients to determine whether surgical treatment will ultimately be needed.

This case illustrates the importance of   high index of suspicion when evaluating a patient   with swelling over chest wall. Early imaging and appropriate microbiological testing can avoid diagnostic delay.

References

  1. Nicholson, R.A. Twenty years of bone and joint tuberculosis in Bradford. J  Bone & Jt. Surg Br. 1974; 56-B: 760-765.
  2. Sharma S, Juneja M, Garg A. Primary tubercular osteomyelitis of the sternum. Indian J Pediatr 2005; 72: 709-710.
  3. Kelly CA, Chetty MN. Primary sternal osteomyelitis. Thorax 1985; 40: 872-873.
  4. McLellan DGJ, Philips KB, Corbett CE, Bronze MS. Sternal osteomyelitis caused by Mycobacterium tuberculosis : case report and review of literature. Am J Med Sci  2000; 319: 250-254.
  5. Kato Y, Horikawa Y, Nishimura Y, Shimoda H, Shigeto E, Ueda K. Sternal tuberculosis in a 9-month-old infant after BCG vaccination. Acta Paediatr 2000; 89: 1495-1497.
  6. Ray M, Kataria S, Singhi P. Unusual presentation of disseminated tuberculosis. Indian Pediatr 2002; 39: 88-91.
  7. Kataria  S.P, Avasthi R. Sternal tuberculosis in combination with thalassemia. J Assoc  Phys  India. 1993; 41: 472.
  8. Martors JA, Olm M, Miro JM, Mallotas J, Letang E, Brancos MA,et al. Chondrocostal tuberculosis in 2 heroin addicts infected with human  immunodeficiency virus. Med Clin [Barc] 1989; 93: 467-470.
  9. Watts RA, Paice EW, White AG. Spontaneous fracture of the sternum and sternal    tuberculosis. Thorax 1987; 42: 984-985.
  10. Rooney JJ Jr, Crocco JA, Kramer S, Lyons HA. Further observations on tuberculin reactions in active tuberculosis. Am J Med  1976; 60: 517-522.
  11. Glassroth J. Diagnosis of tuberculosis. In: Tuberculosis: A Comprehensive International Approach. Reichman LB, Hershfield ES. Ed. New York, Marcel Dekker 1993 pp149-165.

buy viagra online

Here you can easly buy cheap viagra without prescription usa. Trusted viagra without prescription pills. Here you can easly buy viagra online stores cheap.

98cc6df7-01cd-4290-a89b-126aaa595d32

Article Options
FULL TEXT
ABSTRACT
PDF
PRINTER FRIENDLY VERSION
Search PubMed for
Search Google Scholar for
Article Statistics
CITE THIS ARTICLE
Narang M, Dwivedi A, Narang S, Mehrotra GSternal Tuberculosis: An Uncommon Presentation.JCR 2011;1:9-11
CITE THIS URL
Narang M, Dwivedi A, Narang S, Mehrotra GSternal Tuberculosis: An Uncommon Presentation.JCR [serial online] 2011[cited 2024 Jul 13];1:9-11. Available from: http://www.casereports.in/articles/1/1/sternal-tuberculosis.html
Bookmark and Share