An 11-year-old male presented with gradual left breast enlargement for one year duration. Frequently he visited pediatricians and provisionally diagnosed as a case of gynecomastia with reassurance and observation. Past medical, surgical, family and drug history, all were negative.
A firm swelling involving left anterior chest wall elevating the nipple and areolar region. The swelling was ill-defined, non-tender, non-fluctuating, non-illuminating with normal overlying skin. Vital signs were with the normal ranges.
Hematological tests were normal. Ultrasound examination showed a thick wall cystic lesion with internal debris and bone erosion suspecting chronic infection. CT scan of chest revealed a cystic lesion with fluid content measuring 12 x 8 cm in size connecting with a similar cystic lesion in the substernal area through a hole in the fifth rib (Fig. 1, Fig. 2).
Under general anesthesia, in supine position, through anterolateral incision, a thick wall cystic lesion under the skin with a very thick pus content was found connecting to another similar lesion in the anterior mediastinum through a hole in the fifth rib with localized thickening of the pleura. Both of the lesions, the fifth rib with a part of fourth rib and a piece of pleura were resected and sent for histopathological examination which revealed multiple granuloma with caseating material, typical for TB. The wound was closed in layers after insertion of intrathoracic drain (Fig. 3).
The postoperative course was uneventful. The patient was put on anti-TB regular regimen for three months.