A 17-year-old Indian boy presented with 3 month history of left sided chest pain which was increased by inspiration. The pain was stabbing in nature over the left infrascapular and infra axillary region with no radiation to elsewhere. There was no cough, hemoptysis, dyspnea, or fever. There was no past history of tuberculosis or childhood malignancies.
Was essentially normal except for tenderness to palpation over the left infrascapular region and minimal left infrascapular crepitations on auscultation.
His ECG was normal.
Chest X-ray film showed a small peripheral dense opacity at LT lower zone with convexity facing towards the hilum (white arrow), and erosion of the inferior margin of eighth rib posteriorly (black arrow) with pathological fracture (Fig. 1a).
Sputum smear results for malignant cells, acid-fast bacilli (AFB) and fungal elements were negative.
Computerized tomography (CT) of the thorax showed diffuse pleuroparenchymal thickening along the apical, mediastinal and posterolateral aspect of LT hemithorax with a soft tissue mass over the internal surface of the posterior aspect of the LT eighth rib which was eroded. (yellow arrow) (Fig. 1a).
Ultrasound showed heteroechoic pleuroparenchymal thickening measuring 2.6 x 3 cms along with few calcifications and vascularity in LT posterior chest wall. USG guided Percutaneous aspiration of the chest wall mass yielded 5 ml of pus filled material.
The sample material revealed AFB(Acid fast bacilli) on Ziehl-Nielson (Z-N) stain and histopathology showed well defined epitheloid granulomas with extensive areas of caseous necrosis.
The white blood cell count was within normal limits. All biochemical examinations as well as erythrocyte sedimentation rate were within normal ranges. HIV, HCV and HBS Ag tests were negative.
A diagnosis of tubercular osteomyelitis of the Rib probably secondary to extension from pleuroparenchymal foci was made. However it couldn't be established whether the initial lesion was in the rib with extension to pleura and adjoining parenchyma or vice versa but because the incidence of pulmonary tuberculosis is more we presumed it to be a pleuroparenchymal tuberculosis with secondary extension to Rib.
The patient was started on Anti tuberculous treatment (ATT) with category one DOTS, i.e., an initiation phase with four drugs 2HREZ (H= ISONIAZID, R = RIFAMPICIN, E = ETAMBUTOL, Z = PYRAZINAMIDE) thrice weekly which he tolerated well. 2 months later patient visited to our hospital and told improvements of the symptom, he was kept on the continuation phase of anti tubercular therapy that is on two drugs isoniazid and rifampicin and advised for frequent follow ups. On his follow up visit after around two months of continuation phase, chest X ray and computed tomography of chest (Fig. 1b) were taken which showed remarkable healing of the bone with new callus formation and there was no pleura parenchymal thickening. As it is a case of pleura parenchymal along with skeletal involvement, pt was advised to continue continuation phase for a period of 10 months making the total duration of therapy to 12 months. His last chest X ray (Fig. 1c) was taken at the end of 12 months of ATT which has shown remarkable improvement compared to previous ones. Presently the patient is in the follow up period after his ATT treatment as risk of relapse is more during the first two years after completion of ATT.