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Tuberculosis of the ribs — a report of three cases
Respiratory Medicine (1991) 85, 251-253
Case Reports
Tuberculosis of the r i b s -
a report of three cases
ELLEN R. WIEBE AND R. K . ELWOOD*
Division of Tuberculosis Control, British Columbia Centre for Disease Control, Vancouver, B.C., Canada
Introduction
Extrapulmonary forms of tuberculosis constitute approximately one-sixth of all cases of tuberculosis reported in Canada (1). Skeletal tuberculosis is the fourth most common form constituting 2-6% of the total. Involvement of the ribs in skeletal tuberculosis is extremely uncommon. Three cases form the basis of this report, one of which presented with a pathological fracture, another of which appeared to be related to trauma and all of which were suspected of being malignant.
showed granulomatous inflammation with considerable central necrosis consistent with tuberculosis, but no organisms were seen. A very active callus formation was present reflecting the healing fracture. The specimen could not be cultured since the entire cortex was densely ossified. Therapy was initiated with isoniazid 300 rag, rifampin 600mg, pyrazinamide 1.5g for 2 months, completing 9 months with isoniazid and rifampin. His X-ray cleared and he made an uneventful recovery. Case 2
Case 1
A 33-year-old caucasian male presented with rightsided pleuritic chest pain. Two months prior he had been travelling in the Philippines and Central America where he had a 2-week episode of night sweats, fever and a non-productive cough. He had no known exposure to TB and had previously been well. When first seen he was tender over the 10th rib on the right side. A week later he sneezed and experienced a sudden increase in chest pain. Rib views showed fracture of the 10th rib in an area of bone destruction consistent with a pathological fracture (Plate 1). His PA film showed a 4 x 2 cm density in the right lower lobe. A diagnosis of metastatic carcinoma was made. The bone scan showed focal abnormal uptake in the calvarium and rib cage bilaterally with a diffuse uptake throughout the skeleton in the distribution of the red marrow. The needle aspirations were unhelpful. A bone marrow aspiration showed a small circumscribed granuloma, negative on smear for acid fast organisms. His 5 TU PPD skin test was 18 mm. One month after presentation his 10th rib was exposed at surgery revealing a tumour-like mass on its central portion. The histology Received 26 April 1990 and accepted in revised form 2 November 1990. *To whom correspondence should be addressed at: Division of Tuberculosis Control, P.O. Box 34020, Postal Station "D', Vancouver, B.C., V6J 4M3, Canada, 0954-6111/91/030251 + 03 $03.00/0
A 32-year-old Chinese male, born in Hong Kong, presented with cough and right-sided back pain of 2 months duration. His only other symptom was a 7 Ib
q
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Plate I PA of the chest showing a lytic lesion in a pathological fracture of the 10th rib (case l). © 1991 Bailli6re Tindall
252
E. R. Wiebe and R. K. Elwood
O
L Plate 2 CT scan ofthe chest showing a pleural based density with accompanying rib destruction (case 2).
weight loss over 2 months. A mild fullness was evident in the right posterior portion of his chest adjacent to the scapula, which was non-tender. His chest X-ray showed a pleural based mass situated posteriorly in the fight upper lobe. CT scan (Plate 2) showed a solitary pleural based density with accompanying rib destruction. Malignancy was suspected but a fine needle aspiration of the pulmonary lesion was unhelpful. At thoracotomy the 4th to 7th fibs were resected posteriorly. Histologically, typical tuberculous necrotic granulomas were seen in the ribs and in the adjacent lung parenchyma. Cultures of the resected specimen grew typical Mycobacterium tuberculosis resistant to rifampin. He was started on isoniazid 300 mg, rifampin 600 mg, pyrazinamide 1.5 g, replacing the rifampin with ethambutol when the sensitivities were known and completing 12 months therapy in all. He made a full recovery. Case 3
A 27-year-old caucasian male presented in April 1970 with an injury to his left chest sustained when he was hit with a crane hook. The area swelled rapidly but over 2 weeks it gradually reduced in size leaving a residual chest wall mass. A similar injury was sustained in July 1970, again resulting in swelling and pain. A chest X-ray showed a fracture of the left 5th rib with surrounding soft tissue swelling. This was eventually resected. Culture of the marrow from the rib grew typical Mycobacterium tuberculosis. He received 24 months' therapy with para-amino salicylic acid (PAS), isoniazid and streptomycin. Apart from sinus drainage at the site for several weeks, he made a full recovery. Discussion
Tuberculosis of bones and joints, although becoming rarer, still represents a continuing diagnostic challenge. The incidence of skeletal tuberculosis in Canada is reported as 0-5 cases per 100 000 population (2) and is
gradually decreasing at a rate similar to adult type pulmonary tuberculosis. Tuberculous involvement of the ribs is rare with incidence rates varying from 0 to 5% of bone and joint tuberculosis (3). Clinically, tuberculosis of the ribs presents with a combination of rib destruction and an extrapulmonary soft tissue mass. An associated fluctuant chest wall swelling is highly suggestive. Tuberculosis was not considered as a diagnostic possibility in any of the three patients and, not unreasonably, all cases were suspected of having malignancy. Some of the investigations were misleading. Chest X-rays may not be helpful in visualizing the rib destruction (as in case 2) unless special views are requested. The presentation of a discrete pleural mass in the second patient had led to considerable confusion as this was not considered to be characteristic of tuberculosis. This appearance has been described on CT, occurring without effusion or radiographically visible parenchymal disease (4). Bone scintigraphy cannot distinguish between metastatic disease and disseminated tuberculosis of bone (5,6). Pathological rib fractures due to tuberculosis are unusual but have been reported in the femur and in the sternum. The localization of tuberculosis in an area of trauma is of interest and has occurred in the vicinity of closed fractures during the healing process (7). Presumably the mechanism of spread is haematogenous dissemination associated with activation of a latent tuberculous focus. This is probably the commonest mechanism of spread to ribs, although involvement of four consecutive ribs in case 2 suggests that direct extension is a possibility. Considering the frequent tuberculous involvement of the pleura and the rarity of its spread to the ribs, this must be a very uncommon event. Attention has been drawn to the considerable delay in the diagnosis of skeletal tuberculosis and usually biopsy material is required. Destructive rib lesions in patients with positive Mantoux skin test should lead to the consideration of tuberculosis, particularly in younger patients. Early limited biopsy with appropriate cultures and histology should hopefully preclude many unnecessary investigations and extensive surgical procedures, and lead to prompt and appropriate therapy. References
I. Enarson DA, Ashley MJ, Grzybowski S, Ostapkowicz E, Dorken E. Non-respiratory tuberculosis in Canada. Am J Epidemio11980; 112: 341-351. 2. Enarson DA, Fujii M, Nakielna EM, Grzybowski S. Bone and joint tuberculosis. Can Med Assoc J 1979; I20: 139-145. 3. Davies PD, Humphries MJ, Byfield SP et al. Bone and joint tuberculosis-a survey of notification in England and Wales. J Bone Joint Surg 1984;56: 326-330.
Tuberculosis o f the ribs 4. Blunt SB, Harries MG. Discrete pleural masses without effusion in a young man: an unusual presentation of tuberculosis. Thorax 1989; 44: 436--437. 5. Boumpas DT, Vieras F, Acio E, Rohatgi PK. Skeletal tuberculosis resembling metastatic disease on bone scintigraphy. J Nucl Med 1987; 28: 1507-1509.
253
6. Ormerod LP, Grundy M, Rahman MA, Multiple tuberculosis bone lesions simulating metastatic disease. Tubercle 1989; 70: 305-307. 7. Stuart D. Local osteo-articular tuberculosis complicating closed fractures. A report of two cases. Br J Bone Joint Surg 1976; 58: 248-249.
Case Reports
Tuberculosis of the r i b s -
a report of three cases
ELLEN R. WIEBE AND R. K . ELWOOD*
Division of Tuberculosis Control, British Columbia Centre for Disease Control, Vancouver, B.C., Canada
Introduction
Extrapulmonary forms of tuberculosis constitute approximately one-sixth of all cases of tuberculosis reported in Canada (1). Skeletal tuberculosis is the fourth most common form constituting 2-6% of the total. Involvement of the ribs in skeletal tuberculosis is extremely uncommon. Three cases form the basis of this report, one of which presented with a pathological fracture, another of which appeared to be related to trauma and all of which were suspected of being malignant.
showed granulomatous inflammation with considerable central necrosis consistent with tuberculosis, but no organisms were seen. A very active callus formation was present reflecting the healing fracture. The specimen could not be cultured since the entire cortex was densely ossified. Therapy was initiated with isoniazid 300 rag, rifampin 600mg, pyrazinamide 1.5g for 2 months, completing 9 months with isoniazid and rifampin. His X-ray cleared and he made an uneventful recovery. Case 2
Case 1
A 33-year-old caucasian male presented with rightsided pleuritic chest pain. Two months prior he had been travelling in the Philippines and Central America where he had a 2-week episode of night sweats, fever and a non-productive cough. He had no known exposure to TB and had previously been well. When first seen he was tender over the 10th rib on the right side. A week later he sneezed and experienced a sudden increase in chest pain. Rib views showed fracture of the 10th rib in an area of bone destruction consistent with a pathological fracture (Plate 1). His PA film showed a 4 x 2 cm density in the right lower lobe. A diagnosis of metastatic carcinoma was made. The bone scan showed focal abnormal uptake in the calvarium and rib cage bilaterally with a diffuse uptake throughout the skeleton in the distribution of the red marrow. The needle aspirations were unhelpful. A bone marrow aspiration showed a small circumscribed granuloma, negative on smear for acid fast organisms. His 5 TU PPD skin test was 18 mm. One month after presentation his 10th rib was exposed at surgery revealing a tumour-like mass on its central portion. The histology Received 26 April 1990 and accepted in revised form 2 November 1990. *To whom correspondence should be addressed at: Division of Tuberculosis Control, P.O. Box 34020, Postal Station "D', Vancouver, B.C., V6J 4M3, Canada, 0954-6111/91/030251 + 03 $03.00/0
A 32-year-old Chinese male, born in Hong Kong, presented with cough and right-sided back pain of 2 months duration. His only other symptom was a 7 Ib
q
_<}'
Plate I PA of the chest showing a lytic lesion in a pathological fracture of the 10th rib (case l). © 1991 Bailli6re Tindall
252
E. R. Wiebe and R. K. Elwood
O
L Plate 2 CT scan ofthe chest showing a pleural based density with accompanying rib destruction (case 2).
weight loss over 2 months. A mild fullness was evident in the right posterior portion of his chest adjacent to the scapula, which was non-tender. His chest X-ray showed a pleural based mass situated posteriorly in the fight upper lobe. CT scan (Plate 2) showed a solitary pleural based density with accompanying rib destruction. Malignancy was suspected but a fine needle aspiration of the pulmonary lesion was unhelpful. At thoracotomy the 4th to 7th fibs were resected posteriorly. Histologically, typical tuberculous necrotic granulomas were seen in the ribs and in the adjacent lung parenchyma. Cultures of the resected specimen grew typical Mycobacterium tuberculosis resistant to rifampin. He was started on isoniazid 300 mg, rifampin 600 mg, pyrazinamide 1.5 g, replacing the rifampin with ethambutol when the sensitivities were known and completing 12 months therapy in all. He made a full recovery. Case 3
A 27-year-old caucasian male presented in April 1970 with an injury to his left chest sustained when he was hit with a crane hook. The area swelled rapidly but over 2 weeks it gradually reduced in size leaving a residual chest wall mass. A similar injury was sustained in July 1970, again resulting in swelling and pain. A chest X-ray showed a fracture of the left 5th rib with surrounding soft tissue swelling. This was eventually resected. Culture of the marrow from the rib grew typical Mycobacterium tuberculosis. He received 24 months' therapy with para-amino salicylic acid (PAS), isoniazid and streptomycin. Apart from sinus drainage at the site for several weeks, he made a full recovery. Discussion
Tuberculosis of bones and joints, although becoming rarer, still represents a continuing diagnostic challenge. The incidence of skeletal tuberculosis in Canada is reported as 0-5 cases per 100 000 population (2) and is
gradually decreasing at a rate similar to adult type pulmonary tuberculosis. Tuberculous involvement of the ribs is rare with incidence rates varying from 0 to 5% of bone and joint tuberculosis (3). Clinically, tuberculosis of the ribs presents with a combination of rib destruction and an extrapulmonary soft tissue mass. An associated fluctuant chest wall swelling is highly suggestive. Tuberculosis was not considered as a diagnostic possibility in any of the three patients and, not unreasonably, all cases were suspected of having malignancy. Some of the investigations were misleading. Chest X-rays may not be helpful in visualizing the rib destruction (as in case 2) unless special views are requested. The presentation of a discrete pleural mass in the second patient had led to considerable confusion as this was not considered to be characteristic of tuberculosis. This appearance has been described on CT, occurring without effusion or radiographically visible parenchymal disease (4). Bone scintigraphy cannot distinguish between metastatic disease and disseminated tuberculosis of bone (5,6). Pathological rib fractures due to tuberculosis are unusual but have been reported in the femur and in the sternum. The localization of tuberculosis in an area of trauma is of interest and has occurred in the vicinity of closed fractures during the healing process (7). Presumably the mechanism of spread is haematogenous dissemination associated with activation of a latent tuberculous focus. This is probably the commonest mechanism of spread to ribs, although involvement of four consecutive ribs in case 2 suggests that direct extension is a possibility. Considering the frequent tuberculous involvement of the pleura and the rarity of its spread to the ribs, this must be a very uncommon event. Attention has been drawn to the considerable delay in the diagnosis of skeletal tuberculosis and usually biopsy material is required. Destructive rib lesions in patients with positive Mantoux skin test should lead to the consideration of tuberculosis, particularly in younger patients. Early limited biopsy with appropriate cultures and histology should hopefully preclude many unnecessary investigations and extensive surgical procedures, and lead to prompt and appropriate therapy. References
I. Enarson DA, Ashley MJ, Grzybowski S, Ostapkowicz E, Dorken E. Non-respiratory tuberculosis in Canada. Am J Epidemio11980; 112: 341-351. 2. Enarson DA, Fujii M, Nakielna EM, Grzybowski S. Bone and joint tuberculosis. Can Med Assoc J 1979; I20: 139-145. 3. Davies PD, Humphries MJ, Byfield SP et al. Bone and joint tuberculosis-a survey of notification in England and Wales. J Bone Joint Surg 1984;56: 326-330.
Tuberculosis o f the ribs 4. Blunt SB, Harries MG. Discrete pleural masses without effusion in a young man: an unusual presentation of tuberculosis. Thorax 1989; 44: 436--437. 5. Boumpas DT, Vieras F, Acio E, Rohatgi PK. Skeletal tuberculosis resembling metastatic disease on bone scintigraphy. J Nucl Med 1987; 28: 1507-1509.
253
6. Ormerod LP, Grundy M, Rahman MA, Multiple tuberculosis bone lesions simulating metastatic disease. Tubercle 1989; 70: 305-307. 7. Stuart D. Local osteo-articular tuberculosis complicating closed fractures. A report of two cases. Br J Bone Joint Surg 1976; 58: 248-249.