Diagnosis at first sight
A mass over manubrium sterni causing lytic bone lesions
Una masa sobre manubrium sterni que causa lesiones óseas líticas
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"subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X22001409?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X22002714?idApp=UINPBA00004N" "url" => "/2529993X/0000004100000004/v2_202304072117/S2529993X22002714/v2_202304072117/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "A mass over manubrium sterni causing lytic bone lesions" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "245" "paginaFinal" => "246" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Abdurrahman Kaya, Sibel Yıldız Kaya, Azat Abul, Merve Altınkaynak" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Abdurrahman" "apellidos" => "Kaya" "email" => array:1 [ 0 => "dr.abdkaya@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Sibel Yıldız" "apellidos" => "Kaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Azat" "apellidos" => "Abul" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Merve" "apellidos" => "Altınkaynak" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Infectious Disease, Medical School of Cerrahpasa, Istanbul University, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una masa sobre manubrium sterni que causa lesiones óseas líticas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 747 "Ancho" => 1254 "Tamanyo" => 75651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Computed tomography showing bone destruction (arrow) and retosternal air.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical description of the case</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 20-year-old-man presented with a mass over manubrium sterni for 4 months. He is from Ethiopia and came to Turkey 6 months ago. The patient also complained of fatigue and back pain. He had fever and weight loss (8<span class="elsevierStyleHsp" style=""></span>kg), but no cough, and sputum. The patient denied an underlying disease and trauma. The previous medical history was also unremarkable for medications. On examination, the patient looked fatigue and fully cooperative. The mass was about 11<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>cm in size and fluctuating but had no pain and no redness (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The laboratory values showed a total white blood cells count of 9300<span class="elsevierStyleHsp" style=""></span>cells/mcL, with 70% neutrophils, C-reactive protein: 90<span class="elsevierStyleHsp" style=""></span>mg/dL (0–5), sedimentation rate: 105<span class="elsevierStyleHsp" style=""></span>mm/h. He had anemia of chronic disease and hemoglobin level was 10<span class="elsevierStyleHsp" style=""></span>g/dL. Ultrasound revealed a fluid collection with intense content, indicating an abscess formation. Fine needle aspiration puncture was administered for diagnosis. Some fluids were aspirated for culture and ampicillin–sulbactam 1/0.5<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h was empirically administered for pyogenic sternal infection. Despite the administration of the antibiotic for 10 days, the swelling did not regress, on the contrary, continued to increase in size. The gram staining of the samples revealed abundant leukocytes but no microorganisms. The solid and liquid cultures of the materials were all sterile. Also, it was negative for acid-fast bacteria. Urinalysis, basic chemistry, and hepatic function testing were within normal limits. Serologies for syphilis, Brucellosis, Hepatitis B Virus, Human Immunodeficiency Virus, Epstein–Barr Virus, Toxoplasmosis, and Cytomegalovirus were unremarkable.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and evolution</span><p id="par0010" class="elsevierStylePara elsevierViewall">In detailed medical history, there was a positive history of tuberculosis (TB) in his family. Hemocultures were sterile. Computed tomography revealed a mass causing significant bone destruction on manubrium sterni and extending to the anterior mediastinum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In addition, vertebral osteomyelitis was observed, showing enhancement of L1, T12, T11, T10, T9, and T8. Abdominal scan demonstrated a psoas abscess measuring approximately 66<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mm and a gluteal abscess measuring 40<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>56<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Due to the lack of improvement, the sternal mass was surgically removed. The routine bacterial cultures were repeated but remained sterile. A tuberculin skin test was positive (induration<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm). Tuberculosis culture was not available and therefore could not be performed. Polymerase chain reaction (PCR) of the excised tissue was positive for TB. The biopsy disclosed necrotizing granulomatous inflammation which was consistent with TB. A diagnosis of TB was made and quadruple anti-TB drugs including isoniazid, rifampin, pyrazinamide, and ethambutol were initiated. The abdominal abscess was drained completely. A material also tested positive for TB via PCR. The drugs were administered for 9 months. The patient has been doing well for 3 months and no recurrence.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Osteomyelitis of the sternum is a rare condition that can lead to multiple diagnostic differentials in adults. Generally, it results from a complication of sternotomy, trauma and mediastinitis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Commonly, the causative agent is <span class="elsevierStyleItalic">Staphylococcus aureus.</span> Therefore, antibiotics covering this microorganism are administered empirically.</p><p id="par0020" class="elsevierStylePara elsevierViewall">TB is primarily infection of the lungs and rarely bone involvements can be observed. Skeletal tuberculosis refers to TB involvement of the bones and/or joints. It accounts for 10–35 percent of cases of extrapulmonary TB.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Mycobacterial infection of the sternum is an extremely rare condition and constitutes less than 1% of TB osteomyelitis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> Generally, it results from either an extension from hilar lymph nodes or hematogenous/lymphatic dissemination of TB from other infectious focus.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Sternal TB manifests as an insidious swelling and pain. Generally, a single mass occurs on anterior chest wall. Aspiration and anti-TB chemotherapy are treatment options in sternal TB. Surgery is recommended if a large sequestrum needs to be removed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, TB is an infectious disease which can manifest in a variety of clinical entity. As in our case, TB should be included in the differential diagnosis of a patient presenting with a sternal mass, especially in endemic regions.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">There is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical description of the case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis and evolution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1224 "Ancho" => 1254 "Tamanyo" => 78361 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A mass over manubrium sterni.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 747 "Ancho" => 1254 "Tamanyo" => 75651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Computed tomography showing bone destruction (arrow) and retosternal air.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 730 "Ancho" => 1300 "Tamanyo" => 68996 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abdominal scan demonstrating a psoas abscess (red arrow) and a gluteal abscess (black arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary tubercular osteomyelitis of the sternum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. 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Harrington" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/605559" "Revista" => array:5 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2009" "volumen" => "49" "paginaInicial" => "1350" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19793000" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tuberculosis of bones and joints" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.G. Watts" 1 => "R.M. Lifeso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2106/00004623-199602000-00019" "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Am" "fecha" => "1996" "volumen" => "78" "paginaInicial" => "288" "paginaFinal" => "298" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8609123" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sternal swelling presenting as tuberculosis: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Rajan" 1 => "K. Bizanti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13256-021-03008-9" "Revista" => array:5 [ "tituloSerie" => "J Med Case Rep" "fecha" => "2021" "volumen" => "15" "paginaInicial" => "580" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34872599" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000004100000004/v2_202304072117/S2529993X2300014X/v2_202304072117/en/main.assets" "Apartado" => array:4 [ "identificador" => "63560" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Diagnosis at first sight" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000004100000004/v2_202304072117/S2529993X2300014X/v2_202304072117/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X2300014X?idApp=UINPBA00004N" ]
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