This article describes an unusual case of a 3-year-old girl who presented with sternal swelling, later diagnosed as a sign of tuberculosis.
She presented to the hospital with complaints of a non-tender swelling in the sternal region. The swelling was small but gradually increased in size. She denied having any symptoms, such as a cough or fever. However, she reported significant weight loss and increasing lethargy over the previous 2 months.
The girl had an unremarkable past medical and surgical history. She only suffered from constipation, for which the doctors prescribed her movicol. She did not report using any other medicine on a long-term basis.
Tuberculosis: Contact Tracing
The patient moved to the UK after being born in Canada. According to her mother, she received the BCG vaccination at birth and was up-to-date with reference to the vaccination schedule. The girl did not have a history of contact with any TB patients. However, her mother confirmed having TB some 18 years ago, for which she was treated with anti-TB medicines. She also reported developing ATT-induced hepatitis, for which the doctors put her medicines on hold. After a pause, however, she did complete her course and has been asymptomatic since then.
Examination and Investigations
On physical examination of the patient, doctors found a non-tender and non-mobile swelling in the middle of her sternum. They also found another swelling on the left side of the girl’s chest. Both the swellings were firm in consistency and were gradually enlarging in size. To rule out an infectious cause, ESR and CRP tests were done. Results indicated both elevated ESR and CRP. Similarly, her blood profile revealed microcytic anemia, and her chest X-ray showed multiple opacities in the right middle and left upper zones.
Chest involvement with constitutional symptoms such as weight loss and lethargy aroused suspicion for TB. Hence, a rapid TB test was performed. It turned out positive. A PCR for Mycobacterium tuberculosis further confirmed the diagnosis. Doctors also decided to look for further extra-pulmonary involvement. Hence, on a CT abdomen and pelvis, they noticed lymph node involvement throughout the abdomen. Biopsy reports of both swellings revealed granulomas with necrotic centers and multinucleated giant cells.
Treatment for Tuberculosis
Doctors put the girl on anti-tuberculosis therapy, including four drugs: isoniazid, rifampicin, ethambutol, and zinamide. She responded well to medicines, and her swellings resolved after a treatment course of 6 months.
Tuberculosis of the Sternum: How Common?
Extrapulmonary tuberculosis goes hand in hand with pulmonary TB. Many cases that are reported reveal extensive extra-pulmonary involvement, such as those of lymph nodes, bones, and even the brain. However, there are only a handful of cases available of tuberculosis involving the sternum.
Bone involvement in TB usually manifests in the ribs and spine (Pot’s disease/caries). Sternal swelling as the primary manifestation of TB is highly rare, especially in the pediatric age group. Nevertheless, patients who present with such complaints should undergo high-quality imaging investigations and punch biopsy for accurate diagnosis, followed by early treatment with anti-TB medicines. The prognosis with early intervention remains good, and most patients observe complete remission.
