DrGhaniya DrNaveen Viswanath ,DrPramod Pillai (Paed surgery)DrPraveena ,DrC Jayakumar
A 4-year-old Non resident Indian girl presented with swelling in the midline chest for one month.
History of Presenting Illness:
The swelling was first noticed following trauma and gradually increased in size. There were no associated symptoms such as pain, discharge, redness, fever, bone pain, or back pain.
The child had no history of respiratory symptoms, facial edema, other swellings, bleeding manifestations, weight loss, night sweats, seizures, or abnormal movements.
Past History:
– No previous hospital admissions.
– No history of recurrent infections.
Birth History:
– Second child of a non-consanguineous marriage.
– Antenatal period was uneventful.
– Term delivery via lower segment cesarean section (LSCS) due to previous LSCS.
– Birth weight: 2.9 kg.
– Postnatal period was uneventful.
Development and Immunization History:
– Achieved age-appropriate milestones.
– Immunized according to UAE schedule.
Family History:
– Parents are healthy.
– Elder sibling, a 7-year-old male, is healthy.
Contact with maternal grand mother staying in India in infancy is not available
– But she was diagnosed with TB two months ago.
Examination:
– Afebrile,and alert child
– No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema.
– Anthropometry: Weight 14 kg, Height 103 cm, Head Circumference 50 cm, Mid-Arm Circumference 12.5 cm.
– Swelling over sternum measuring 3×3 cm, firm, non-tender, with normal overlying skin, and no local rise in temperature.
– Respiratory and cardiovascular systems were unremarkable.
– Abdomen soft, non-tender with positive bowel sounds.
– Normal central nervous system examination.
Differential Diagnosis
– Post-traumatic herniation of mediastinal lesion.
– Ewing’s sarcoma/primary sternal tumor.
– Bone tuberculosis.
– Metastasis.
– Brodie’s abscess (subacute osteomyelitis).
– Self-limiting sternal tumor of childhood (SELSTOC).
– Bronchogenic cyst/dermoid cyst.
Investigations
– CBC :Hemoglobin 11.9 g/dl, Total leukocyte count 9.14 x 10^3/uL, Neutrophils 41.3%, Lymphocytes 47.4%, Platelets 421 x 10^3/uL.
– CRP : 3.09 mg/L.
– LDH :423 U/L.
– Peripheral Smear : Microcytic hypochromic RBC with thrombocytosis and reactive neutrophilia.
– Chest X-ray :No infiltrates.
– Ultrasound Chest :Well-defined lobulated mildly vascular soft tissue overlying the lower manubrium extending into the anterior mediastinum (3×2.5 cm). No bone destruction.
– CT Chest : Lytic lesion involving the body of the sternum with heterogeneous enhancing soft tissue component (3 x 3.3 x 3.7 cm), non-enhancing necrotic foci, extension to anterior mediastinum, abutting mediastinal pleura and pericardium.
Diagnosis
Biopsy revealed necrotizing granulomatous inflammation. Tissue GeneXpert detected Mycobacterium tuberculosis complex, negative for rifampicin resistance.
Treatment
The child was started on anti-tuberculosis therapy (ATT) and is tolerating it well.
Discussion
Sternal TB is a rare form of skeletal tuberculosis, usually presenting as a painless swelling. Early diagnosis is critical to prevent complications such as bone deformity and abscess formation. Imaging, particularly MRI, plays a key role in detecting the extent of the lesion. Confirmatory diagnosis is achieved through biopsy and molecular tests like GeneXpert.
Conclusion
This case highlights the importance of considering tuberculosis in the differential diagnosis of chest wall swellings in children, especially in endemic regions. Early diagnosis and treatment are crucial for favorable outcomes.