October - LRS Institute of Tuberculosis & Respiratory Diseases

TUBERCULOUS OSTEOMYELITIS OF THE STERNUM
K.S.V.K. SUBBA RAO*, B.K. GUPTA* AND K. RAMAKRISHNAN**
Summary : A case of tuberculous osteomyelitis of the sternum is reported and the diagnostic and
therapeutic aspects reviewed. It should be considered in any indolent infection of the sternum even when
there is no evidence of tuberculosis elsewhere in the body.
Osteoarticular tuberculosis is a therapeutic
problem and tuberculous osteomyelitis of the
thoracic cage (including the vertebrae) forms
7% of all cases of bone and joints tuberculosis
(Nicholson, 1974). Involvement of the sternum
without and tuberculous focus elsewhere is
uncommon enough to warrant special mention
and more so because of the morbidity associated
with the intrathoracic spread of the disease and
the therapeutic challenge the entity poses.
by stainless steel wire G-24. The lower part of
the rib was fixed by chromic catgut sutures to
the rectus abdominus.
Case Report
A 50 years old male labourer came with a
history of a chronic non-healing ulcer over the
body of the sternum, gradually increasing in
size, and not responding to antibiotics and
dressings in different hospitals. On initial presentation
the diagnosis of rodent ulcer/dermatitis
artifacta was considered. Radiologically,
no lesion was evident over the sternum then.
Microscopic examination of tissue biopsy
showed a chronic nonspecific infection.
Examination of the patient was unremarkable
except for a punched out ulcer
over the body of the sternum measuring 5 cms
in diameter with seropurulent discharge. Tenderness
was present over the adjoining sternal body
and left fourth costal cartilage. No systemic
abnormality could be made out clinically. A
lateral radiograph of the chest showed periosteal
reaction of the deep surface of the second piece
of the sternum and destruction of the lower
piece of the sternum. Mantoux test was positive
(24 mm). The sedimentation rate was high
(60 mm/hr). Sinogram showed the dye in the
anterior mediastinum suggesting complete destruction
of the bone. Lung fields were clear.
There was no evidence of any tuberculous
lesion elsewhere also.
Without further delay., the excision of the
sternum along with the ulcer from the second
piece to the xiphoid and the adjoining costal
cartilages from the ITI to the VII was undertaken
(Fig. 1). The right VII rib was used to
replace the sternum and it was held in position
Fig.l. Photograph of the posterior surface of the excised
specimen showing irregular destruction of the
bone.
Postoperatively the patient was put on
Gentamicin and Fiagyl. The tissue histology
showed tuberculous granulation tissue. Antibiotics
were discontinued following subsidence
of toxaemia and the patient was started on antituberculous
regime. Postoperative wound
infection due to staphylococcus aureus was
managed by specific antibiotics and wound
irrigation. The cortex of the rib was perforated
over a small area to allow granulations to
proliferate and the raw area was skin grafted.
Patient was discharged with antituberculous
drugs and when seen six months later he was
asymntomatic and the wound healed well.
Discussion
Pyogenic osteomyelitis of the sternum has
been described after median sternotomies for
cardiovascular surgical procedures, and secondary
to mediastinal sepsis (Wray et al, 1973).
Spread of specific infections from ribs, vertebrae,
paravertebral or internal mammary lymph nodes
may also be postulated. Tuberculous osteomyelitis
of the sternum can occur following a
* Assistant Professor
** Senior Resident
Department of Cardio-thoracic Surgery, Jawaharlal Institute of Postgraduate Medical Education and
Research, Pondicherry-605 006.
Ind. J. Tub., Vol. XXIX, No, 4