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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 196-198

An unusual vertical swelling over the back


Department of Pulmonology, Apollo First Med Hospital, Chennai, Tamil Nadu, India

Date of Submission20-Jun-2018
Date of Acceptance19-Aug-2019
Date of Web Publication11-Sep-2019

Correspondence Address:
Vinod Kumar Viswanathan
Apollo First Med Hospital, Chennai - 600 010, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_56_18

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  Abstract 


Skeletal tuberculosis (TB) accounts for 1%–2% of all types of TB. The most common form of skeletal TB is Pott's disease, a disease of the spine; this entity comprises approximately half of skeletal TB cases. Tuberculous cold abscess can present as swelling on the back usually originating from the thoracic spine. Herewith is presented a rare case presentation of a patient who presented with a vertical swelling over the paraspinal region who on evaluation was found to have a cold abscess of tuberculous etiology arising from the ribs and tracking down the paraspinal region. This case is presented here for its rarity being a primary chest wall TB with no pulmonary involvement.

Keywords: Chest wall tuberculosis, cold abscess, skeletal tuberculosis


How to cite this article:
Viswanathan VK. An unusual vertical swelling over the back. Apollo Med 2019;16:196-8

How to cite this URL:
Viswanathan VK. An unusual vertical swelling over the back. Apollo Med [serial online] 2019 [cited 2019 Sep 20];16:196-8. Available from: http://www.apollomedicine.org/text.asp?2019/16/3/196/266788




  Introduction Top


Tuberculosis (TB) is a global health problem and a major concern, particularly in developing and less developed countries. TB, though commonly involves the lungs, has varied presentations and can involve other systems as well. Musculoskeletal TB accounts for 1%–2% of all types of TB and 10%–35% of extrapulmonary TB. The most common form of skeletal TB is Pott's disease, a disease of the spine; this entity comprises approximately half of musculoskeletal TB cases. The next most common form of musculoskeletal TB is tuberculous arthritis, followed in frequency by extraspinal tuberculous osteomyelitis.[1]

Involvement of the ribs can occur rarely and is usually associated with rib destruction and chest wall abscess. Isolated involvement of rib in TB without pulmonary involvement is quite unusual, with very few case reports in the literature.[2],[3],[4] We herein report an unusual case of rib TB with paravertebral cold abscess with no pulmonary involvement.

Tubercular abscess of the chest wall accounts for 1%–5% of all cases of musculoskeletal TB. Skeletal TB is usually seen in association with primary pulmonary form. Primary TB of the chest wall is a rare entity.


  Case Report Top


A 60-year-old male presented with complaints of swelling on the right paravertebral region with inability to lie down on the back [Figure 1]. There were no significant respiratory complaints. On examination, the swelling was devoid of signs of inflammation and hence was provisionally diagnosed as a tuberculous cold abscess.
Figure 1: The patient's vertical back swelling

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Chest radiograph revealed no pulmonary involvement. Computed tomography (CT) of the chest revealed cold abscess originating from the ribs associated with rib destruction with vertebral sparing. No pulmonary focus was observed in the CT chest [Figure 2]. His HIV status was negative, and he was not a diabetic.
Figure 2: Computed tomography scan images of the patient showing the rib destruction with cold abscess tracking along the paraspinal region

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The patient was subjected to a nondependant drainage of the pus, and about 200 ml of pus was drained. Pus aspirated from the lesion was sent for investigations, and acid-fast bacilli smear was negative. Pus culture and sensitivity did not reveal any growth. Cartridge-based nucleic acid amplification testing (CB-NAAT) from the pus reported a drug-sensitive tuberculous cold abscess. The patient was started on an initial phase of daily antituberculous therapy using four drugs, namely isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months and continued with isoniazid and rifampicin for a total duration of 9 months. Following his full course of TB treatment, the lesion healed completely, and the patient was asymptomatic [Figure 3] and [Figure 4].
Figure 3: The patient at the end of treatment

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Figure 4: Computed tomography image of the patient showing good healing near the completion of treatment

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  Discussion Top


The existence of osteoarticular TB has been found in prehistoric humans. In immunocompetent individuals, the skeletal TB occurs in 10% of patients with extrapulmonary TB. Commonly, TB affects the spine and hip joint. Other sites affected include knee joint, foot bones, elbow and hand bones, and rarely, the shoulder joint.[5]

Skeletal TB occurs usually due to hematogenous spread and affects all bones. In most cases, skeletal TB is associated with pulmonary TB. Rare cases of isolated chest wall and rib TB without pulmonary involvement have been reported in the literature.[2],[3],[4]

When ribs are involved rarely in the disease, it is usually not diagnosed till swelling or sinuses due to cold abscess have formed. Radiological assessment of sternum and rib TB is very difficult and may reveal irregular destruction and cavities. The diseased ribs may be thickened very much or expanded with punched-out lesions. Surgery is not routinely required in these patients. However, it may be needed to establish the diagnosis or removal of the sequestrum. Response to antituberculous therapy is usually good.[5]

The case presented here is unique in that the lesion was confined to the ribs and also the cold abscess had tracked down, causing an unusual swelling on the back. Utility of CBNAAT in the detection of TB is such rare extrapulmonary sites also needs to be emphasized.


  Conclusion Top


Primary rib TB with cold abscess is quite an unusual presentation of musculoskeletal TB and usually involves the shaft of the rib. Chest wall TB manifesting as cold abscess is a rare disease and may resemble chest wall tumor, especially in elderly patients. This case which is presented as primary rib TB with cold abscess without pulmonary involvement is a rarity.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997;79:562-6.  Back to cited text no. 1
    
2.
Singha SK, Guptab V, Ahmada Z, Bhargavaa R, Pandeya DK, Sachdeva S. Tuberculous osteomyelitis of ribs-A case report. Respir Med CME 2009;2:128-9.  Back to cited text no. 2
    
3.
Agrawal V, Joshi MK, Jain BK, Mohanty D, Gupta A. Tuberculotic osteomyelitis of rib – A surgical entity. Interact Cardiovasc Thorac Surg 2008;7:1028-30.  Back to cited text no. 3
    
4.
Sinoff CL, Segal I. Tuberculous osteomyelitis of the rib. A case report. S Afr Med J 1975;49:865-6.  Back to cited text no. 4
    
5.
Sharma SK. Tuberculosis. 2nd ed. Jaypee Brothers Medical Publishers; 2009.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Case Report
Discussion
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