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1/1/2017 SternalTuberculosis

AnnMedHealthSciRes.2013Nov3(Suppl1):S21S23. PMCID:PMC3853599
doi:10.4103/21419248.121213

SternalTuberculosis
RSachdeva,SSachdeva, 1andSArora2

DepartmentofTBandRespiratoryMedicine,Pt.B.D.Sharma,PGIMS,Rohtak,India
1
DepartmentofCommunityMedicine,Pt.B.D.Sharma,PGIMS,Rohtak,India
2
DepartmentofAnesthesia,LadyHardingMedicalCollege,NewDelhi,India
Addressforcorrespondence:Dr.SandeepSachdeva,DepartmentofCommunityMedicine,Pt.B.D.Sharma,PGIMS,Rohtak124001,
India.Email:drsachdeva@hotmail.com

Copyright:AnnalsofMedicalandHealthSciencesResearch

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Extrapulmonarytuberculosisconstitutes1520%oftotaltuberculosis(TB)caseloadinimmunocompetent
patients.Afflictionoftheskeletalsystemisrarewithstillrarerpresentationofsternalosteomyelitisevenin
endemiccountries.ApatientwithprimarysternalTBpresentingwithmultiplecutaneoussinusesoverthe
anteriorchestwallisbeingreported.Ahighelementofsuspicionisneededmoresoinresourcelimited
settingforearlydiagnosisandtreatment.

Keywords:Asia,Tuberculosis,Skeletal,Sternum

Introduction
Sternumisoneoftheleastcommonbonesofthebodytogetinfected.Sternalosteomyelitisaccountsforless
than2%ofcasesofosteomyelitis.[1]Thediagnosisisusuallymadelateduringpresentationwithlimitedcase
reportedinpeerreviewedjournalsintheliteraturesearch.[2,3]Ahighelementofsuspicionisneededfor
diagnosisandinstitutionofantituberculartreatmentthatcanpreventcomplications.

CaseReport
A26yearoldmalepresentedwithaprimarycomplaintofswellinganddischargeintheupperpartof
sternumsincelast6months[Figure1].Therewashistoryofdevelopmentofdischargingsinusandfistula
followingpusaspirationfromswelling.Healsocomplainedofintermittentfever,anorexiaandweightlossof
nearly7kgduringlast6months.TherewasnopasthistoryofKoch's.Onexamination,therewasa
dischargingsinusinupperpartofthesternum.Restgeneralphysicalandsystemicexaminationwaswithin
normallimits.Routinebloodinvestigationscompletebloodcount,kidneyfunctiontest,liverfunctiontest,
randombloodsugarandserumelectrolyteswerewithinnormallimitshemoglobinwas11g/dlerythrocyte
sedimentationrate64mm/hMantoux15mm15mmchestradiographwasnormalpatientwasnon
reactivetoHIVtestultrasoundchestrevealedtwohypoechoiclineartractscommunicatingwithskinpus
aspiratewaspositiveforacidfastbacillionZiehlNeelsenstainingContrastenhancedcomputed
tomography(CECT)ofthethorax[Figures2and3]showedperipherallyenhancinghypodensecollection
seeninthesubcutaneousplanewithunderlyingirregularityofbodyofsternumcariesofsternumwithfew
calcifiedlymphnodenoticedinparatrachealregionunderlyinglungparenchymaappearednormal.Patient
wascounseledandstartedonantituberculartherapyunderdirectlyobservedtherapyshortcourse(DOTS)
ofalternatedayregimeprescribedunderRevisedNationalTuberculosisControlProgram,i.e.,isoniazid(600
mg),rifampicin(450mg),pyrazinamide(1500mg)andethambutol(1200mg).Thepatientisunderfollow
upandhasimprovedclinicallywithafibrilestatus,weightgain,resolutionofpusandhealingofsinuses.Itis
plannedtoadministerintermittenttherapyunderDOTSfor9months.

Discussion
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1/1/2017 SternalTuberculosis

Discussion
Tuberculosis(TB)caninvolveanyorgansysteminthebody.PulmonaryTBisthemostcommon
presentationwhileextrapulmonarytuberculosis(EPTB)constitutes1520%ofcaseload.Further,spineand
hiparethemostcommonsitesaffectedunderskeletalsystem.[4]Sternumisresistanttoinfectionsandthus
infrequentsiteofosteomyelitis.Pyogenicinfections,especiallyduetostaphylococcusarereportedasthe
mostcommoncauseofsternalosteomyelitis.InvolvementduetoTBisrareeveninendemiccountrieswhere
thediseaseisextensive.IndiaisthesecondmostpopulouscountryintheworldwithmorenewTBcases
annuallythananyothercountry.Accordingtomostrecentdataofglobalannualincidenceof9.4millionTB
cases,2millionwereestimatedtohaveoccurredinIndia,contributingtoafifthoftheglobalburdenofTBin
thecountry.NotificationofnewEPTBundernationalprogramwas226,965witharateof19/100,000
populationduring2011.[5]Howeverduetovariouschallengesandissues,trueburdeninabsolutenumber
couldbestillhigherduetounderreporting.

SternalTBispredominantlyseeninmiddleagedadultsalthoughnoageisimmuneandithasalsobeen
reportedinaninfant.[6]Itcanariseprimarilyduetohematogenousrouteordirectextensionfromthehilar
lymphnodesand/orcouldbeduetolymphaticdissemination.Tubercularmultiplecutaneoussinusesoverthe
anteriorchestwallmaybeamanifestationofTBoftheinternalmammarylymphnodesspreadingalong
perforatorsoranextensionoftubercularsternalosteomyelitis.[7]Inourpatient,itseemedtobelymphatic
spreadastherewasevidenceofparatracheallymphadenopathyalongwithmultiplecutaneoussinusesover
thechestwall.

Thecomputedtomography(CT)scanismoresensitiveforanatomicallocalizationandindetectingosseous
destructionandsofttissueabnormalities.Khaliletal.reviewedtheutilityofCTscanfindingsinthe
diagnosisofchestwallTBanddescribedcharacteristicringenhancinghypodensesofttissuelesion.[8]
Atasoyetal.suggestedtheroleofmagneticresonanceimaging(MRI)fordetectingearlymarrowandsoft
tissueinvolvementduetohighcontrastresolution.[9]TBosteomyelitisischaracterizedbylowsignal
replacementofthenormalmarrowfatsignalonT1weightedimages,withhighsignalintensitiesonT2
weightedimagesandenhancementonT1weightedimages.[10]

PossiblecomplicationsofsternalTBosteomyelitisincludesecondaryinfection,fistulaformation,
spontaneousfracturesofthesternum,compressionorerosionofthelargebloodvessels,compressionofthe
tracheaandmigrationofTBabscessintothemediastinum,pleuralcavityorsubcutaneoustissues.[11]
Diagnosisrestslargelywiththehistologicalandmicrobiologicalexaminationofsternaltissue.Needle
aspiration,ascomparedtosurgicalexploration,islessinvasiveandmayrepresentthediagnosticprocedure
offirstchoice.Intermittentshortcoursechemotherapyregimensof69monthsarerecommended
internationallyforallformsofEPTB,whichisusuallypaucibacillaryinnature.[12,13,14]Majorityof
authorsareoftheopinionthatstandardantitubercularchemotherapyissufficientwhereassomebelievethat
surgicaldebridementwithprimaryclosureshouldbecombinedwithextendedchemotherapyupto24
monthstopreventrecurrence.

Acknowledgments
DepartmentsofTBandRespiratoryMedicineandRadiology,Pt.B.D.Sharma,PGIMS,Rohtak.

Footnotes
SourceofSupport:Nil.

ConflictofInterest:Nonedeclared.

References
1.TuliSM.Tuberculosisofraresites,girdleandflatbones.In:TuliSM,editor.TuberculosisoftheSkeletal
System.2nded.Delhi:JaypeeBrothersMedicalPublishers2000.

2.VasaM,OhikhuareC,BricknerL.Primarysternaltuberculosisosteomyelitis:Acasereportand
discussion.CanJInfectDisMedMicrobiol.200920:e1814.[PMCID:PMC2807243]
[PubMed:21119799]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853599/?report=printable 2/5
1/1/2017 SternalTuberculosis

3.KhairaA,KhairaDD,GuptaA,BhowmikD,KalraOP,TiwariSC.Tuberculosisofsternum:Threecases
withdifferentpresentations.JAssocPhysiciansIndia.200957:5956.[PubMed:20209722]

4.SharmaSK,MohanA.Extrapulmonarytuberculosis.IndianJMedRes.2004120:31653.
[PubMed:15520485]

5.MinistryofHealthandFamilyWelfare.NewDelhi:GovernmentofIndia2012.TBIndia:AnnualStatus
Report.

6.KatoY,HorikawaY,NishimuraY,ShimodaH,ShigetoE,UedaK.Sternaltuberculosisina9monthold
infantafterBCGvaccination.ActaPaediatr.200089:14957.[PubMed:11195244]

7.GargPK,TeckchandaniN,HadkeNS.Sternaltuberculosispresentingasmultiplecutaneoussinuses.
SouthMedJ.2008101:3034.[PubMed:18364662]

8.KhalilA,LeBretonC,TassartM,KorzecJ,BigotJ,CaretteM.UtilityofCTscanforthediagnosisof
chestwalltuberculosis.EurRadiol.19999:163842.[PubMed:10525881]

9.AtasoyC,OztekinPS,OzdemirN,SakSD,ErdenI,AkyarS.CTandMRIintuberculoussternal
osteomyelitis:Acasereport.ClinImaging.200226:1125.[PubMed:11852218]

10.ShahJ,PatkarD,ParikhB,ParmarH,VarmaR,PatankarT,etal.Tuberculosisofthesternumand
clavicle:Imagingfindingsin15patients.SkeletalRadiol.200029:44753.[PubMed:11026712]

11.SharmaS,JunejaM,GargA.Primarytubercularosteomyelitisofthesternum.IndianJPediatr.
200572:70910.[PubMed:16131781]

12.WaresF,BalasubramanianR,MohanA,SharmaSK.TuberculosisControlinIndia.NewDelhi:
MinistryofHealthandFamilyWelfare2005.[Lastaccessed2012Aug4].Extrapulmonarytuberculosis:
Managementandcontrolpp.95114.Availablefrom:
http://www.tbcindia.nic.in/./tuberculosis%20control%20in%20india11.pdf.

13.BouchikhS,StirnemannJ,PrendkiV,PorcherR,KesthmandH,MorinAS,etal.Treatmentdurationof
extrapulmonarytuberculosis:6monthsormore?TBINFOdatabaseanalysis.RevMedInterne.
201233:66571.[PubMed:22703726]

14.Geneva:WorldHealthOrganization2010.TreatmentofTuberculosis:Guidelines.

FiguresandTables

Figure1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853599/?report=printable 3/5
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Youngmalewithmultiplecutaneoussinusandfistulaoverupperpartofsternum

Figure2

CECTthoraxshowingcariessternum(crosssectionalview)

Figure3

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1/1/2017 SternalTuberculosis

CECTthoraxshowingcariessternum(longitudinalview)

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