Purpose or Case Report: Primary tubercular osteomyelitis accounts for less than 10% of extra-pulmonary tuberculosis (TB) in childhooduMultifocal tuberculosis with more than one site especially in immune-competent children is rare. Very few cases of multifocal involvement of ribs and sternum are reported. We are presenting a case of a 14-year-old boy presented with painless swelling in the chest.
Clinical history
The 4-year-old child presented with painless swelling on his anterior chest in midline and back pain on and off for 3 months duration. No history of trauma. However, he lost about 3 kilograms of his weight in this duration. On examination, the swelling was soft and painless on palpation. No exit points in the skin. There was no lymphadenopathy. However, other systemic examinations were unremarkable. Lab parameters revealed a WBC count of 11,000 with lymphocyte-predominant.
In children, the bones most commonly affected are the metaphysis of the long bones (femur, tibia, fibula, radius, ulna and humerus), spine, pelvic girdle and skull bones. Multifocal skeletal tuberculosis is uncommon in children and accounts for less than 10% of skeletal tuberculosis. Sternum TB commonly occurs by reactivation of latent focuses formed throughout the course of hematogenous or lymphatic dissemination of primary tuberculosis. Extra-pulmonary tuberculosis in children varies from 21-44%. Pericardial involvement is one of the crucial sites of involvement. About 10% of children develop constrictive pericarditis in follow up for pericardial effusion.
The diagnosis of bone tuberculosis is particularly challenging as the presentation of skeletal tuberculosis is often insidious, with an absence of the classical features of pulmonary tuberculosis or typical systemic features such as fever, cough, night sweats or weight loss (history of localized painless swelling and weight loss were present in our case). The gold standard for diagnosis comprises histological examination verification. Needle aspiration or excisional biopsy for histopathological diagnosis of sternum TB is obligatory. Both Needle aspiration and biopsy were performed in our case.
The clinical presentation in patients with multifocal musculoskeletal tuberculosis may closely mimic that in patients with multiple bone metastases, which makes the accurate clinical diagnosis challenging. Clinical and even radiological findings may be indistinguishable from malignant disease, so histopathological evaluation is warranted in such cases.
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