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DOI: 10.1259/bjr/82634045
Pictorial review
Abstract. Tuberculous abscesses of the chest wall, though uncommon are not infrequently encountered in
countries endemic to the disease. This pictorial review of 14 patients highlights the varied appearance of
tuberculosis (TB) of the chest wall on CT. The patients ranged in age from 9 to 55 years (a mean of 25 years)
with a preponderance of chest wall lesions in young adults and in females (male to female ratio of 2:5). Cases in
which there was no involvement of the chest wall other than of the spine have been excluded. In all cases CT
demonstrated peripherally enhancing chest wall collections some of which were accompanied by changes in
adjacent bone. Enlargement of intrathoracic lymph nodes with comparatively lesser involvement of lung
parenchyma and pleura was also seen.
found at the margins of the sternum and along the rib shafts
[13]. A predilection for the rib shaft is seen in nine cases. The
parasternal region (Figures 13, 11, 13, 14), costovertebral
junction (Figures 5, 9, 13, 14), and vertebra (Figures 5 and 9)
are involved less frequently. Multiplicity of the chest wall
lesions seen in half the cases could be the result of a
suppressed immunological response by host tissue.
Destruction of bone adjacent to TB abscesses though a
common finding, is not always seen [12, 1416]. It can take the
form of disruption of the cortical margin or of an osteolytic
lesion, which could be expansile in nature [15]. Of 10 patients
with lesions along the rib shaft, erosion of the ribs is seen in
5 patients and a periosteal reaction in 4. Bone erosions are
identified in only two of eight patients with lesions at or near
the sternum (Figures 1 and 13). Frank rib destruction as in
Figure 6 is a less common finding. Extensive destruction of
bone can often raise a differential of other pathologies, e.g.
infective (pyogenic/fungal) and neoplastic. However, necrosis even if present in such lesions is unlikely to simulate the
appearance of tuberculous caseous collections.
Pleural thickening at sites remote from chest wall lesions,
parenchymal infiltrates and pericardial thickening (Figures 1
and 11) were each seen in two of the 14 patients. Cold
abscesses on the inner surface of the parietal wall indented the
contour of the liver in four patients (Figures 3, 4, 7 and 10).
On initial ultrasound evaluation, the encapsulated collection
in two of these patients mimicked a diseased gallbladder
(Figure 7). An extension of the paravertebral abscess into the
spinal canal was seen in two patients (Figures 9 and 13);
neither patient had a neurological deficit.
449
(a)
(b)
Figure 1. A 40-year-old lady presented with a painful swelling on the right side of the chest over a period of 3 months. (a) A section
through the mid-thorax reveals sternal erosion by a lesion in the chest wall. An extrapleural component is seen to abut the pericardium. (b) A section 10 mm caudal to the previous image reveals uniform thickening of the pericardium, which is a striking finding in
this patient.
450
(a)
(b)
Figure 3. A fluctuant swelling of several months duration on the sternum of a 17-year-old woman prompted need for a chest radiograph.
Superior mediastinal widening coupled with bilateral hilar prominence suggested extensive adenopathy. There was subtle notching of the posterolateral aspect of the left fifth rib. (a) An encapsulated low attenuation collection anterior to the sternum is seen to communicate with coalescent and necrotic pre-vascular lymph nodes. Pre-tracheal, tracheobronchial and carinal nodes are also noted. (b) A cold abscess along the
lateral parietal wall displaces the contour of the liver. There are enlarged necrotic epiphrenic lymph nodes and multiple discrete granulomas
(23 mm in size) within a mildly enlarged spleen. Sections through the upper abdomen (not shown) revealed multiple, necrotic coeliac and
peripancreatic lymph nodes.
451
(a)
(b)
Figure 5. (a) An extrapleural soft tissue mass in an 18-year-old man is seen adjacent to the anterolateral chest wall at the mid-thoracic
level. (b) A section through the lower thorax, at bone window settings reveals scalloping of the inner margin of the ribs by the extrapleural mass. Erosion of the pedicle and body of D8 with bilateral paravertebral abscesses was the cause of pronounced tenderness
along the spine.
452
Figure 7. A 27-year-old woman who was treated for pulmonary tuberculosis 5 years earlier came for evaluation of a swelling on the parietal wall. A low attenuation, encapsulated,
extraperitoneal collection along the inner aspect of the anterior
parietal wall displaces the adjacent capsule of the liver, which
otherwise appears unremarkable. This collection was mistaken
for a mucocoele of the gall bladder on preliminary ultrasound.
(a)
(b)
Figure 9. Multiple lesions in the thoracic cage were detected on a CT of a 15-year-old girl who presented with painless cervical adenopathy, anorexia, weight loss and an evening rise in body temperature. (a) Loculated, low attenuation collections are seen along the
inner aspect of the left fifth rib, which is expanded by irregular periosteal reaction. An abscess within the back muscles is seen at the
same level. (b) reveals a paravertebral abscess adjacent to an excavating lesion along the margin of the sixth dorsal vertebra. Despite
demonstrable epidural extension into the spinal canal, the girl had no neurological manifestations. A CT done 12 weeks later showed
a significant reduction in size of the lesions despite an absence of reparative bone changes in the affected rib and vertebra.
453
(a)
(b)
Figure 10. Over 100 ml of caseous material was aspirated from a subcostal swelling of a 35-year-old woman in whom a preliminary
ultrasound examination suggested an amoebic liver abscess. Past tuberculosis of the ribs on the right side of the chest however suggested the probability of resurgent infection. (a) Axial and (b) parasagittal reformatted images show an encapsulated collection tracking along the inner surface of the thoracic cage up to the costal margin. The liver though displaced appears otherwise normal.
454
(a)
(b)
Figure 11. Ill-defined haziness over the heart border on a plain radiograph of the chest of a 55-year-old man with a parasternal
swelling suggested an extraparenchymal lesion. (a) A section through the mid-thorax shows a low attenuation peripherally enhancing
lesion with intrathoracic and extrathoracic components. (b) A section taken a few centimetres caudal shows pericardial thickening
and indentation of cardiac contour by the cold abscess.
455
(a)
(b)
Figure 14. CT was done for an 11-year-old girl with fever and chest pain. (a) An axial image just below the carina shows linear
periosteal reaction at the vertebral end of the left 5th rib adjacent to a large extrapleural collection which is contiguous with necrotic
mediastinal and left hilar lymph nodes. Caseous collections in the anterior chest wall partially encircle the sternum without evidence
of bone erosion. Florid periosteal reaction was seen along the posterior aspect of the 4th to 8th ribs on the left side. (b) A reconstructed image in the coronal plane shows the extent of the thoracic paravertebral abscess from the level of D1 to D10. Periosteal
reaction is seen to cause expansion of the vertebral ends of the adjacent ribs.
Conclusion
CT is ideal for evaluating tuberculous chest wall lesions
as it demonstrates the nature and extent of soft tissue
collections, and accompanying intrathoracic adenopathy
and bone erosion. Hitherto unsuspected lesions in lung
parenchyma and the upper abdomen are also detected.
Acknowledgment
The authors would like to thank the editorial board of
the Journal of the International Skeletal Society for permitting them to incorporate a case report and other
material from the article Multifocal musculoskeletal tuberculosis in children: appearances on computed tomography (Skeletal Radiol 2002;31:18) [13].
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