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The Journal of Emergency Medicine, Vol. 36, No. 4, pp. 342–344, 2009Copyright © 2009 Elsevier Inc.
Printed in the USA. All rights reserved0736-4679/09 $–see front matter
doi:10.1016/j.jemermed.2007.06.017
ClinicalCommunications: Adults
STERNAL TUBERCULOSIS
Ali Mohammadi, MD* and John M. Howell, MD, FACEP†
*Department of Emergency Medicine, George Washington University Medical Center, Washington, DC and †Department of EmergencyMedicine, INOVA Fairfax Hospital, Falls Church, Virginia
Reprint Address: John M. Howell, MD, FACEP, INOVA Fairfax Hospital Emergency Department, 3300 Gallows Road,
Falls Church, VA 22042Amssmnastl
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Abstract—Tuberculosis is a public health problemorldwide. Between 19% and 43% of the world’s popula-
ion is infected with Mycobacterium tuberculosis. Tubercu-ar sternal osteomyelitis is a rare manifestation of tubercu-osis. Tuberculous sternal osteomyelitis manifests withever, weight loss, and chest wall lesions. Computed tomog-aphy (CT) scan defines the extent of the thoracic extension,nd standard microbiologic methods diagnose this entity.our-drug anti-tuberculous therapy is effective. The au-
hors report a case of tuberculous osteomyelitis of the ster-um not associated with pulmonary tuberculosis. © 2009lsevier Inc.
Keywords—tuberculosis; sternum; osteomyelitis
INTRODUCTION
he sternum is one of the least common bones of theody to become infected. Sternal osteomyelitis accountsor only 0.3–1.8% of all cases of ostemyelitis (1). Sternaluberculosis represents � 1% of tubercular ostemyelitis.ince 1985, tuberculous sternal osteomyelitis (TSO) haseen reported in association with spontaneous sternalracture, disseminated tuberculosis, thalassemia, and cor-nary artery-bypass surgery (2). We found 33 reportedases of sternal tuberculosis in the medical literature.xtrasternal disease is detectable in fewer than half ofases (3). We present a case of isolated TSO with noxtrasternal tuberculosis.
ECEIVED: 16 June 2005; FINAL SUBMISSION RECEIVED: 30
CCEPTED: 11 February 2007342
CASE REPORT
32-year-old man presented to the Emergency Depart-ent (ED) with three distinct chest wall lesions that were
tated to be 3 months old. The first lesion was a coin-ized area of redness just medial to the right nipple. Oneonth after the onset of this initial lesion, the patient
oticed two left-sided chest wall lesions similar in char-cter and size. These lesions progressively increased inize, particularly over the 2 weeks before ED presenta-ion. The patient came to the ED after his lesions becamearger in size and began draining pus.
The patient reported subjective fever, but he had notaken his temperature. He also reported night sweats overhe prior week. The patient denied chest pain, shortnessf breath, and cough. He also denied chest wall injury,nsect bite, or exposures that could have predisposed himo chest wall infection. He further denied human immu-odeficiency virus (HIV) and HIV risk factors (e.g.,ntravenous drug use or unsafe sexual activities). Theatient moved to the United States from El Salvador 3ears before presentation. He worked in agriculture in Elalvador. Since moving to the United States, the patientad worked in a restaurant.
Vital signs were: temperature 37°C (99.2°F), bloodressure 117/61 mm Hg, heart rate 65 beats/min, respi-atory rate 17 breaths/min, and oxygen saturation 98%n room air. The patient was a well-developed, well-ourished man lying in bed in no apparent distress. The
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Sternal Tuberculosis 343
ead and neck examinations were normal without ten-erness or lymphadenopathy. The heart examination wasormal. The lung sounds were clear bilaterally withoutheezes, rhonchi, or rales. Examination of the chest wall
evealed a 10 � 8 cm fluctuant, non-tender, subcutane-us mass just medial to the right nipple. There was mildverlying erythema and mild induration on the superiorspect of this lesion. There also was a 6 � 8 cm raisedhest wall lesion located superior to the first lesion withverlying erythema and purulent yellow drainage. Thehird lesion was a 1 � 2 cm red, mildly raised pustuleocated between the first two lesions (Figure 1). Theemaining physical examination was normal.
The complete blood count and chemistries were nor-al. Urinalysis revealed a specific gravity of 1.084, trace
etones, 5–10 red blood cells/high power field and 0–2hite blood cells/high power field. Blood and wound
ultures were obtained. A computed tomography (CT)can revealed two bilateral, thick, cystic structures con-istent with abscesses extending between the pectoralisajor and pectoralis minor muscles. Calcifications were
resent within the left abscess. In addition, modeling andestruction of the upper sternum and CT scan evidencef sternal osteomyelitis were present inferior to the ster-oclavicular joints. There was a small abscess in thenterior mediastinum along the left para-sternal regioneasuring 1.5 cm. A 1.2-cm left axillary lymph node
lso was present. The lungs and heart were radiograph-cally normal (Figure 2).
The patient was admitted and started on piperacilline-azobactam, levofloxacin, and vancomycin. A CT-guidedternal biopsy and right chest fluid aspiration were done.erum tests for HIV, hepatitis B, and hepatitis C wereegative. A PPD test was positive, with 10 mm ofnduration. Bacterial blood culture and aspiration cultureere negative. Aspiration Gram’s stain and acid fastacillus stain also were negative. Sternal fine needle
oigure 1. Chest wall abscesses. One of the abscesses israining slowly.
spiration revealed cellular necrosis with acute inflam-ation. The Auramine stain of sternal debris was posi-
ive for acid fast organisms. Four-drug anti-tuberculosisreatment (i.e., isoniazide, pyrazinamide, ethambutol,nd rifampin) was started. The patient steadily improvednd was discharged 10 days later. After 3 weeks, Myco-acterium tuberculosis grew in cultures of aspirationuid.
DISCUSSION
uberculosis remains a public health problem world-ide. Its incidence has recently increased 1.8%/yearorldwide due to inadequate local resources and thelobal epidemic of HIV infection. From 1993–2003, thencidence of tuberculosis in the United States declinedharply (44%), but the incidence of tuberculosis amongoreign-born persons increased about 30% from 1992 to003. Lack of access to medical services due to cultural,inguistic, financial, and legal barriers results in delays inhe diagnosis and treatment of tuberculosis among for-ign-born patients and in ongoing transmission of theisease (4).
Sternal osteomyelitis caused by M. tuberculosis isare. Since the advent of modern anti-tuberculous ther-py, a limited number of detailed cases have been re-orted. Even more uncommon are atypical mycobacteriauch as Mycobatrium cheloance and Mycobactruim bo-is, which cause sternal osteomyelitis as complicationsf median strenotomy and bacille Calmette-Guérin re-accination (5,6).
Sternal tuberculosis can arise from either direct exten-ion (hilar lymph nodes), or from hematogenous or lym-hatic dissemination. Bone lesions begin with the formation
igure 2. Chest CT scan shows chest wall abscesses (whiterrow) and sternum osteomyelitis (black arrow).
f bone marrow tubercles. Caseification and liquefication
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344 A. Mohammadi and J. M. Howell
reate an abscessed cavity. At this point, tuberculosis canpread to contiguous soft tissues and form abscesses.
Musculoskeletal tuberculosis involves the spine inpproximately one-half of patients with tuberculosis. Thehest region is most commonly affected, followed byumbar and cervical spine (3). Table 1 lists the locationsf tuberculous thoracic wall involvement among caseeports reviewed by Tristano et al. in 2004. Among the3 reported cases of sternal tuberculosis, fewer than halfad extrasternal involvement (3).
TSO cannot be discriminated from pyogenic bacterialsteomyelitis clinically. The most common presentingymptom is swelling over the sternum. Constitutionalymptoms are uncommon (7). There are no pathogno-onic radiographic findings on either CT scan or mag-
etic resonance imaging study for TSO (3). A CT scannd a magnetic resonance imaging study help determinehe extent of disease (e.g., involvement of adjacent softissues), but are not useful in confirming the diagnosis ofuberculosis (8). Radiological sequelae usually occuruch later than presenting clinical features. Definitive
iagnosis depends largely upon the histologic and mi-robiologic examinations of sternal tissue. Either needlespiration or excisional biopsy is diagnostic. Diagnosis isased on histologic examination of infected tissues andycobacterial stains and cultures.There is no consensus on the optimal treatment (i.e.,
pecific antimicrobials) of chest wall tuberculosis.
able 1. Cases of Thoracic Tuberculosis Reportedin Literature*
Localization Cases
ternum 33lavicle 2ibs 6ternoclavicular joint 8pine 3
ntercostal 1eristernal soft tissues 1ediastinum 2
Modified from (3): Tristano AG, Willson ML, Lopez A, et al.ternal osteomyelitis caused by Mycobacterium tuberculosis:ase report and review of the literature. Infect Dis Clin Pract004;12:174–7.
hereas some authors conclude that spinal tuberculosis1
s a surgical entity, others believe the combination ofnti-tuberculosis chemotherapy and surgical debride-ent should be the mainstays of treatment (9,10). In two
ase series, the treatment of extrapulmonary tuberculosisith four anti-tuberculosis drugs for 6–9 months results
n cure rates approaching 95% (11,12).
CONCLUSION
ost reported TSO cases occur outside of the Unitedtates. Tuberculous sternal osteomyelitis, although uncom-on, has been reported in several clinical settings. TSO
hould be considered in patients with sternal pain andwelling, especially in young patients who live in or areoming from a country in which tuberculosis is endemic, justs in this case (4). Standard anti-tuberculous chemotherapy,ith or without surgical debridement, may be successful.
REFERENCES
1. Kalra P, Sharanja BK, Banerjea CK, Khosla VK. Sternal involve-ment in disseminated tuberculosis. J Assoc Physicians India 1988;36:292–3.
2. Prakash A, Hira HS. Tuberculosis osteomyelitis of sternum. IndianJ Tuberc 2001;48:35.
3. Tristano AG, Willson ML, Lopez A, et al. Sternal osteomyelitiscaused by Mycobacterium tuberculosis: case report and review ofthe literature. Infect Dis Clin Pract 2004;12:174–7.
4. Taylor Z, Nolan C, Blumberg H. Controlling tuberculosis in theUnited States. Recommendations from the American ThoracicSociety, CDC, and the Infectious Diseases Society of America.MMWR Recomm Rep 2005;54(No. RR-12):1–81.
5. Grange JM. Mycobacterial infections following heart valve re-placement. J Heart Valve Dis 1992;1:102–9.
6. Simila SE, Liedes E, Kinnunen P. Sternal abscess as a complica-tion of BCG revaccination. Tubercle 1988;69:67–9.
7. McLellan DG, Philips KB. Sternal osteomyelitis caused by My-cobacterium tuberculosis: case report and review of the literature.Am J Med Sci 2000;319:250–4.
8. Shah J, Patkar D, Parikh B, et al. Tuberculosis of the sternum andclavicle: imaging findings in 15 patients. Skeletal Radiol 2000;29:447–53.
9. Ray M, Kataria S, Singhi P. Unusual presentation of disseminatedtuberculosis. Indian Pediatr 2002;39:89–91.
0. Hsu HS, Wang LS, Wu YC, et al. Management of primary chest walltuberculosis. Scand J Thorac Cardiovasc Surg 1995;29:119–23.
1. Cohn D, Catlin BJ, Peterson K, Judson FN, Sbarbaro JA. A62-dose, 6-month therapy for pulmonary and extrapulmonary tu-berculosis. A twice-weekly, directly observed, and cost-effectiveregimen. Ann Intern Med 1990;112:407–15.
2. Dutt AK, Moers D, Stead WW. Short course chemotherapy forextrapulmonary tuberculosis. Ann Intern Med 1986;104:7–12.
