Pre Sternal Cold Abscess

 

Pictorial CME
Fig. 1 : Photograph showing pre sternal swelling
Fig. 3 : Saggital T1- wt. MRI showing soft tissue intensities inprevertebral, epidural, and peristernal areas.
A 55 years female presented with fever for 3 months alongwith weight loss and had a soft, fluctuant swelling infront of the chest becoming prominent on coughing,sneezing and straining, and partially reducible onpressure. There was no history of chest trauma, anyrespiratory symptom, palpitation, angina, pedal edema,facial puffiness, skin rash, joint pain, urinary orabdominal symptoms. She gave a history of dull deepseated back pain sometimes radiating by the sides ofchest for months. Her past, personal, and family historywas non- contributory.
Fig. 2 : Saggital T1-wt. MRI showing vertebral and sternal lesionswith destruction of vertebral bodies and diminution of disc spaces.

On examination, patient was febrile. A soft, fluctuant, reducible, swelling was noted in front of the manubrium sterni with out any local signs of inflammation or sinusformation (Fig. 1). Tenderness was elicited on pressure on the spinous processes of D8-D9 vertebrae. There was noneurodeficit. Examination of all other system was unrevealing.

Routine hemogram showed anemia (Hb= 8.3gm %) and elevated sedimentation rate (110 mm at 1st hour). Chest X- rayPA view and right posterior- oblique view showed a soft tissue density in front of manubrium with erosion of bonymargin. There was destruction of vertebral bodies of D 4, 5, 8, 9 along with diminution of joint space. Saggital T1-weighted M R I scan showed involvement of D4-D5 and D8-D9 vertebral bodies and intervening discs associated withprevertebral and epidural soft tissue components. The body of the sternum also showed abnormal signal intensityalong with adjacent soft tissue intensity (Figs. 2 and 3). Aspiration yielded a yellow, cheesy material which on Z Nstain showed acid- fast bacilli. Mycobacterium tuberculosis was grown on culture. Serology for HIV was negative. Adiagnosis of pre sternal cold abscess was made. Patient was treated with combination anti tubercular drugs alongwith corset for vertebral lesions. Swelling subsided gradually and fever responded.

SK Bandyopadhyay, A Moulick J Ghosal, Anita Dutta

Assistant Professor; Post Graduate Student; Professor; Department of Medicine, Nil Ratan Sircar Medical College andHospital, 138, A J C Bose Road, Kolkata-700014.

Received : 16.5.2005; Accepted : 15.9.2005