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Pictorial review

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

Abstract. Tuberculous abscesses of the chest wall, though uncommon are not infrequently encountered incountries endemic to the disease. This pictorial review of 14 patients highlights the varied appearance oftuberculosis (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 inwhich there was no involvement of the chest wall other than of the spine have been excluded. In all cases CTdemonstrated peripherally enhancing chest wall collections some of which were accompanied by changes inadjacent bone. Enlargement of intrathoracic lymph nodes with comparatively lesser involvement of lungparenchyma and pleura was also seen.

Tuberculosis (TB) of the chest wall constitutes 1% to 5%of all cases of musculoskeletal TB [1–5] which in turn is farless frequently encountered than pulmonary infectionalone and represents between 1% and 2% of TB overall[6–8]. A resurgence of TB throughout the world canlargely be attributed to widespread HIV infection [9]. TB isconsidered second only to metastasis as a cause of ribdestruction [10] and is thought to be the most commonlyencountered inflammatory lesion of the ribs [11]. Theendemic nature of TB accounts for the concurrence of lunginfection in nine of 14 patients with chest wall abscesses.

TB of bone is thought to result from either lymphatic orhaematogenous dissemination of bacilli from a site ofprimary infection a Ghon focus, in the lungs. Erosion ofbone in TB results from pressure necrosis by granulationtissue and also by the direct action of invading organisms.Faure et al [12] hypothesized that infection of lymph nodesin the chest results from pleuritis caused by invasion of thetubercle bacilli. The extraparenchymal (subpleural) collec-tions made up of caseous material from the necrosedlymph nodes are termed ‘‘cold abscesses’’. These canburrow through the chest wall to form visible swellings onthe exterior without erythema or tenderness. This explainsthe contiguity of chest wall collections with enlarged andcaseous intrathoracic lymph nodes in half the patients.Internal mammary nodes are found to be the most com-monly involved.

Tuberculous abscesses of the chest wall can involve thesternum, costochondral junctions, rib shafts, costoverte-bral 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. Theparasternal region (Figures 1–3, 11, 13, 14), costovertebraljunction (Figures 5, 9, 13, 14), and vertebra (Figures 5 and 9)are involved less frequently. Multiplicity of the chest walllesions seen in half the cases could be the result of asuppressed immunological response by host tissue.

Destruction of bone adjacent to TB abscesses though acommon finding, is not always seen [12, 14–16]. It can take theform of disruption of the cortical margin or of an osteolyticlesion, which could be expansile in nature [15]. Of 10 patientswith lesions along the rib shaft, erosion of the ribs is seen in5 patients and a periosteal reaction in 4. Bone erosions areidentified in only two of eight patients with lesions at or nearthe sternum (Figures 1 and 13). Frank rib destruction as inFigure 6 is a less common finding. Extensive destruction ofbone can often raise a differential of other pathologies, e.g.infective (pyogenic/fungal) and neoplastic. However, necro-sis even if present in such lesions is unlikely to simulate theappearance of tuberculous caseous collections.

Pleural thickening at sites remote from chest wall lesions,parenchymal infiltrates and pericardial thickening (Figures 1and 11) were each seen in two of the 14 patients. Coldabscesses on the inner surface of the parietal wall indented thecontour of the liver in four patients (Figures 3, 4, 7 and 10).On initial ultrasound evaluation, the encapsulated collectionin two of these patients mimicked a diseased gallbladder(Figure 7). An extension of the paravertebral abscess into thespinal canal was seen in two patients (Figures 9 and 13);neither patient had a neurological deficit.

Received 28 October 2002 and in final form 1 December 2003 andaccepted, accepted 3 February 2004.

The British Journal of Radiology, 77 (2004), 449–457 E 2004 The British Institute of Radiology

DOI: 10.1259/bjr/82634045

449The British Journal of Radiology, May 2004

(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 sectionthrough the mid-thorax reveals sternal erosion by a lesion in the chest wall. An extrapleural component is seen to abut the pericar-dium. (b) A section 10 mm caudal to the previous image reveals uniform thickening of the pericardium, which is a striking finding inthis patient.

Figure 2. CT of a 15-year-old boy with a painful swelling inthe parasternal region of about 10 months shows a peripherallyenhancing necrotic lesion at the right costochondral junction.

B S Morris, M Maheshwari and A Chalwa

450 The British Journal of Radiology, May 2004

(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 pos-terolateral aspect of the left fifth rib. (a) An encapsulated low attenuation collection anterior to the sternum is seen to communicate with coa-lescent and necrotic pre-vascular lymph nodes. Pre-tracheal, tracheobronchial and carinal nodes are also noted. (b) A cold abscess along thelateral 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 andperipancreatic lymph nodes.

Pictorial review: CT appearance of chest wall TB


Figure 4. The larger of two chest wall swellings in a 25-year-oldman located on the posterolateral aspect of the rib cage appearscontiguous with an intrathoracic component, which confers a scal-loped configuration to adjacent liver contour. Drainage of thesmaller lesion on the anterior chest wall had led to the formationof a discharging sinus. A lung abscess was present within the upperlobe of the right side.

(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-thoraciclevel. (b) A section through the lower thorax, at bone window settings reveals scalloping of the inner margin of the ribs by the extra-pleural mass. Erosion of the pedicle and body of D8 with bilateral paravertebral abscesses was the cause of pronounced tendernessalong the spine.

Figure 6. A plain radiograph of a 47-year-old woman whopresented with a painful swelling in the lower rib cage on theleft side suggested malignancy. CT shows irregular rib expan-sion and destruction with a break in continuity of the posterioraspect of the sixth and seventh ribs. Fine nodular opacities(,1 mm in diameter) are disseminated throughout the lungfields. CT repeated 10 months later showed dramatic resolutionof the lesion, though residual bone deformity with a minimalpleural reaction was found to persist.



Figure 7. A 27-year-old woman who was treated for pulmon-ary tuberculosis 5 years earlier came for evaluation of a swell-ing on the parietal wall. A low attenuation, encapsulated,extraperitoneal collection along the inner aspect of the anteriorparietal wall displaces the adjacent capsule of the liver, whichotherwise appears unremarkable. This collection was mistakenfor a mucocoele of the gall bladder on preliminary ultrasound.

Figure 8. A 17-year-old woman came with a protuberant andfluctuant swelling of 8 months duration over the upper chest. CTreveals an encapsulated and peripherally enhancing low attenua-tion collection in the infraclavicular region contiguous withenlarged and necrotic paratracheal lymph nodes. Drainage of thechest wall abscess was later undertaken for cosmetic reasons.

(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 ade-nopathy, anorexia, weight loss and an evening rise in body temperature. (a) Loculated, low attenuation collections are seen along theinner aspect of the left fifth rib, which is expanded by irregular periosteal reaction. An abscess within the back muscles is seen at thesame level. (b) reveals a paravertebral abscess adjacent to an excavating lesion along the margin of the sixth dorsal vertebra. Despitedemonstrable epidural extension into the spinal canal, the girl had no neurological manifestations. A CT done 12 weeks later showeda significant reduction in size of the lesions despite an absence of reparative bone changes in the affected rib and vertebra.



(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 preliminaryultrasound examination suggested an amoebic liver abscess. Past tuberculosis of the ribs on the right side of the chest however sug-gested the probability of resurgent infection. (a) Axial and (b) parasagittal reformatted images show an encapsulated collection track-ing along the inner surface of the thoracic cage up to the costal margin. The liver though displaced appears otherwise normal.



Figure 13. A 9-year-old girl came with anorexia and weightloss. Painful swellings on the forehead, chest wall and palmwere noticed over a period of 2 months. A section through theupper thorax shows large, encapsulated low attenuation collec-tions in the chest wall, encircling the upper half of the sternumcontiguous with necrotic superior mediastinal lymph nodes.The sternum and the costochondral junctions mainly on theleft side appear eroded. A pre-vertebral abscess with epiduralextension at the mid-dorsal level was not associated with aneurological deficit.

Figure 12. A 20-year-old woman who had received treatmentfor pulmonary tuberculosis 4 years earlier was investigated forsecondary infertility. A plain radiograph of the chest revealed agiant emphysematous bulla with atelectasis of the left lowerlobe. CT reveals an extrapleural mass with a small nodularfocus of calcification adjacent to the inner aspect of the upperrib cage. There is no evidence of bone erosion.

(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 parasternalswelling suggested an extraparenchymal lesion. (a) A section through the mid-thorax shows a low attenuation peripherally enhancinglesion with intrathoracic and extrathoracic components. (b) A section taken a few centimetres caudal shows pericardial thickeningand indentation of cardiac contour by the ‘‘cold abscess’’.



Conclusion

CT is ideal for evaluating tuberculous chest wall lesionsas it demonstrates the nature and extent of soft tissuecollections, and accompanying intrathoracic adenopathyand bone erosion. Hitherto unsuspected lesions in lungparenchyma and the upper abdomen are also detected.

Acknowledgment

The authors would like to thank the editorial board ofthe Journal of the International Skeletal Society for per-mitting them to incorporate a case report and othermaterial from the article ‘‘Multifocal musculoskeletal tuber-culosis in children: appearances on computed tomogra-phy’’ (Skeletal Radiol 2002;31:1–8) [13].

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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 linearperiosteal reaction at the vertebral end of the left 5th rib adjacent to a large extrapleural collection which is contiguous with necroticmediastinal and left hilar lymph nodes. Caseous collections in the anterior chest wall partially encircle the sternum without evidenceof bone erosion. Florid periosteal reaction was seen along the posterior aspect of the 4th to 8th ribs on the left side. (b) A recon-structed image in the coronal plane shows the extent of the thoracic paravertebral abscess from the level of D1 to D10. Periostealreaction is seen to cause expansion of the vertebral ends of the adjacent ribs.



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