|Year : 2021 | Volume
| Issue : 3 | Page : 170-172
Infantile sternal tuberculosis: A rare condition
Maulin M Shah1, Gaurav Gupta2, Pranav Modi3, S Baldev1, Prajapati4
1 Consultant Paediatric Orthopaedic Surgeon at OrthoKids Clinic, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
2 Clinical Fellow (Paediatric Orthopaedics) at OrthoKids Clinic, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
3 Consultant, CVTS Surgeon, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
4 HOD and Professor of Pediatrics, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
|Date of Submission||13-Mar-2021|
|Date of Decision||27-Jul-2021|
|Date of Acceptance||09-Aug-2021|
|Date of Web Publication||31-Aug-2021|
Dr. Maulin M Shah
Orthokids Clinic, 7th Floor, Golden Icon, Opp. Medilink Hospital, Near Shivranjini Flyover, Satellite, Ahmedabad - 380 015, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Tuberculosis (TB) of sternum is one of the rarest forms of skeletal TB. Incidence of sternal TB has been calculated to be <1.5% amongst osteo-articular TB, with very few cases reported in infants. Due to its subtle signs and symptoms, early diagnosis of this entity becomes a challenge. Clinical Description: We reported case of 6-month-old boy who presented with complaints of progressively increasing swelling at the anterior chest wall. Radiological, histological, and microbiological investigations helped establish a diagnosis of infantile sternal TB. Management: Drainage of the lesion and excision of affected necrotic tissue was done. Culture and histopathological examination were suggestive of tubercular osteomyelitis of sternum. Weight adjusted antitubercular medications were given for 1 year. At 3 years of follow-up, the lesion had healed well without any recurrence, sinus formation or local deformity. Conclusions: High index of suspicion and detailed diagnostic work up are required for early diagnosis and management of infantile sternal tuberculous osteomyelitis.
Keywords: Infantile, osteomyelitis, sternal, tuberculosis
|How to cite this article:|
Shah MM, Gupta G, Modi P, Baldev S, Prajapati. Infantile sternal tuberculosis: A rare condition. Indian Pediatr Case Rep 2021;1:170-2
|How to cite this URL:|
Shah MM, Gupta G, Modi P, Baldev S, Prajapati. Infantile sternal tuberculosis: A rare condition. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Dec 8];1:170-2. Available from: http://www.ipcares.org/text.asp?2021/1/3/170/325101
About 2.8 million new and relapsed cases of tuberculosis (TB) are diagnosed each year in India. Among them 10% are below the age of 15 years. Pulmonary TB is the most common type of TB. Skeletal affection of Mycobacterial TB is unusual with the overall incidence reported as 0.87%. Tuberculosis of the sternum is one of the rarest forms of skeletal TB, with a calculated incidence of <1.5% among osteoarticular TB. Around 164 cases of sternal tubercular osteomyelitis have been reported in scientific literature till date. The countries from where most of these cases originated were India (95), South Africa (14) and USA (10). Majority of cases reported were primary (67.3%) followed by secondary (20.8%) and postoperative (11.9%) in origin. Postoperative cases were noted mostly after cardiac surgeries. Due to the subtlety of signs and symptoms, early diagnosis is a challenge.
We report a case of tubercular osteomyelitis of the sternum in a 6-month-old boy. The purpose of this report is to create awareness among clinicians so that they consider sternal TB as a differential diagnosis of anterior chest wall swelling in an infant.
| Clinical Description|| |
A 6-month-old boy was referred to us with a progressively increasing swelling on his chest for 1.5 months. The swelling was painless, without any signs of local inflammation or any active discharge. There was no history of fever, cough, weight loss, or any other constitutional symptoms. There was no history of local trauma or swelling anywhere else in the body.
The baby was delivered at full term by lower segment caesarean section with a birth weight of 3.92 kg and an uneventful perinatal period. His immunization was complete till date. Bacille Calmette-Guerin vaccination was administered on the 1st day of birth. Patient was vaccinated as per the age. There was no significant past history or positive history of contact with TB in the family. Developmental milestones were appropriate for his age. The infant was being exclusively breast fed.
At admission, the child was stable with normal vital parameters. The weight was 5.5 kg (−2 standard deviation [SD]), length 65 cm (−1 SD), and head circumference 41.8 cm (−1 SD). Local examination revealed a swelling of size 2 cm × 2 cm, over the lower part of sternum [Figure 1]. It was nonmobile, nontender, nonerythematous, nonfluctuant and hard in consistency [Figure 1]a. The overlying skin was normal and there was no discharging sinus. No pallor or lymphadenopathy was observed. The respiratory examination was normal and there was no hepatosplenomegaly. There was no other contributory findings on the rest of the systemic examination.
|Figure 1: (a) A midline globular swelling of 2 cm × 2 cm × 1 cm over the lower part of sternum at the time of presentation. (b) Dimensions of the swelling on axial section of computed tomography scan|
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| Management and Outcome|| |
Salient laboratory reports included leukocytosis (total leukocyte count 19,900/mm3), increased erythrocyte sedimentation rate 30 mm in the 1st h, normal C-reactive protein and liver function tests. HIV status was negative for both the child and the mother. An ultrasonogram of the swelling confirmed the presence of a hypo-echoic area in the left side of the anterior chest wall that was communicating with the anterior mediastinumas a horse-shoe shaped swelling around the wall of sternum. A high-resolution computed tomography scan of the thorax was planned to delineate the anatomy further. This showed a cystic swelling lying over the lower part of the sternum that extended to the left retrosternal region, with erosion of the adjacent surface of the sternum and costal cartilage [Figure 1]b. Underlying pleura, lungs and pericardium were not infiltrated. There was no mediastinal lymph node enlargement. Fine-needle aspiration cytology (FNAC) of the swelling reported pink, amorphous, caseous, necrotic background with few epithelioid clusters, polymorphs, and leukocytes suggestive of infection by Mycobacterium. Based on the clinical profile and investigations, we kept a diagnosis of sternal TB and started the infant on four-drug oral anti-tuberculous therapy (ATT) as per standard protocol. A multidisciplinary approach including pediatrician, pediatric orthopedic surgeon, and cardiothoracic surgeon managed the case.
As the swelling persisted for 6 weeks without regression, the cardiothoracic vascular surgeon advised drainage of the cystic lesion along with excision of the affected adjacent tissue. A 4 cm transverse incision was placed over the swelling, pus drained, and wide debridement performed with excision of osteomyelitic cartilage [Figure 2]a and [Figure 2]b. Retrosternal soft tissue including mediastinal fat was also debrided. The left internal mammary artery was sacrificed. Pericardium and pleura were devoid of any infective tissue. Thorough saline wash was given and wound was primarily closed over a negative pressure suction drain. Retrieved fluid was sent for bacterial and tuberculous cultures and cartridge based nucleic acid amplification test (CBNAAT), which was positive. The wound remained healthy postoperatively and sutures were removed 15 days' postsurgery.
|Figure 2: (a) Aspiration of frank pus from the swelling. (b) The necrotic granulation tissue being removed from the swelling|
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The treatment plan that was decided on was ATT to continue for 1 year; 2 months intensive phase and 10 months maintenance phase. Pyridoxine (10 mg/day) was continued for the entire duration of ATT. Regular monthly follow ups were done for the first 2 months followed by 3 monthly follow-ups till 1 year of age, and subsequently, 6 monthly follow ups till 3 years. At the final follow-up at 3 years, the lesion healed completely without any signs of residual pain, swelling, or sinus formation. Child demonstrated growth and development within normal range.
| Discussion|| |
Out of the 164 cases of sternal tubercular osteomyelitis reports till date, the youngest age of presentation was 9 months in a Japanese child., The diagnosis was confirmed by biopsy and the child was managed with first line ATT for 9 months., The majority of other cases were beyond infancy. To the best of our knowledge, our case is the youngest child diagnosed with sternal tubercular osteomyelitis. Reactivation of the latent loci of mycobacterium is the most common cause of sternal TB. The usual routes of spread are hematogenous and lymphatics. Subclinical contamination and immunocompromised condition can also be the possible pathogenesis. Direct seeding from mediastinal lymph nodes and through inhalation have also been mentioned., Like most of the previous case reports, the primary reason of the infection in this case could not be ascertained.
The differential diagnosis of chest wall swellings includes pyogenic infections, metastasis, malignancy, brodies abscess, and granulomatous lesion. Unlike pyogenic osteomyelitis, in tuberculous lesions there is a slow destruction of the cartilage and hence the delay in diagnosis. Thus, TB of the sternum can present with an indolent, painless swelling without any constitutional symptoms, as was seen in this case. Sternal TB can also present with a painful swelling associated with erythema, warmth, tenderness, and enlarged lymph nodes. If timely diagnosis is not made, any form of sternal TB can result in bone deformity, fracture, draining abscess or sinus formation.
The diagnosis of sternal TB is usually delayed owing to slow growing character of organism. Chest radiograph is not contributory in detecting early bone changes, periostitis, osteopenia, or fractures. Magnetic resonance imaging (MRI) scan can detect abscess formation, bone marrow invasion and extent of soft tissue mass, even better than CT scan. However, due to logistic issues, we could not get MRI and had to proceed with the CT scan. FNAC and excisional biopsy can confirm diagnosis. CBNAAT is a cartridge-based nucleic acid amplification test for rapid diagnosis of TB and assessing sensitivity of isoniazid and rifampicin. Khan et al. described two cases of multi drug resistant sternal TB in their series of 14 sternal TB. Two patients required surgical treatment apart from first-line ATT and one patient with advanced disease developed pectus excavatum. None of the patients were HIV positive.,
Incision and drainage of the pus along with excision of the cystic wall is the ideal choice of treatment. Debridement of the affected tissue and histopathological examination can be of great help in diagnosing atypical presentations of TB. To conclude, a high index of suspicion and detailed diagnostic work up is required for early diagnosis of infantile sternal tuberculous osteomyelitis. To the best of our knowledge, this is the youngest patient (6 months) of sternal TB reported in literature till date.
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]