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Chest wall tuberculosis: a review of CT appearances

Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai 400 012, India

View larger version (60K): [in a new window]   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.

View larger version (103K): [in a new window]   Figure 2. CT of a 15-year-old boy with a painful swelling in the parasternal region of about 10 months shows a peripherally enhancing necrotic lesion at the right costochondral junction.

View larger version (84K): [in a new window]   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 (2–3 mm in size) within a mildly enlarged spleen. Sections through the upper abdomen (not shown) revealed multiple, necrotic coeliac and peripancreatic lymph nodes.

View larger version (138K): [in a new window]   Figure 4. The larger of two chest wall swellings in a 25-year-old man located on the posterolateral aspect of the rib cage appears contiguous with an intrathoracic component, which confers a scalloped configuration to adjacent liver contour. Drainage of the smaller lesion on the anterior chest wall had led to the formation of a discharging sinus. A lung abscess was present within the upper lobe of the right side.

View larger version (53K): [in a new window]   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.

View larger version (126K): [in a new window]   Figure 6. A plain radiograph of a 47-year-old woman who presented with a painful swelling in the lower rib cage on the left side suggested malignancy. CT shows irregular rib expansion and destruction with a break in continuity of the posterior aspect of the sixth and seventh ribs. Fine nodular opacities (<1 mm in diameter) are disseminated throughout the lung fields. CT repeated 10 months later showed dramatic resolution of the lesion, though residual bone deformity with a minimal pleural reaction was found to persist.

View larger version (153K): [in a new window]   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.

View larger version (100K): [in a new window]   Figure 8. A 17-year-old woman came with a protuberant and fluctuant swelling of 8 months duration over the upper chest. CT reveals an encapsulated and peripherally enhancing low attenuation collection in the infraclavicular region contiguous with enlarged and necrotic paratracheal lymph nodes. Drainage of the chest wall abscess was later undertaken for cosmetic reasons.

View larger version (66K): [in a new window]   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.

View larger version (99K): [in a new window]   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.

View larger version (70K): [in a new window]   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".

View larger version (119K): [in a new window]   Figure 12. A 20-year-old woman who had received treatment for pulmonary tuberculosis 4 years earlier was investigated for secondary infertility. A plain radiograph of the chest revealed a giant emphysematous bulla with atelectasis of the left lower lobe. CT reveals an extrapleural mass with a small nodular focus of calcification adjacent to the inner aspect of the upper rib cage. There is no evidence of bone erosion.

View larger version (92K): [in a new window]   Figure 13. A 9-year-old girl came with anorexia and weight loss. Painful swellings on the forehead, chest wall and palm were noticed over a period of 2 months. A section through the upper thorax shows large, encapsulated low attenuation collections in the chest wall, encircling the upper half of the sternum contiguous with necrotic superior mediastinal lymph nodes. The sternum and the costochondral junctions mainly on the left side appear eroded. A pre-vertebral abscess with epidural extension at the mid-dorsal level was not associated with a neurological deficit.

View larger version (85K): [in a new window]   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.