British Journal of Radiology (2004) 77, 449-457
© 2004 British Institute of Radiology
doi: 10.1259/bjr/82634045
Chest wall tuberculosis: a review of CT appearances
B S Morris, DMRD, MD,
M Maheshwari, MD and
A Chalwa, DMRD
Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai 400 012, India
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Abstract
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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.
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Introduction
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Tuberculosis (TB) of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB [1–5] which in turn is far less frequently encountered than pulmonary infection alone and represents between 1% and 2% of TB overall [6–8]. A resurgence of TB throughout the world can largely be attributed to widespread HIV infection [9]. TB is considered second only to metastasis as a cause of rib destruction [10] and is thought to be the most commonly encountered inflammatory lesion of the ribs [11]. The endemic nature of TB accounts for the concurrence of lung infection in nine of 14 patients with chest wall abscesses.
TB of bone is thought to result from either lymphatic or haematogenous dissemination of bacilli from a site of primary infection a Ghon focus, in the lungs. Erosion of bone in TB results from pressure necrosis by granulation tissue and also by the direct action of invading organisms. Faure et al [12] hypothesized that infection of lymph nodes in the chest results from pleuritis caused by invasion of the tubercle bacilli. The extraparenchymal (subpleural) collections made up of caseous material from the necrosed lymph nodes are termed "cold abscesses". These can burrow through the chest wall to form visible swellings on the exterior without erythema or tenderness. This explains the contiguity of chest wall collections with enlarged and caseous intrathoracic lymph nodes in half the patients. Internal mammary nodes are found to be the most commonly involved.
Tuberculous abscesses of the chest wall can involve the sternum, costochondral junctions, rib shafts, costovertebral joints and the vertebrae. They are most frequently 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 1–3
, 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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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".
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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.
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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.
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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.
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Destruction of bone adjacent to TB abscesses though a common finding, is not always seen [12, 14–16]. 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.
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Conclusion
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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.
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Acknowledgments
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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;31:1–8) [13].
Received for publication October 28, 2002.
Revision received December 1, 2003.
Accepted for publication February 3, 2004.
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Abstract
Introduction
