Primary Tuberculous Sternal Osteomyelitis: A Clinical Rarity
Vijay Yashpal Bhatia, MCh,
Vinod Aggarwal, MCh1,
Umesh Sharma, MS,
Anubhav Gupta, MCh
Department of Plastic & Reconstructive Surgery
1 Department of Cardiothoracic & Vascular Surgery Vadilal Sarabhai General Hospital & NHL Medical College Ahmedabad, India
Vijay Yashpal Bhatia, MCh Tel: +91 9825073828 Fax: +91 7926407617 Email: bhatia101{at}gmail.com, Burns, Plastic & Cosmetic Surgery Hospital, Ground Floor, Sunder Gopal Complex, Ambawadi Circle, Ahmedabad–380006, India.
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ABSTRACT
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Primary tuberculous sternal osteomyelitis is a rare condition, presenting as painful swelling and discharging sinuses over the chest wall. Diagnosis is based on radiological findings and histological examination of debrided infected tissues, with specific cultures for mycobacteria. Two cases were successfully treated by surgical debridement and reconstruction using pectoralis major muscle flaps, followed by antituberculous therapy.
Key Words: Osteomyelitis • Sternum • Tuberculosis • Osteoarticular
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INTRODUCTION
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Primary tuberculous lesions involving the manubrium sterni are uncommon, and reports of tuberculous sternal osteomyelitis are scanty.1 Delayed presentations can be in the form of sinuses at the chest wall, spontaneous fracture of the sternum, extrasternal spread and sepsis.2 Diagnosis can be made reliably by computed tomography of the chest wall, and Ziehl-Neelsen staining of aspirate from the lesion.2 We describe 2 cases of asymptomatic primary sternal tuberculosis, with no apparent risk factors, presenting with swelling of the central chest wall. Both patients required sequestrectomy in the form of partial or total sternectomy, with pectoralis major muscle flap reconstruction.
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CASE 1
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A 21-year-old man with no significant history presented with swelling of the upper central chest wall for 3 months. He was apparently healthy. Chest radiography in lateral view showed thickening of the manubrium and upper sternum, with a collection in the soft tissues anterior to the sternum (Figure 1
). Computed tomography (CT) of the thorax showed thickening of the manubrium and sternum and infective arthritic changes at the sternomanubrial joint (Figure 2). The patient was explored via a midline incision. The whole of the sequestrum was debrided and sent for histopathology. The resulting defect in the upper sternum was reconstructed with a right-sided pectoralis major flap, which was turned over on itself (based on its secondary pedicles) after dividing the clavicular and humeral attachments. The skin was closed over a negative-suction drain kept at the pectoralis major muscle bed. Bilateral intercostal drains were also placed, as the pleura were inadvertently opened. The patient had an uneventful recovery, the intercostal drains were removed on the 6th postoperative day, and the negative-suction drain was removed on the 9th postoperative day. Antituberculous chemotherapy was started when the patient had stabilized and histopathological confirmation had been obtained. He was discharged on 11th postoperative day.
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Figure 1. Chest radiograph in lateral aspect showing a collection in the soft tissue anterior to the sternum, with arthritic changes in the sternomanubrial joint, in case 1.
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Figure 2. Computed tomography of the thorax showing an abscess in the soft tissues anterior and posterior to the sternum, in case 1.
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CASE 2
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A 70-year-old man with no significant history presented with a swelling at the anterior chest wall for 4 months, and redness of the overlying skin for 1 week. All routine investigations were within normal limits. Radiography of the chest wall in lateral view showed sternal hypertrophy. CT of the thorax showed sequestrum involving the whole of the sternum, with an abscess spreading in the soft tissues anterior and posterior to the sternum (Figure 3). This patient was also explored by midline incision. The whole of the sternum was found to be involved in the diseased process. Debridement was performed and hemostasis ensured. The resulting defect in the sternum was reconstructed with bilateral pectoralis major muscle flaps. The right-sided muscle was turned over on itself at its medial attachment, based on the secondary vascular pedicles from the internal mammary artery. The left-sided muscle was transposed into the defect, based on its primary pedicle from the thoracoacromial vessels. The skin was closed over negative-suction drains kept at the pectoralis major muscle beds on both sides. Bilateral intercostal drains were placed in the pleura. This patient was also given antituberculous chemotherapy from the 4th postoperative day. He made an uneventful recovery, the intercostal drains were removed on the 8th postoperative day, and the negative-suction drains on the 12th postoperative day. He was discharged on the 14th postoperative day.
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Figure 3. Computed tomography of the thorax showing a large sternal abscess extending anteriorly in the soft tissues and posteriorly in the extrapleural space, in case 2.
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DISCUSSION
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Primary sternal osteomyelitis is a rare condition. According to Gill and Stevens,3 there were 57 reported cases of primary sternal osteomyelitis up to 1989, of which only 6 were tuberculous osteomyelitis. Tuberculous sternal osteomyelitis became very rare after 1952, as reported by Watts and colleagues.1 However, there are many case reports in the English literature in the last 10 years, most of them are from developing countries. The incidence is 2%–3% of all cases of osteoarticular tuberculosis.4 Yew and colleagues5 recovered Mycobacterium fortuitum from sternotomy wounds of cardiac surgery patients. Resurgence of tuberculosis due to HIV may be responsible for atypical presentations.6
This disease has an indolent course and can present as swelling, multiple sinuses, fever, redness, and pain over the central chest wall. Both patients described here had no underlying disease or predisposing factors. In cases of delayed presentation, it can presents as spontaneous sternal fracture, mediastinitis, or sepsis. Other lesions affecting at this area, such as cellulitis and primary bone tumors, should be considered in the differential diagnosis. CT and magnetic resonance imaging are very helpful for diagnosis. Tuberculous osteomyelitis manifests as cartilaginous destruction and soft tissue masses with calcification and rim enhancement on CT scans. Bone scans with technetium-99m pyrophosphate or gallium-67 citrate are helpful, but they lack specificity and are not readily available. The mainstay of confirmation remains tissue diagnosis by histology and culture of the resected specimen.
The treatment options depend on the extent of disease. Early presentations are rare as there are few signs and symptoms in the initial stages. However, if diagnosed incidentally, early disease can be treated with antituberculous drugs only, with regular follow-up for radiological evidence of improvement. Patients with localized disease not resolving with antituberculous treatment can undergo local curettage of the bony lesion or partial resection of the sternum. Vacuum-assisted closure has been used after debridement of the lesion, resulting in faster recovery.7 Total sternectomy may be required for cases where there is a large sequestrum with involvement of the whole sternum. Reconstruction of the resultant defect can be achieved with pectoralis major muscle flaps.
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REFERENCES
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- Watts RA, Paice EW, White AG. Spontaneous fracture of the sternum and sternal tuberculosis. Thorax 1987;42:984.[Free Full Text]
- Sharma S, Juneja M, Garg A. Primary tubercular osteomyelitis of sternum. Indian J Pediatr 2005;72:709–10.[Medline]
- Gill EA Jr, Stevens DL. Primary sternal osteomyelitis. West J Med 1989;151:199–203.[Medline]
- Hajjar W, Logan AM, Belcher PR. Primary sternal tuberculosis treated by resection and reconstruction. Thorac Cardiovasc Surg 1996;44:317–8.[Medline]
- Yew WW, Kwan SY, Ma WK, Khin MA, Mok CK. Single daily-dose ofloxacin monotherapy for Mycobacterium fortuitum sternotomy infection. Chest 1989;96:1150–2.[Abstract/Free Full Text]
- Khan SA, Varshney MK, Hasan AS, Kumar A, Trikha V. Tuberculosis of the sternum: a clinical study. J Bone Joint Surg Br 2007;89:17–20.
- Ford SJ, Rathinam S, King JE, Vaughan R. Tuberculous osteomyelitis of the sternum: successful management with debridement and vacuum assisted closure. Eur J Cardiothorac Surg 2005;28:645–7.[Abstract/Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:310-312
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104751
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ABSTRACT
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