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Sternal Tuberculosis
The Journal of Emergency Medicine, Vol. 36, No. 4, pp. 342–344, 2009 Copyright © 2009 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/09 $–see front matter
doi:10.1016/j.jemermed.2007.06.017
Clinical Communications: Adults
STERNAL TUBERCULOSIS Ali Mohammadi,
MD*
and John M. Howell,
MD, FACEP†
*Department of Emergency Medicine, George Washington University Medical Center, Washington, DC and †Department of Emergency Medicine, INOVA Fairfax Hospital, Falls Church, Virginia Reprint Address: John M. Howell, MD, FACEP, INOVA Fairfax Hospital Emergency Department, 3300 Gallows Road, Falls Church, VA 22042
e Abstract—Tuberculosis is a public health problem worldwide. Between 19% and 43% of the world’s population is infected with Mycobacterium tuberculosis. Tubercular sternal osteomyelitis is a rare manifestation of tuberculosis. Tuberculous sternal osteomyelitis manifests with fever, weight loss, and chest wall lesions. Computed tomography (CT) scan defines the extent of the thoracic extension, and standard microbiologic methods diagnose this entity. Four-drug anti-tuberculous therapy is effective. The authors report a case of tuberculous osteomyelitis of the sternum not associated with pulmonary tuberculosis. © 2009 Elsevier Inc.
CASE REPORT A 32-year-old man presented to the Emergency Department (ED) with three distinct chest wall lesions that were stated to be 3 months old. The first lesion was a coinsized area of redness just medial to the right nipple. One month after the onset of this initial lesion, the patient noticed two left-sided chest wall lesions similar in character and size. These lesions progressively increased in size, particularly over the 2 weeks before ED presentation. The patient came to the ED after his lesions became larger in size and began draining pus. The patient reported subjective fever, but he had not taken his temperature. He also reported night sweats over the prior week. The patient denied chest pain, shortness of breath, and cough. He also denied chest wall injury, insect bite, or exposures that could have predisposed him to chest wall infection. He further denied human immunodeficiency virus (HIV) and HIV risk factors (e.g., intravenous drug use or unsafe sexual activities). The patient moved to the United States from El Salvador 3 years before presentation. He worked in agriculture in El Salvador. Since moving to the United States, the patient had worked in a restaurant. Vital signs were: temperature 37°C (99.2°F), blood pressure 117/61 mm Hg, heart rate 65 beats/min, respiratory rate 17 breaths/min, and oxygen saturation 98% on room air. The patient was a well-developed, wellnourished man lying in bed in no apparent distress. The
e Keywords—tuberculosis; sternum; osteomyelitis
INTRODUCTION The sternum is one of the least common bones of the body to become infected. Sternal osteomyelitis accounts for only 0.3–1.8% of all cases of ostemyelitis (1). Sternal tuberculosis represents ⬍ 1% of tubercular ostemyelitis. Since 1985, tuberculous sternal osteomyelitis (TSO) has been reported in association with spontaneous sternal fracture, disseminated tuberculosis, thalassemia, and coronary artery-bypass surgery (2). We found 33 reported cases of sternal tuberculosis in the medical literature. Extrasternal disease is detectable in fewer than half of cases (3). We present a case of isolated TSO with no extrasternal tuberculosis.
RECEIVED: 16 June 2005; FINAL ACCEPTED: 11 February 2007
SUBMISSION RECEIVED:
30 January 2007; 342
Sternal Tuberculosis
head and neck examinations were normal without tenderness or lymphadenopathy. The heart examination was normal. The lung sounds were clear bilaterally without wheezes, rhonchi, or rales. Examination of the chest wall revealed a 10 ⫻ 8 cm fluctuant, non-tender, subcutaneous mass just medial to the right nipple. There was mild overlying erythema and mild induration on the superior aspect of this lesion. There also was a 6 ⫻ 8 cm raised chest wall lesion located superior to the first lesion with overlying erythema and purulent yellow drainage. The third lesion was a 1 ⫻ 2 cm red, mildly raised pustule located between the first two lesions (Figure 1). The remaining physical examination was normal. The complete blood count and chemistries were normal. Urinalysis revealed a specific gravity of 1.084, trace ketones, 5–10 red blood cells/high power field and 0 –2 white blood cells/high power field. Blood and wound cultures were obtained. A computed tomography (CT) scan revealed two bilateral, thick, cystic structures consistent with abscesses extending between the pectoralis major and pectoralis minor muscles. Calcifications were present within the left abscess. In addition, modeling and destruction of the upper sternum and CT scan evidence of sternal osteomyelitis were present inferior to the sternoclavicular joints. There was a small abscess in the anterior mediastinum along the left para-sternal region measuring 1.5 cm. A 1.2-cm left axillary lymph node also was present. The lungs and heart were radiographically normal (Figure 2). The patient was admitted and started on piperacillinetazobactam, levofloxacin, and vancomycin. A CT-guided sternal biopsy and right chest fluid aspiration were done. Serum tests for HIV, hepatitis B, and hepatitis C were negative. A PPD test was positive, with 10 mm of induration. Bacterial blood culture and aspiration culture were negative. Aspiration Gram’s stain and acid fast bacillus stain also were negative. Sternal fine needle
Figure 1. Chest wall abscesses. One of the abscesses is draining slowly.
343
Figure 2. Chest CT scan shows chest wall abscesses (white arrow) and sternum osteomyelitis (black arrow).
aspiration revealed cellular necrosis with acute inflammation. The Auramine stain of sternal debris was positive for acid fast organisms. Four-drug anti-tuberculosis treatment (i.e., isoniazide, pyrazinamide, ethambutol, and rifampin) was started. The patient steadily improved and was discharged 10 days later. After 3 weeks, Mycobacterium tuberculosis grew in cultures of aspiration fluid. DISCUSSION Tuberculosis remains a public health problem worldwide. Its incidence has recently increased 1.8%/year worldwide due to inadequate local resources and the global epidemic of HIV infection. From 1993–2003, the incidence of tuberculosis in the United States declined sharply (44%), but the incidence of tuberculosis among foreign-born persons increased about 30% from 1992 to 2003. Lack of access to medical services due to cultural, linguistic, financial, and legal barriers results in delays in the diagnosis and treatment of tuberculosis among foreign-born patients and in ongoing transmission of the disease (4). Sternal osteomyelitis caused by M. tuberculosis is rare. Since the advent of modern anti-tuberculous therapy, a limited number of detailed cases have been reported. Even more uncommon are atypical mycobacteria such as Mycobatrium cheloance and Mycobactruim bovis, which cause sternal osteomyelitis as complications of median strenotomy and bacille Calmette-Guérin revaccination (5,6). Sternal tuberculosis can arise from either direct extension (hilar lymph nodes), or from hematogenous or lymphatic dissemination. Bone lesions begin with the formation of bone marrow tubercles. Caseification and liquefication
344
A. Mohammadi and J. M. Howell
Table 1. Cases of Thoracic Tuberculosis Reported in Literature* Localization
Cases
Sternum Clavicle Ribs Sternoclavicular joint Spine Intercostal Peristernal soft tissues Mediastinum
33 2 6 8 3 1 1 2
* Modified from (3): Tristano AG, Willson ML, Lopez A, et al. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Infect Dis Clin Pract 2004;12:174 –7.
create an abscessed cavity. At this point, tuberculosis can spread to contiguous soft tissues and form abscesses. Musculoskeletal tuberculosis involves the spine in approximately one-half of patients with tuberculosis. The chest region is most commonly affected, followed by lumbar and cervical spine (3). Table 1 lists the locations of tuberculous thoracic wall involvement among case reports reviewed by Tristano et al. in 2004. Among the 33 reported cases of sternal tuberculosis, fewer than half had extrasternal involvement (3). TSO cannot be discriminated from pyogenic bacterial osteomyelitis clinically. The most common presenting symptom is swelling over the sternum. Constitutional symptoms are uncommon (7). There are no pathognomonic radiographic findings on either CT scan or magnetic resonance imaging study for TSO (3). A CT scan and a magnetic resonance imaging study help determine the extent of disease (e.g., involvement of adjacent soft tissues), but are not useful in confirming the diagnosis of tuberculosis (8). Radiological sequelae usually occur much later than presenting clinical features. Definitive diagnosis depends largely upon the histologic and microbiologic examinations of sternal tissue. Either needle aspiration or excisional biopsy is diagnostic. Diagnosis is based on histologic examination of infected tissues and mycobacterial stains and cultures. There is no consensus on the optimal treatment (i.e., specific antimicrobials) of chest wall tuberculosis. Whereas some authors conclude that spinal tuberculosis
is a surgical entity, others believe the combination of anti-tuberculosis chemotherapy and surgical debridement should be the mainstays of treatment (9,10). In two case series, the treatment of extrapulmonary tuberculosis with four anti-tuberculosis drugs for 6 –9 months results in cure rates approaching 95% (11,12). CONCLUSION Most reported TSO cases occur outside of the United States. Tuberculous sternal osteomyelitis, although uncommon, has been reported in several clinical settings. TSO should be considered in patients with sternal pain and swelling, especially in young patients who live in or are coming from a country in which tuberculosis is endemic, just as in this case (4). Standard anti-tuberculous chemotherapy, with or without surgical debridement, may be successful. REFERENCES 1. Kalra P, Sharanja BK, Banerjea CK, Khosla VK. Sternal involvement in disseminated tuberculosis. J Assoc Physicians India 1988; 36:292–3. 2. Prakash A, Hira HS. Tuberculosis osteomyelitis of sternum. Indian J Tuberc 2001;48:35. 3. Tristano AG, Willson ML, Lopez A, et al. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Infect Dis Clin Pract 2004;12:174 –7. 4. Taylor Z, Nolan C, Blumberg H. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep 2005;54(No. RR-12):1– 81. 5. Grange JM. Mycobacterial infections following heart valve replacement. J Heart Valve Dis 1992;1:102–9. 6. Simila SE, Liedes E, Kinnunen P. Sternal abscess as a complication of BCG revaccination. Tubercle 1988;69:67–9. 7. McLellan DG, Philips KB. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Am J Med Sci 2000;319:250 – 4. 8. Shah J, Patkar D, Parikh B, et al. Tuberculosis of the sternum and clavicle: imaging findings in 15 patients. Skeletal Radiol 2000;29: 447–53. 9. Ray M, Kataria S, Singhi P. Unusual presentation of disseminated tuberculosis. Indian Pediatr 2002;39:89 –91. 10. Hsu HS, Wang LS, Wu YC, et al. Management of primary chest wall tuberculosis. Scand J Thorac Cardiovasc Surg 1995;29:119 –23. 11. Cohn D, Catlin BJ, Peterson K, Judson FN, Sbarbaro JA. A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. Ann Intern Med 1990;112:407–15. 12. Dutt AK, Moers D, Stead WW. Short course chemotherapy for extrapulmonary tuberculosis. Ann Intern Med 1986;104:7–12.
doi:10.1016/j.jemermed.2007.06.017
Clinical Communications: Adults
STERNAL TUBERCULOSIS Ali Mohammadi,
MD*
and John M. Howell,
MD, FACEP†
*Department of Emergency Medicine, George Washington University Medical Center, Washington, DC and †Department of Emergency Medicine, INOVA Fairfax Hospital, Falls Church, Virginia Reprint Address: John M. Howell, MD, FACEP, INOVA Fairfax Hospital Emergency Department, 3300 Gallows Road, Falls Church, VA 22042
e Abstract—Tuberculosis is a public health problem worldwide. Between 19% and 43% of the world’s population is infected with Mycobacterium tuberculosis. Tubercular sternal osteomyelitis is a rare manifestation of tuberculosis. Tuberculous sternal osteomyelitis manifests with fever, weight loss, and chest wall lesions. Computed tomography (CT) scan defines the extent of the thoracic extension, and standard microbiologic methods diagnose this entity. Four-drug anti-tuberculous therapy is effective. The authors report a case of tuberculous osteomyelitis of the sternum not associated with pulmonary tuberculosis. © 2009 Elsevier Inc.
CASE REPORT A 32-year-old man presented to the Emergency Department (ED) with three distinct chest wall lesions that were stated to be 3 months old. The first lesion was a coinsized area of redness just medial to the right nipple. One month after the onset of this initial lesion, the patient noticed two left-sided chest wall lesions similar in character and size. These lesions progressively increased in size, particularly over the 2 weeks before ED presentation. The patient came to the ED after his lesions became larger in size and began draining pus. The patient reported subjective fever, but he had not taken his temperature. He also reported night sweats over the prior week. The patient denied chest pain, shortness of breath, and cough. He also denied chest wall injury, insect bite, or exposures that could have predisposed him to chest wall infection. He further denied human immunodeficiency virus (HIV) and HIV risk factors (e.g., intravenous drug use or unsafe sexual activities). The patient moved to the United States from El Salvador 3 years before presentation. He worked in agriculture in El Salvador. Since moving to the United States, the patient had worked in a restaurant. Vital signs were: temperature 37°C (99.2°F), blood pressure 117/61 mm Hg, heart rate 65 beats/min, respiratory rate 17 breaths/min, and oxygen saturation 98% on room air. The patient was a well-developed, wellnourished man lying in bed in no apparent distress. The
e Keywords—tuberculosis; sternum; osteomyelitis
INTRODUCTION The sternum is one of the least common bones of the body to become infected. Sternal osteomyelitis accounts for only 0.3–1.8% of all cases of ostemyelitis (1). Sternal tuberculosis represents ⬍ 1% of tubercular ostemyelitis. Since 1985, tuberculous sternal osteomyelitis (TSO) has been reported in association with spontaneous sternal fracture, disseminated tuberculosis, thalassemia, and coronary artery-bypass surgery (2). We found 33 reported cases of sternal tuberculosis in the medical literature. Extrasternal disease is detectable in fewer than half of cases (3). We present a case of isolated TSO with no extrasternal tuberculosis.
RECEIVED: 16 June 2005; FINAL ACCEPTED: 11 February 2007
SUBMISSION RECEIVED:
30 January 2007; 342
Sternal Tuberculosis
head and neck examinations were normal without tenderness or lymphadenopathy. The heart examination was normal. The lung sounds were clear bilaterally without wheezes, rhonchi, or rales. Examination of the chest wall revealed a 10 ⫻ 8 cm fluctuant, non-tender, subcutaneous mass just medial to the right nipple. There was mild overlying erythema and mild induration on the superior aspect of this lesion. There also was a 6 ⫻ 8 cm raised chest wall lesion located superior to the first lesion with overlying erythema and purulent yellow drainage. The third lesion was a 1 ⫻ 2 cm red, mildly raised pustule located between the first two lesions (Figure 1). The remaining physical examination was normal. The complete blood count and chemistries were normal. Urinalysis revealed a specific gravity of 1.084, trace ketones, 5–10 red blood cells/high power field and 0 –2 white blood cells/high power field. Blood and wound cultures were obtained. A computed tomography (CT) scan revealed two bilateral, thick, cystic structures consistent with abscesses extending between the pectoralis major and pectoralis minor muscles. Calcifications were present within the left abscess. In addition, modeling and destruction of the upper sternum and CT scan evidence of sternal osteomyelitis were present inferior to the sternoclavicular joints. There was a small abscess in the anterior mediastinum along the left para-sternal region measuring 1.5 cm. A 1.2-cm left axillary lymph node also was present. The lungs and heart were radiographically normal (Figure 2). The patient was admitted and started on piperacillinetazobactam, levofloxacin, and vancomycin. A CT-guided sternal biopsy and right chest fluid aspiration were done. Serum tests for HIV, hepatitis B, and hepatitis C were negative. A PPD test was positive, with 10 mm of induration. Bacterial blood culture and aspiration culture were negative. Aspiration Gram’s stain and acid fast bacillus stain also were negative. Sternal fine needle
Figure 1. Chest wall abscesses. One of the abscesses is draining slowly.
343
Figure 2. Chest CT scan shows chest wall abscesses (white arrow) and sternum osteomyelitis (black arrow).
aspiration revealed cellular necrosis with acute inflammation. The Auramine stain of sternal debris was positive for acid fast organisms. Four-drug anti-tuberculosis treatment (i.e., isoniazide, pyrazinamide, ethambutol, and rifampin) was started. The patient steadily improved and was discharged 10 days later. After 3 weeks, Mycobacterium tuberculosis grew in cultures of aspiration fluid. DISCUSSION Tuberculosis remains a public health problem worldwide. Its incidence has recently increased 1.8%/year worldwide due to inadequate local resources and the global epidemic of HIV infection. From 1993–2003, the incidence of tuberculosis in the United States declined sharply (44%), but the incidence of tuberculosis among foreign-born persons increased about 30% from 1992 to 2003. Lack of access to medical services due to cultural, linguistic, financial, and legal barriers results in delays in the diagnosis and treatment of tuberculosis among foreign-born patients and in ongoing transmission of the disease (4). Sternal osteomyelitis caused by M. tuberculosis is rare. Since the advent of modern anti-tuberculous therapy, a limited number of detailed cases have been reported. Even more uncommon are atypical mycobacteria such as Mycobatrium cheloance and Mycobactruim bovis, which cause sternal osteomyelitis as complications of median strenotomy and bacille Calmette-Guérin revaccination (5,6). Sternal tuberculosis can arise from either direct extension (hilar lymph nodes), or from hematogenous or lymphatic dissemination. Bone lesions begin with the formation of bone marrow tubercles. Caseification and liquefication
344
A. Mohammadi and J. M. Howell
Table 1. Cases of Thoracic Tuberculosis Reported in Literature* Localization
Cases
Sternum Clavicle Ribs Sternoclavicular joint Spine Intercostal Peristernal soft tissues Mediastinum
33 2 6 8 3 1 1 2
* Modified from (3): Tristano AG, Willson ML, Lopez A, et al. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Infect Dis Clin Pract 2004;12:174 –7.
create an abscessed cavity. At this point, tuberculosis can spread to contiguous soft tissues and form abscesses. Musculoskeletal tuberculosis involves the spine in approximately one-half of patients with tuberculosis. The chest region is most commonly affected, followed by lumbar and cervical spine (3). Table 1 lists the locations of tuberculous thoracic wall involvement among case reports reviewed by Tristano et al. in 2004. Among the 33 reported cases of sternal tuberculosis, fewer than half had extrasternal involvement (3). TSO cannot be discriminated from pyogenic bacterial osteomyelitis clinically. The most common presenting symptom is swelling over the sternum. Constitutional symptoms are uncommon (7). There are no pathognomonic radiographic findings on either CT scan or magnetic resonance imaging study for TSO (3). A CT scan and a magnetic resonance imaging study help determine the extent of disease (e.g., involvement of adjacent soft tissues), but are not useful in confirming the diagnosis of tuberculosis (8). Radiological sequelae usually occur much later than presenting clinical features. Definitive diagnosis depends largely upon the histologic and microbiologic examinations of sternal tissue. Either needle aspiration or excisional biopsy is diagnostic. Diagnosis is based on histologic examination of infected tissues and mycobacterial stains and cultures. There is no consensus on the optimal treatment (i.e., specific antimicrobials) of chest wall tuberculosis. Whereas some authors conclude that spinal tuberculosis
is a surgical entity, others believe the combination of anti-tuberculosis chemotherapy and surgical debridement should be the mainstays of treatment (9,10). In two case series, the treatment of extrapulmonary tuberculosis with four anti-tuberculosis drugs for 6 –9 months results in cure rates approaching 95% (11,12). CONCLUSION Most reported TSO cases occur outside of the United States. Tuberculous sternal osteomyelitis, although uncommon, has been reported in several clinical settings. TSO should be considered in patients with sternal pain and swelling, especially in young patients who live in or are coming from a country in which tuberculosis is endemic, just as in this case (4). Standard anti-tuberculous chemotherapy, with or without surgical debridement, may be successful. REFERENCES 1. Kalra P, Sharanja BK, Banerjea CK, Khosla VK. Sternal involvement in disseminated tuberculosis. J Assoc Physicians India 1988; 36:292–3. 2. Prakash A, Hira HS. Tuberculosis osteomyelitis of sternum. Indian J Tuberc 2001;48:35. 3. Tristano AG, Willson ML, Lopez A, et al. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Infect Dis Clin Pract 2004;12:174 –7. 4. Taylor Z, Nolan C, Blumberg H. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep 2005;54(No. RR-12):1– 81. 5. Grange JM. Mycobacterial infections following heart valve replacement. J Heart Valve Dis 1992;1:102–9. 6. Simila SE, Liedes E, Kinnunen P. Sternal abscess as a complication of BCG revaccination. Tubercle 1988;69:67–9. 7. McLellan DG, Philips KB. Sternal osteomyelitis caused by Mycobacterium tuberculosis: case report and review of the literature. Am J Med Sci 2000;319:250 – 4. 8. Shah J, Patkar D, Parikh B, et al. Tuberculosis of the sternum and clavicle: imaging findings in 15 patients. Skeletal Radiol 2000;29: 447–53. 9. Ray M, Kataria S, Singhi P. Unusual presentation of disseminated tuberculosis. Indian Pediatr 2002;39:89 –91. 10. Hsu HS, Wang LS, Wu YC, et al. Management of primary chest wall tuberculosis. Scand J Thorac Cardiovasc Surg 1995;29:119 –23. 11. Cohn D, Catlin BJ, Peterson K, Judson FN, Sbarbaro JA. A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. Ann Intern Med 1990;112:407–15. 12. Dutt AK, Moers D, Stead WW. Short course chemotherapy for extrapulmonary tuberculosis. Ann Intern Med 1986;104:7–12.