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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 21-23

Sternal tuberculous osteomyelitis in a young adult presenting as atypical chest pain: A rare case report


Department of Orthopedics, Near Adlux Convention Center, Apollo-Adlux Hospital, Ernakulam, Kerala, India

Date of Submission29-Mar-2021
Date of Acceptance03-Apr-2021
Date of Web Publication25-Jul-2021

Correspondence Address:
K R Renjith
Department of Orthopedics, Near Adlux Convention Center, Apollo-Adlux Hospital, Cable Junction, National Highway 47, Karukutty, Angamaly, Ernakulam - 683 576, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_10_21

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  Abstract 


Sternal tuberculosis (TB) is an uncommon involvement of osteoarticular tissues where the diagnosis is most often delayed due to an insidious presentation. We present an unusual case of a young female with TB osteomyelitis of the sternum presenting as atypical chest pain in which a timely diagnosis could result in successful management by conservative means.

Keywords: Antituberculous therapy, sternum, tuberculosis


How to cite this article:
Sunil P P, Renjith K R, Ajayakumar T, Vijayan AP. Sternal tuberculous osteomyelitis in a young adult presenting as atypical chest pain: A rare case report. J Orthop Assoc South Indian States 2021;18:21-3

How to cite this URL:
Sunil P P, Renjith K R, Ajayakumar T, Vijayan AP. Sternal tuberculous osteomyelitis in a young adult presenting as atypical chest pain: A rare case report. J Orthop Assoc South Indian States [serial online] 2021 [cited 2021 Dec 9];18:21-3. Available from: https://www.joasis.org/text.asp?2021/18/1/21/322296




  Introduction Top


Although tuberculosis (TB) can involve any organ, sternal TB is an extremely rare manifestation of musculoskeletal TB with a reported incidence of 0.3% even in endemic countries where the disease burden is high.[1] Rarity of this location along with an insidious onset symptomatology demands a high index of suspicion to diagnose this infrequent entity, especially in the absence of associated pulmonary TB. We report our experience of a young female with tuberculous osteomyelitis of the sternum presenting as atypical chest pain.


  Case Report Top


Our patient was a 23-year-old woman, an IT professional, preparing for her departmental promotion examination scheduled 2 months later. She visited our outpatient department with insidious onset, gradually progressive, central chest pain of 3-month duration, which restricted her from sitting and reading for prolonged duration. The pain was unrelieved by medications from a nearby clinic, and she had undergone a thorough cardiology evaluation before consulting our hospital. Her mother noticed that she had lost weight considerably over this period, and her appetite has drastically come down. Apart from this, she did not report any other constitutional symptoms such as fever, cough, or night sweats and her past medical history was unremarkable including normal menstrual cycles. Clinical examination revealed a firm, diffuse swelling over the anterior chest and manubrium sterni which was tender on deep palpation but nonerythematous and nonfluctuant. Initial laboratory investigations showed no abnormality other than an elevated erythrocyte sedimentation rate (ESR) (70 mm/h). Chest radiographs' posteroanterior view was normal whereas lateral view demonstrated a periosteal reaction of the body of the sternum anteriorly and posteriorly along with marked osteopenia [Figure 1].
Figure 1: Lateral chest radiograph showing periosteal reaction of the body of the sternum

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Magnetic resonance imaging (MRI) showed diffuse marrow edema in the body of the sternum with a hyperintense localized collection anteriorly measuring 3 cm × 2.2 cm × 2 cm which is extending to the adjacent costochondral junction [Figure 2]. Two internal mammary lymph nodes were also found enlarged on the right side with a confluent soft-tissue mass in the lower paratracheal region. The patient was offered open biopsy to obtain a tissue diagnosis, and intraoperatively, the sternum anterior cortex was found very thin with an overlying collection of straw-colored, viscous fluid [Figure 3]. The histopathology reports showed caseous necrosis with granulomatous changes, and acid-fast bacilli (AFB) was grown in the culture. She was immediately started on chemotherapy as per the WHO index TB guidelines,[2] and on her final follow-up at 6 months, she showed significant symptomatic improvement with resolution of swelling and radiographic regression of lesion.
Figure 2: Sagittal and axial T2-weighted magnetic resonance imaging showing diffuse bone marrow edema of the body of the sternum and hyperintense collection anteriorly

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Figure 3: Intraoperative image showing loculated fluid collection anterior to the sternum

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  Discussion Top


Osteoarticular TB accounts for 6%–10% of extrapulmonary TB cases of which the involvement of the sternum has been limited to <1%.[3],[4] Three reported theories on the pathogenesis of this uncommon spread include late complication of pulmonary TB, reactivation of latent foci formed during hematogenous or lymphatic dissemination of primary TB, or direct extension from mediastinal lymph nodes (probable etiology in our patient).[5] Classically being described as a disease commonly affecting young adults with a slightly increased preponderance for males, there have been reports on the pediatric population as well.[6] The manubrium was found to be more commonly affected than the body of the sternum.[7]

A slow insidious onset and fewer constitutional symptoms often make the diagnosis difficult in early stages of sternal TB. Even though radiological changes lag behind clinical symptoms, features if present are better appreciated in the lateral projection of chest X-ray. MRI and computerized tomography scans help in better delineation of bone destruction and soft-tissue involvement which further aids in early detection of this uncommon disease entity. Blood investigations have only a limited role and are essentially normal in most cases apart from a raised ESR. Tissue diagnosis remains as the gold standard which can be obtained by open or percutaneous biopsy where the disease can be confirmed by the presence of caseous necrosis and granuloma in histopathology and/or positive AFB cultures.

Chemotherapy forms the mainstay of treatment like any other tuberculous infection, and surgical management in the form of debridement with or without chest wall reconstruction is reserved for cases with large sequestrated bony fragments or patients not responding to an adequate trial of anti-TB treatment.[5] Anti-tubercular treatment (ATT) regimen is the same as that used for osteoarticular TB with a 2-month intensive phase consisting of four drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol), followed by a continuation phase lasting 10–16 months.[2] Surgical debridement if indicated can result in complications associated with skin closure which may require additional reconstructive procedures such as rotational flaps or vacuum-assisted closure to cover the chest wall defect.


  Conclusion Top


Sternal TB, although rare, should be considered as an important differential diagnosis for atypical chest pain, especially in young adults, as early detection can prevent disease progression and complex surgical procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Saifudheen K, Anoop TM, Mini PN, Ramachandran M, Jabbar PK, Jayaprakash R. Primary tubercular osteomyelitis of the sternum. Int J Infect Dis 2010;14:e164-6.  Back to cited text no. 1
    
2.
Ministry of Health and Family Welfare, Government of India and World Health Organization. INDEX TB guidelines: Guidelines on extra-pulmonary tuberculosis for India. New Delhi: MOHFW March, 2016.  Back to cited text no. 2
    
3.
Rieder HL, Snider DE Jr., Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990;141:347-51.  Back to cited text no. 3
    
4.
Allali N, Dafiri R. Tuberculosis of the sternum. J Radiol 2005;86:655-6.  Back to cited text no. 4
    
5.
Khan SA, Varshney MK, Hasan AS, Kumar A, Trikha V. Tuberculosis of the sternum: A clinical study. J Bone Joint Surg Br 2007;89:817-20.  Back to cited text no. 5
    
6.
Vasa M, Ohikhuare C, Brickner L. Primary sternal tuberculosis osteomyelitis: A case report and discussion. Can J Infect Dis Med Microbiol 2009;20:e181-4.  Back to cited text no. 6
    
7.
Yuan SM. Sternal mycobacterial infections. Ann Thorac Med 2016;11:103-11.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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