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Tuberculosis of the ribs
ClinicalRadiology (1980) 31, 6 8 1 - 6 8 4 © 1980 Royal College of Radiologists
0009-9260/80/00920681502.00
Tuberculosis of the Ribs T. S. B R O W N
Bradford Royal Infirmary, Duckworth Lane, Bradford The radiological appearances o f seven Cases o f rib tuberculosis are discussed. The c o m b i n a t i o n o f rib destruction and an extrapleural soft tissue opacity in an Asian i m m i g r a n t makes tuberculosis a highly likely diagnosis. The presence o f an associated fluctuant chest wall swelling, enables a diagnosis o f tuberculosis to be made w i t h confidence even in Caucasians.
Rib i n v o l v e m e n t in tuberculosis has n o t attracted m u c h a t t e n t i o n i n the English literature in recent years. A p a r t f r o m occasional reports f r o m N o r t h America (Pepper and Berinson, 1973; Wolstein et al., 1974) it has received only passing m e n t i o n in papers by Stevenson (1962), N i c h o l s o n (1974) and Goldblatt and Cremin (1978). The present paper describes the radiological appearances o f seven cases o f rib tuberculosis.
and a large extrapleural soft tissue mass (Fig. 3). Biopsy of the breast mass produced histological evidence of tuberculosis. Case 7. N. A., a 23-year-old Asian female, presented initially with enlarged left supraclavicular glands, and a soft tissue lesion over the left occipital bone. Biopsy of the supraclavicular glands revealed evidence of tuberculosis. At this time her chest X-ray was normal, but a follow-up chest radiograph showed development of a large extrapleural soft tissue swelling at the right apex, and ill-defined destruction of the posterior end of the first right rib, associated with periosteal reaction.
CASE REPORTS Case 1. P. M., a 48-year-old Asian male, presented with a fluctuant swelling of the right anterior chest wall. The chest radiograph showed a destructive lesion, with well-defined margins, involving the middle third of the fourth right rib (Fig. 1). Periosteal reaction was noted as was a prominent extrapleural soft tissue opacity associated with the bone destruction Case 2. D. M., a 33-year-old Asian male, was admitted with an acute episode of pancreatitis, proven biochemically. Once the acute episode had settled, however, pain persisted in the left upper quadrant and a chest radiograph showed a pathological fracture of the ninth left rib. Biopsy and culture of the lesion revealed evidence of M. tuberculosis. Case 3. M. A., a 27-year-old Caucasian female born in the United Kingdom, presented with a fluetuant mass on the right posterior chest wall. A chest radiograph showed destruction of the inferior margin of the posterior third of the ninth right rib, with extrapleural soft tissue swelling. Exploration of the lesion revealed an abscess cavity, from which M. tuberculosis was cultured. Case 4. A. A., a 69-year-old Asian male, presented with a sinus of the right chest wall. Chest radiograph was normal. Exploration of the sinus showed it to extend to the costal cartilage of the third right ~ib, and material removed at that time showed histological evidence of tuberculosis. Case 5. H. P., a 16-year-old Asian female, presented with a fluctuant swelling of the right chest wall, and enlarged glands in the right supraclavicular fossa. An initial chest radiograph was normal. Gland biopsy revealed evidence of M. tuberculosis. A chest radiograph taken six weeks after presentation, showed ill-defined destruction of the axillary third of the tenth right rib, with associated periosteal reaction and a small extrapleural soft tissue shadow (Fig. 2). Case 6. S. C., a 68-year-old Asian female, presented with a mass in the right breast. A chest radiograph showed a destructive lesion of the fifth right rib, with well-defined margins
Fig. 1 - Case 1, showing rib destruction with a well-defined posterior margin and some periosteal reaction extending into the anterior third of the rib.
682
CLINICAL RADIOLOGY
Fig. 3 - Case 6, showing a destructive lesion of the fifth right rib with a very well-defined posterior margin and a dearly seen large extrapleural soft tissue mass.
Fig. 2 - Case 5, showing ill-defined deslzuetion of the middle third of the tenth right rib associated with a small extrapleural soft tissue shadow.
Tables 1 and 2 summarise the salient radiological features seen in these seven cases. DISCUSSION
Rib tuberculosis has been described as rare (Johnson and Rothstein, 1952) or uncommon (Wolstein et a/., 1974; Leader 1950). Such involvement has previously been reported predominantly in young adult males (Wassersug, 1941; Leader, 1950). A rib lesion is usually single, and isolated (Wassersug, 1941) but Tatelman and Drouillard (1953) found disease elsewhere in nearly two-thirds of their cases; all of the cases described by Wolstein et al. (1974) showed other tuberculosis lesions. Two of the current series
had lymph node involvement and of these, one had a tuberculous lesion of the skull vault. A distinction has been made between tuberculous chondritis and tuberculous osteitis by Johnson and Rothstein (1952) and Wolstein et al. (1974). Tuberculosis of the costal cartilage may produce no abnormality in the chest radiograph as in Case 4. However, a cold abscess of the chest wall arising from the costal cartilage might produce a soft tissue shadow on the Table 1 - Showing age, sex and site o f involvement in seven cases o f rib tubercle.
Patient
Age
1
(P.M.)
Sex
48
M
2 (D.M.) 3 (M.A.) 4 (A.A.)
33 27 60
M F M
5 (H.P.) 6 (S.C.) 7 (N.A.)
16 68 23
F F F
* Costal cartilage.
Rib involved 4
R
9 L 9 R CC* 3 R 10 R 5 R 1 R
683
TUBERCULOSIS OF THE RIBS Table 2 - Showing salient radiologieal features of the tuberculous lesions Patient
Rib destruction
1 (P.M.)
Middle third Yes
Yes
No
2 (D.M.)
Middle third No
No
No
3 (M.A.)
Posterior third inferior margin C.C* - r e Middle third Middle third
No
No
No
No Yes Yes
No Yes Yes
No Yes No
Yes
Yes
Yes
4 (A.A.) 5 (H.P.) 6 (S.C.) 7 (N.A.)
Posterior end
Periosteal reaction
Extrapleural TB Margins of shadow elsewhere lesion
Well defined Path. fracture IU defined
No lesion Ill defined Well defined Hazy
* Costal cartilage.
chest radiograph. Tuberculous osteitis of the rib occurred in the remaining six patients. All lesions were characterised by rib destruction, which may affect the whole segment of the involved rib or one margin only. In two patients, the margins of the lesions were very clearly defined (Fig. 3), a feature previously described by Tatelman and Drouillard (1953) and Wolstein et al. (1974). An extrapleural soft tissue shadow associated with the rib destruction was seen in five patients; very oblique views may be required to show it clearly. A chest wall abscess may precede rib destruction (Johnson and Rothstein, 1952) as occurred in Case 5 of the present series (Fig. 2). Six weeks after initial presentation with a cold abscess of the chest wall and supraclavicular gland, a previously normal chest radiograph showed evidence of ill-defined rib destruction, associated with a small extrapleural shadow. Pathological fracture of tuberculous rib lesions are rare (Wassersug, 1941; Leader, 1950) but pain from this drew attention to the rib lesion in Case 2. Periosteal reaction in coloured people with bone tuberculosis is well described in standard texts (Murray and Jacobson, 1977) and was reaffirmed by Goldblatt and Cremin (1978). Five of the present series (including the one Caucasian patient) had destructive bone lesions associated with such reaction (Fig. 1). Healing is usually complete on adequate chemotherapy but may produce some residual deformity (Fig. 4). Tuberculosis has been described as the commonest inflammatory lesion of rib (Wolstein et al., 1974). Tatelman and Drouillard (1953) state that it is second only to metastic malignancy as a cause of destructive rib lesions. More recently Firooznia et al. (1973) reported rib as the commonest extrapuhnonary site
of tuberculosis in heroin addicts. Felson (1973), in listing the differential diagnosis of destructive rib lesions, included tuberculosis as well as myeloma, lymphoma, primary or secondary neoplasm and
Fig. 4 - Case 6, showing healing with residual deformity after adequate chemotherapy.
684
CLINICAL RADIOLOGY
included amongst other causes of the extrapleural shadow lipoma, neurofibroma or haematoma. In urban areas o f the United Kingdom, with large immigrant populations, rib tuberculosis is n o t uncommon. A combination of rib destruction and extrapleurai soft tissue shadowing in an immigrant is highly suggestive o f tuberculosis. If an associated fluctuant chest wall mass can be demonstrated the diagnosis can be made with confidence, even in Caucasian patients. Acknowledgements. I should like to extend my thanks to my two colleagues Dr D. K. Stevenson and Dr A. J. King, consultant chest physicians, for their permission to make use of clinical records of cases under their care. I should .also like to thank Mr Peter Harrison who kindly prepared the photographs.
REFERENCES
Felson, B. (1973). Chest Roentgenology, W. B. Saunders Company, Philadelphia, London, Toronto. Firooznia, H., Seliger, G., Abrams, R. A., Valensi, V. & Shamoun, J. (1973). Disseminated extrapulmonary tuber-
culosis in association with heroin addication. Radiology 109, 291-296. Goldblatt, M. & Cremin, B. J. (1978). Osteo-articular tUber. culosis; its presentaion in coloured races. Clinical Radio. logy, 29, 669-677. Johnson, M. P. & Rothstein, E. (1952). Tuberculosis of the rib. Journal of Bone and Joint Surgery, 34A, 878-887. Leader, S. A. (1950). Tuberculosis of ribs. American Journal
of Roentgenology, Radiotherapy and Nuclear Medicine, 63, 354-359. Murray, R. O. & Jacobson, H. G. (1977). Radiology of Skeletal Disorders, 2nd edn., Churchill Livingstone, London. Nicholson, R. A. (1974). Twenty years of bone and joint tuberculosis in Bradford. Journal of Bone and Joint Surgery, 56B, 760-765. Pepper, H. W. & Berinson, H. S. (1973). Roentgenograrn of the month. Extrapleural mass with neurological signs. Chest, 64, 345-346. Stevenson, D. K. (1962). Tuberculosis in Pakistanis in Bradford. British Medical Journal, 1, 1382-1386. Tatelman, M. & Drouillard, E. J. P. (1953). Tuberculosis of the ribs. American Journal of Roentgenology, 70, 923935. Wassersug, J. D. (1941). Tuberculosis of ribs. American Review of Tuberculosis, 44, 716-721. Wolstein, D., Rabinowitz, J. G. & Twersky, J. (1974). Tuberculosis of the rib. Journal of the Canadian Association of Radiologists, 25, 307-309.
0009-9260/80/00920681502.00
Tuberculosis of the Ribs T. S. B R O W N
Bradford Royal Infirmary, Duckworth Lane, Bradford The radiological appearances o f seven Cases o f rib tuberculosis are discussed. The c o m b i n a t i o n o f rib destruction and an extrapleural soft tissue opacity in an Asian i m m i g r a n t makes tuberculosis a highly likely diagnosis. The presence o f an associated fluctuant chest wall swelling, enables a diagnosis o f tuberculosis to be made w i t h confidence even in Caucasians.
Rib i n v o l v e m e n t in tuberculosis has n o t attracted m u c h a t t e n t i o n i n the English literature in recent years. A p a r t f r o m occasional reports f r o m N o r t h America (Pepper and Berinson, 1973; Wolstein et al., 1974) it has received only passing m e n t i o n in papers by Stevenson (1962), N i c h o l s o n (1974) and Goldblatt and Cremin (1978). The present paper describes the radiological appearances o f seven cases o f rib tuberculosis.
and a large extrapleural soft tissue mass (Fig. 3). Biopsy of the breast mass produced histological evidence of tuberculosis. Case 7. N. A., a 23-year-old Asian female, presented initially with enlarged left supraclavicular glands, and a soft tissue lesion over the left occipital bone. Biopsy of the supraclavicular glands revealed evidence of tuberculosis. At this time her chest X-ray was normal, but a follow-up chest radiograph showed development of a large extrapleural soft tissue swelling at the right apex, and ill-defined destruction of the posterior end of the first right rib, associated with periosteal reaction.
CASE REPORTS Case 1. P. M., a 48-year-old Asian male, presented with a fluctuant swelling of the right anterior chest wall. The chest radiograph showed a destructive lesion, with well-defined margins, involving the middle third of the fourth right rib (Fig. 1). Periosteal reaction was noted as was a prominent extrapleural soft tissue opacity associated with the bone destruction Case 2. D. M., a 33-year-old Asian male, was admitted with an acute episode of pancreatitis, proven biochemically. Once the acute episode had settled, however, pain persisted in the left upper quadrant and a chest radiograph showed a pathological fracture of the ninth left rib. Biopsy and culture of the lesion revealed evidence of M. tuberculosis. Case 3. M. A., a 27-year-old Caucasian female born in the United Kingdom, presented with a fluetuant mass on the right posterior chest wall. A chest radiograph showed destruction of the inferior margin of the posterior third of the ninth right rib, with extrapleural soft tissue swelling. Exploration of the lesion revealed an abscess cavity, from which M. tuberculosis was cultured. Case 4. A. A., a 69-year-old Asian male, presented with a sinus of the right chest wall. Chest radiograph was normal. Exploration of the sinus showed it to extend to the costal cartilage of the third right ~ib, and material removed at that time showed histological evidence of tuberculosis. Case 5. H. P., a 16-year-old Asian female, presented with a fluctuant swelling of the right chest wall, and enlarged glands in the right supraclavicular fossa. An initial chest radiograph was normal. Gland biopsy revealed evidence of M. tuberculosis. A chest radiograph taken six weeks after presentation, showed ill-defined destruction of the axillary third of the tenth right rib, with associated periosteal reaction and a small extrapleural soft tissue shadow (Fig. 2). Case 6. S. C., a 68-year-old Asian female, presented with a mass in the right breast. A chest radiograph showed a destructive lesion of the fifth right rib, with well-defined margins
Fig. 1 - Case 1, showing rib destruction with a well-defined posterior margin and some periosteal reaction extending into the anterior third of the rib.
682
CLINICAL RADIOLOGY
Fig. 3 - Case 6, showing a destructive lesion of the fifth right rib with a very well-defined posterior margin and a dearly seen large extrapleural soft tissue mass.
Fig. 2 - Case 5, showing ill-defined deslzuetion of the middle third of the tenth right rib associated with a small extrapleural soft tissue shadow.
Tables 1 and 2 summarise the salient radiological features seen in these seven cases. DISCUSSION
Rib tuberculosis has been described as rare (Johnson and Rothstein, 1952) or uncommon (Wolstein et a/., 1974; Leader 1950). Such involvement has previously been reported predominantly in young adult males (Wassersug, 1941; Leader, 1950). A rib lesion is usually single, and isolated (Wassersug, 1941) but Tatelman and Drouillard (1953) found disease elsewhere in nearly two-thirds of their cases; all of the cases described by Wolstein et al. (1974) showed other tuberculosis lesions. Two of the current series
had lymph node involvement and of these, one had a tuberculous lesion of the skull vault. A distinction has been made between tuberculous chondritis and tuberculous osteitis by Johnson and Rothstein (1952) and Wolstein et al. (1974). Tuberculosis of the costal cartilage may produce no abnormality in the chest radiograph as in Case 4. However, a cold abscess of the chest wall arising from the costal cartilage might produce a soft tissue shadow on the Table 1 - Showing age, sex and site o f involvement in seven cases o f rib tubercle.
Patient
Age
1
(P.M.)
Sex
48
M
2 (D.M.) 3 (M.A.) 4 (A.A.)
33 27 60
M F M
5 (H.P.) 6 (S.C.) 7 (N.A.)
16 68 23
F F F
* Costal cartilage.
Rib involved 4
R
9 L 9 R CC* 3 R 10 R 5 R 1 R
683
TUBERCULOSIS OF THE RIBS Table 2 - Showing salient radiologieal features of the tuberculous lesions Patient
Rib destruction
1 (P.M.)
Middle third Yes
Yes
No
2 (D.M.)
Middle third No
No
No
3 (M.A.)
Posterior third inferior margin C.C* - r e Middle third Middle third
No
No
No
No Yes Yes
No Yes Yes
No Yes No
Yes
Yes
Yes
4 (A.A.) 5 (H.P.) 6 (S.C.) 7 (N.A.)
Posterior end
Periosteal reaction
Extrapleural TB Margins of shadow elsewhere lesion
Well defined Path. fracture IU defined
No lesion Ill defined Well defined Hazy
* Costal cartilage.
chest radiograph. Tuberculous osteitis of the rib occurred in the remaining six patients. All lesions were characterised by rib destruction, which may affect the whole segment of the involved rib or one margin only. In two patients, the margins of the lesions were very clearly defined (Fig. 3), a feature previously described by Tatelman and Drouillard (1953) and Wolstein et al. (1974). An extrapleural soft tissue shadow associated with the rib destruction was seen in five patients; very oblique views may be required to show it clearly. A chest wall abscess may precede rib destruction (Johnson and Rothstein, 1952) as occurred in Case 5 of the present series (Fig. 2). Six weeks after initial presentation with a cold abscess of the chest wall and supraclavicular gland, a previously normal chest radiograph showed evidence of ill-defined rib destruction, associated with a small extrapleural shadow. Pathological fracture of tuberculous rib lesions are rare (Wassersug, 1941; Leader, 1950) but pain from this drew attention to the rib lesion in Case 2. Periosteal reaction in coloured people with bone tuberculosis is well described in standard texts (Murray and Jacobson, 1977) and was reaffirmed by Goldblatt and Cremin (1978). Five of the present series (including the one Caucasian patient) had destructive bone lesions associated with such reaction (Fig. 1). Healing is usually complete on adequate chemotherapy but may produce some residual deformity (Fig. 4). Tuberculosis has been described as the commonest inflammatory lesion of rib (Wolstein et al., 1974). Tatelman and Drouillard (1953) state that it is second only to metastic malignancy as a cause of destructive rib lesions. More recently Firooznia et al. (1973) reported rib as the commonest extrapuhnonary site
of tuberculosis in heroin addicts. Felson (1973), in listing the differential diagnosis of destructive rib lesions, included tuberculosis as well as myeloma, lymphoma, primary or secondary neoplasm and
Fig. 4 - Case 6, showing healing with residual deformity after adequate chemotherapy.
684
CLINICAL RADIOLOGY
included amongst other causes of the extrapleural shadow lipoma, neurofibroma or haematoma. In urban areas o f the United Kingdom, with large immigrant populations, rib tuberculosis is n o t uncommon. A combination of rib destruction and extrapleurai soft tissue shadowing in an immigrant is highly suggestive o f tuberculosis. If an associated fluctuant chest wall mass can be demonstrated the diagnosis can be made with confidence, even in Caucasian patients. Acknowledgements. I should like to extend my thanks to my two colleagues Dr D. K. Stevenson and Dr A. J. King, consultant chest physicians, for their permission to make use of clinical records of cases under their care. I should .also like to thank Mr Peter Harrison who kindly prepared the photographs.
REFERENCES
Felson, B. (1973). Chest Roentgenology, W. B. Saunders Company, Philadelphia, London, Toronto. Firooznia, H., Seliger, G., Abrams, R. A., Valensi, V. & Shamoun, J. (1973). Disseminated extrapulmonary tuber-
culosis in association with heroin addication. Radiology 109, 291-296. Goldblatt, M. & Cremin, B. J. (1978). Osteo-articular tUber. culosis; its presentaion in coloured races. Clinical Radio. logy, 29, 669-677. Johnson, M. P. & Rothstein, E. (1952). Tuberculosis of the rib. Journal of Bone and Joint Surgery, 34A, 878-887. Leader, S. A. (1950). Tuberculosis of ribs. American Journal
of Roentgenology, Radiotherapy and Nuclear Medicine, 63, 354-359. Murray, R. O. & Jacobson, H. G. (1977). Radiology of Skeletal Disorders, 2nd edn., Churchill Livingstone, London. Nicholson, R. A. (1974). Twenty years of bone and joint tuberculosis in Bradford. Journal of Bone and Joint Surgery, 56B, 760-765. Pepper, H. W. & Berinson, H. S. (1973). Roentgenograrn of the month. Extrapleural mass with neurological signs. Chest, 64, 345-346. Stevenson, D. K. (1962). Tuberculosis in Pakistanis in Bradford. British Medical Journal, 1, 1382-1386. Tatelman, M. & Drouillard, E. J. P. (1953). Tuberculosis of the ribs. American Journal of Roentgenology, 70, 923935. Wassersug, J. D. (1941). Tuberculosis of ribs. American Review of Tuberculosis, 44, 716-721. Wolstein, D., Rabinowitz, J. G. & Twersky, J. (1974). Tuberculosis of the rib. Journal of the Canadian Association of Radiologists, 25, 307-309.