Rib Shaft Tuberculous Granuloma an Osteolytic Malignant Mimic Lesion: A Case Report

Abstract

SESSION TITLE: Infectious Disease Global Case Reports SESSION TYPE: Global Case Report PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM 02:30 PM INTRODUCTION: Chest wall involvement is a rare manifestation of tuberculosis.Globally, musculoskeletal tuberculosis (TB) occurs in 1-3% of patients with TB, while TB of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB.The risk of medical laboratory staff acquiring TB is 5 times more than non laboratory workers. CASE PRESENTATION: 36 year-old male was presented with back pain and non-painful swelling on the left side of the chest anterior over a period of 3 months. The medical history of this patient was unremarkable. He had no pulmonary symptoms, such as a productive cough, or other symptoms.General examination revealed that the patient was a febrile and well nourished.A large, firm, non-mobile, and non-tender mass in the left anterior thoracic wall , overlying skin appeared normal, with no wounds, scars, rash, or sinuses. no other swellings in the body, no lymph nodes enlargement. A plain radiograph of the chest revealed normal findings. CT showed : osteolytic lesion with swelling in the left 7Th rib anterior arc, suggesting malignancy. CT also shows destruction of the rib shaft with some depress of bone in the side of the soft tissue swelling with segment of about 2 cm break in the continuity of the rib. The white blood cell count was normal. All biochemical examinations as well as erythrocyte sedimentation rate were within normal ranges. A tuberculin test was positive 15 mm. HIV, HCV and HBS Ag tests were negative. CT guided fine needle aspiration was done and revealed small fragments of chronic granulomatous inflammatory tissue in a background of traumatic blood fragments of fibrocollagenous tissue contains some microgranulomas.There were composed of loose aggregates of epithelioid cells and dense aggregates of lymphocytes around. focal areas of early caseation necrosis.No evidence of neoplasia was seen.The patient is currently receiving daily antituberculous chemotherapy. DISCUSSION: The granulomatous inflammation of tuberculosis commonly affects the lungs and the hilar lymph nodes, rarely to affect the chest wall and rarer to cause TB granulomatous osteolytic mass in the rib shaft. Chondroma, osteochondroma, fibrous dysplasia, and lipoid granuloma are the common benign tumors involving the ribs while the malignant lesions are chondrosarcoma, myeloma multiplex and secondary deposits from the lung and breast. All these present as expansion of the rib at the affected site, lytic lesion or pathological fractures. Therefore, this case of osteolytic rib shaft mass with bone debris inside without pulmonary, pleural affection and moreover no central caseation or history of tuberculosis or toxemic manifestation make the case more mimic tumor in the rib.Radiologically, presence of an osteolytic lesion, widening of the rib with periosteal reaction and presence of sequestrum may indicate tuberculosis. A solitary rib involvement usually present and the most frequent location is the rib shaft (60%) (1) and this was evident in our case. In addition to history and a good clinical examination, uses of CT-scan and percutaneous needle biopsy CT guided, remain the gold standard for the diagnosis and that was followed in our case. However, Chang et al.(2) could confirm TB in all of their twelve cases only following rib resection, and opinionated that surgery is a final diagnostic and therapeutic option in parietal chest wall TB. FREE TO VIEW http://journal.publications.chestnet.org/article.aspx?articleID=1913027 1 of 2 5/12/2015 7:02 PM PDF created with pdfFactory trial version www.pdffactory.com Tuberculosis infections have been increasing in incidence during the last decades for a variety of reasons, including increasing numbers of patients with immunity-depressive diseases, drug resistance, aging population, and health care worker exposure (3). In the current case, the patient is medical laboratory technician for more than 14 years. He manipulated TB suspected samples. Also, absence of TB history in close contacts may increase the possibility of laboratory acquired infection CONCLUSIONS: The granulomatous inflammation of tuberculosis may mimic osteolytic lesion in ribs of the thoracic cage especially if early without radiologic evidence of caseation, this can occurs in immunocompetent. Reference #1: Chang JH, Kim SK, Lee WY. Diagnostic issues in tuberculosis of the ribs with a review of 12 urgically proven cases. Respirology 1999 Sep;4:249253. Reference #2: Faure E, Souilamas R, Riquet M, Chehab A, Le Pimpec-Barthes F, Manac’h D, Debesse B. Cold abscess of the chest wall: a surgical entity? Ann Thorac Surg 1998 Oct; 66:1174-1178. Reference #3: Watts HG, Lifeso RM: Current concepts review: tuberculosis of bones and joints. J Bone Joint Surg Am 1996, 78:288-98. DISCLOSURE: The following authors have nothing to disclose: Abdelbaset Saleh, Magda Ahmad, Nabil Awadalla No Product/Research Disclosure Information Copyright © 2015 American College of Chest Physicians http://journal.publications.chestnet.org/article.aspx?articleID=1913027 2 of 2 5/12/2015 7:02 PM PDF created with pdfFactory trial version www.pdffactory.com