After a dramatic decline during the past several decades, Cold Abscess of the Chest Wall: A Surgical Entity?

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1 Cold Abscess of the Chest Wall: A Surgical Entity? Eric Faure, MD, Redha Souilamas, MD, Marc Riquet, MD, Antoine Chehab, MD, Françoise Le Pimpec-Barthes, MD, Dominique Manac h, MD, and Bernard Debesse, MD Service de Chirurgie Thoracique, Hôpital Laennec, Paris, France Background. Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently. Methods. During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study. Results. Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli. Conclusions. Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity. (Ann Thorac Surg 1998;66:1174 8) 1998 by The Society of Thoracic Surgeons After a dramatic decline during the past several decades, tuberculosis is again a significant public health problem in western countries because of immigration, nonimmunization of elderly people, and the epidemic infection with the human immunodeficiency virus. Skeletal localizations are not frequent, accounting for only 2.6% of all cases [1]. In this group the lesions of vertebrae, hips, and knees are relatively common, but rib involvement is a rare manifestation. Because of the recent resurgence of tuberculosis, it is important to update this pathology of the chest wall. Obviously the diagnosis of rib tuberculosis with cold abscess of the chest wall (CACW) may be difficult [2], and its treatment remains controversial. Our purpose was to study the role of surgical treatment in this thoracic form of tuberculosis. Patients and Methods Accepted for publication May 13, Address reprint requests to Dr Riquet, Sve de Chirurgie Thoracique, Hôpital Laennec, 42 rue de Sèvres, Paris, France ( marc.riquet@inc.ap-hop-paris.fr). We retrospectively reviewed 18 patients with one or more cold abscesses of the ribs managed between 1980 and Patients with tuberculous empyema and subsequent chest wall invasion were excluded from this study. The diagnosis was established on identification of epithelioid giant cells and caseous necrosis or tubercle bacilli in fine-needle aspiration fluid or surgical material. We tried to define the epidemiologic characteristics, the main indications for surgery, the different methods, and the results of the surgical treatment of these CACW. Moreover we reviewed the pathogenesis of this form of extrapulmonary tuberculosis. Results There were 16 men and 2 women, with ages ranging from 20 to 76 years (mean, 45 years): 11 were younger than 50. Sixteen were immigrants. Only 1 patient had an history of intravenous drug abuse and was infected with human immunodeficiency virus. There was a past history of tuberculosis in 9 patients (7 pulmonary and 2 mediastinal tuberculosis). Six patients had concomitant active pulmonary tuberculosis (the diagnosis was made retrospectively in 2 patients on culture results of previously collected samples: gastric, sputum). There were no tuberculous antecedents in 3 patients. In 16 patients there was a single chest wall lesion; 1 patient had two abscesses and another had three ab by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)00770-X

2 Ann Thorac Surg FAURE ET AL 1998;66: COLD ABSCESS OF THE CHEST WALL 1175 Fig 1. Computed tomographic scan showing a soft-tissue lesion destroying the sternum and extending anteriorly and posteriorly. The parasternal mass with low attenuation center and rim enhancement probably corresponds to a necrosis of an internal mammary lymph node. scesses. A mass was clinically palpable in 12 patients (one mass in 11 patients and two masses in 1 patient). On the whole, there were 21 lesion locations: one of these lesions was located over a fractured sternum (Fig 1), 4 were parasternal (Fig 2) at the level of the lateral thoracic nodes, 12 in the rib shaft, and 4 in the costovertebral joint (Fig 3). Eleven patients underwent a chest computed tomographic scan, which revealed chest wall images with low-density central area and ring enhancement (see Figs 1 3). Needle aspiration or biopsy of the abscess was performed in 11 patients: the direct smear disclosed acid-fast bacilli in 3 patients and histologic analysis showed tuberculoid lesions in 1 patient. Culture results were positive Fig 2. Computed tomographic scan showing a parasternal cold abscess (arrow) clearly resulting from a necrosis of the internal mammary lymph nodes. Fig 3. Computed tomographic scan showing a costovertebral cold abscess with destruction of the rib and the transverse process. in only 2 patients. On the whole, these procedures enabled a definite diagnosis to be rapidly established in 4 patients. These 4 patients received antituberculous treatment before surgical treatment. Four other patients with associated active pulmonary tuberculosis were also given chemotherapy. Thus 8 patients underwent medical treatment (three-drug therapy in 3 patients and fourdrug therapy in 5 patients). There was no definitive diagnosis of tuberculosis at time of operation in the other 10 patients. Only 1 patient with proven tuberculotic abscess was cured by four-drug therapy. The surgical indications (n 17) were establishing a diagnosis in 12 patients (10 without diagnosis, 2 with a presumed diagnosis who received preoperative antituberculous treatment but presented also a suspicious costal lysis), and failure of regression of the mass despite an adequate treatment in 5 patients (3 with a confirmed diagnosis and 2 with a probable one). The duration of the treatment was variable at time of operation: 2 weeks in 1 patient, 3 weeks in 2 patients, 4 and 6.5 months in the 2 others. Surgical management consisted in excision of the cold abscesses and required a costal or chondral resection in 15 patients. In 2 patients, no costochondral resection was performed because there was clinically neither osteitis nor chondritis: nevertheless, one of these 2 patients experienced recurrence and was reoperated on later. The pleural cavity was accessed in 12 patients. There were pleural adhesions in 6 patients, loose in 3 patients and tight in 3 others. Neither pleural nor pulmonary tuberculous lesions adjacent to the CACW were found; therefore, no parenchymal resection was performed at that time. In 1 patient with a costovertebral abscess we had to resect a segment of a transverse process because of osteitis (Fig 3). In 15 of the 17 patients, histologic analysis of the resected tissues disclosed typical lesions of tuberculosis; in the other 2 patients, the lesions were evocative of this diagnosis. A costal or chondral lesion was found in 12 of 15 patients who underwent a costochondral resection and

3 1176 FAURE ET AL Ann Thorac Surg COLD ABSCESS OF THE CHEST WALL 1998;66: Table 1. Frequency of Chest Wall Involvement in Different Series of Bone and Joint Tuberculosis Author No. of Patients Frequency of Chest Wall Tuberculosis (%) Rathakrishnan [3] 71 0 Goldblatt [4] Newton et al. [5] Davies [6] Tatelman and Drouillard [7] Lafond [8] was associated with a granulomatous invasion of the adjacent tissues in 11 patients. Although evocative on computed tomographic scan, involvement of the underlying nodes could not be demonstrated at operation. Histology did not help in establishing lymph node involvement because there was no en bloc resection. Acidfast bacilli were identified in only 1 of 14 patients on smears, but cultures were positive in 10 of 13 patients. In the 3 patients in whom they were negative, a preoperative treatment had been given. An antituberculous treatment was administered postoperatively to 15 of 17 patients. One patient refused this treatment and had recurrence later. Another patient had tuberculous past history and underwent resection of costal cartilages five through eight. Tuberculosis was not confirmed on histologic analysis and no further treatment was administered. Nine patients were closely followed up between 2 months and 6.5 years (mean follow-up, 2 years). Two other patients were contacted but it was impossible to obtain precise information. Six patients were lost to follow-up. One patient underwent a lobectomy 1 month after the excision of the abscess because of severe hemoptysis. The long-term mortality rate was 1 of 11 (unrelated to tuberculosis). One patient who had only undergone an excision of a parasternal cold abscess without costochondral resection was reoperated on 2 years later because of a recurrence at the same location that manifested clinically as a cutaneous fistula. She had refused the postoperative medical treatment. The reoperation revealed a sinus tract extending through the body of the sternum associated with an osteochondritis of two ribs, which were resected. The only patient who was not operated on is still alive and faring well (1 year followup). Comment Tuberculous locations in the chest wall are not frequent, accounting for less than 10% of skeletal tuberculosis (Table 1). Even if thoracic vertebral locations are included, chest wall involvement remains rare: Newton and colleagues [5] have identified only one case among 74 patients who had 80 skeletal tuberculous lesions. Cold abscesses of the chest wall are generally solitary but multiple lesions are possible: 12 of the 14 patients in Burke s study [9] had a single mass. In our study 16 of 18 patients had a single location. Abscesses occur more frequently at the margins of the sternum and in the shaft of the ribs (Table 2). Our study is in agreement with these results (60% in the shaft). In western countries, patients with cold abscesses are very often immigrants. In the Ward series [14] this represented 81% and was 89% in ours. Cold abscesses of the chest wall occur more frequently in men (ratio 2.5:1 for Tatelman [7]; 3:1 for the 8 patients of Lee and coworkers [10], and 5:2 for the 7 patients of Hsu and associates [2]). In our study, there was also a clear prevalence of men (8:1). The age of the patients is variable: according to some authors [7, 10, 13], patients are more often between 15 and 35 years. For others, the mean age is higher [2, 15] and 40% of our patients were older than 50 years. In our series, 15 patients (83%) had past history of tuberculosis. Daghfous [11] found this also in 19 of 23 patients (83%). An active pulmonary tuberculosis was present in 6 of our 18 patients (33%). This association is variable in other series, ranging from 17.4% to 62.5% [7, 9, 10]. Smears and sputum cultures were negative in the 7 patients of Hsu and associates [2]. Many authors perform a needle aspiration or a biopsy of the lesion, first to establish diagnosis of tuberculosis and second to exclude other diagnoses. This procedure can show tuberculoid lesions [16 18], acid-fast bacilli in the direct smear [2, 14, 16] or more often tubercle bacilli in the culture [2, 14, 15]. Nevertheless needle aspiration Table 2. Sites of Cold Abscesses in Different Series Author Number of Sites Parasternal Site Rib Shaft Costovertebral Junction (%) Tatelman and Drouillard [7] 26 3 (12) 15 (56) 8 (32) Lee et al. [10] 13 7 (54) 5 (38) 1 (8) Daghfous [11] 23 3 (13) 16 (70) 14 (7) Burke [9] (88) 2 (12)... Monod et al. [12] (50) 9 (45) 1 (5) Brown and Trenton [13] 5 4 (80)... 1 (20) Personal series 21 4 (20) 12 (60) 4 (20)

4 Ann Thorac Surg FAURE ET AL 1998;66: COLD ABSCESS OF THE CHEST WALL 1177 and biopsy are not always reliable [2]. In our series needle aspiration was performed in 11 patients and enabled establishing the diagnosis in only 4 cases. The optimal treatment of CACW remains controversial. Others [2, 15, 16] reported good results with only antituberculous drugs during several months as was the case for 1 patient of our series. Chen and coworkers [15], having successfully treated 3 patients with a current chemotherapy regimen, even consider surgical excision unnecessary. However, the total number of patients treated by the preceding authors was small (5), and the follow-up was sometimes too short (2 months for Blunt and Harries [16]). Moreover, abscesses were not cured, and even developed despite an adequate medical treatment [2, 11, 17] as was the case for 5 patients of our series. Hence medical treatment alone is not suitable, and other authors recommend combining medical and surgical management [14]: the optimal approach consists in excising the abscess and performing a primary closure; the abscess should not be left open as that favors chronic sinus formation. According to Kaufmann [19], it is necessary to resect a part of the rib, even if it is macroscopically normal, because the origin of the abscess is deeper. Brown and Trenton [13] recommend extensive debridement of the lesion, especially if there is involvement of bone and cartilage. These conclusions regarding the surgical management are based on the pathophysiology of spread of the disease and particularly the one dealing with lymphatic extension. If we consider the pathogenesis of rib tuberculosis, the review of the literature suggests three mechanisms: Direct extension from underlying pleural or pulmonary parenchymal disease [2], which is not the subject of this study. Hematogenous dissemination associated with activation of a dormant tuberculous focus [20]. Direct extension from a lymphadenitis of the chest wall [12, 19]. Kaufmann [19] demonstrated in 1930 by histologic examination of 12 specimens removed en bloc at time of operation that most of them took origin in caseous lymph nodes of the chest wall (internal mammary, intercostal, and paravertebral nodes). Rib infection, when it was present (2 of 12), was always adjacent to lymphadenitis. According to this author, the steps in the evolution of a CACW would be as follows: tubercle bacilli invade the pleural space and set up a pleuritis. Some bacilli are transported from the pleural space to the lymph nodes of the chest wall, which become caseous. Necrotic and caseous material burrow externally to form a CACW. As Kaufmann s observations indicate, the CACW would be lymph-borne sequelae of tuberculous pleuritis. Burke [9] agreed because only 3 of 14 patients had no previous pleurisy. In 1952 Brown and Trenton [13] demonstrated at operation the involvement of the underlying nodes in 3 patients who had tuberculous abscesses of the chest wall. In our study, histologic examinations did not identify tuberculous lymph nodes adjacent to lesions of the ribs: this could be explained by the fact that the surgical specimens were not resected en bloc [19]. Nevertheless the locations of the abscesses in the same places as the parietal intrathoracic nodes (mammary, lateral intercostal, and paravertebral nodes) and the existence of large internal mammary lymph nodes on the computed tomographic scan (Figs 1 and 2) are in favor of a lymph-borne dissemination of tubercle bacilli. In conclusion, chest wall tuberculosis is a rare disease manifestating as cold abscesses. The most likely mechanism of spreading of this tuberculous location appears to be chest wall lymphadenitis. The most appropriate management scheme would be to perform first a needle aspiration or biopsy; if tuberculous infection is then confirmed or strongly suspected, a combination regimen of antituberculous chemotherapy should be considered as initial treatment. If definitive diagnosis is lacking or if the lesion fails to improve after 1 to 3 months of medication or worsens, surgical intervention is indicated. Extensive resection is the basis of therapy removing osteochrondritic lesions; additional adjuvant antituberculotic therapy is essential to avoid recurrence. References 1. Enarson DA, Ashley MJ, Grzybowski S, Ostapkowicz E, Dorken E. Non-respiratory tuberculosis in Canada: epidemiologic and bacteriologic features. Am J Epidemiol 1980; 112: Hsu HS, Wang LS, Wu YC, Fahn HJ, Huang MH. Management of primary chest wall tuberculosis. Scand J Thorac Cardiovasc Surg 1995;29: Rathakrishnan V, Mohd TH. Osteo-articular tuberculosis. Skeletal Radiol 1989;18: Goldblatt M, Cremin BJ. Osteo-articular tuberculosis: its presentation in coloured races. Radiology 1978;29: Newton P, Sharp J, Barnes KL. Bone and joint tuberculosis in greater Manchester. Ann Rheum Dis 1982;41: Davies PDO, Humphries MJ, Byfield SP, et al. Bone and joint tuberculosis: a survey of notifications in England and Wales. J Bone Joint Surg (Br) 1984;66B: Tatelman M, Drouillard EJP. Tuberculosis of the ribs. AJR Am J Roentgenol 1953;70: Lafond EM. An analysis of adult skeletal tuberculosis. J Bone Joint Surg 1958;40A: Burke HE. The pathogenesis of certain forms of extrapulmonary tuberculosis: spontaneous cold abscesses of the chest wall and Pott s disease. Am Rev Tuberc 1950;62: Lee G, Im JG, Kim JS, Kang HS, Han MC. Tuberculosis of the ribs: CT appearance. J Comput Assist Tomogr 1993;17: Daghfous J. Vingt-trois cas d abcès froids tuberculeux endothoraciques sous-costaux. Thèse Médecine, no. 47. Paris (Necker) Monod O, Kateb E, Almosni M. A propos des abcès froids tuberculeux de la paroi thoracique. Rev Tuberc Pneumol 1965;29: Brown RB, Trenton J. Chronic abscesses and sinuses of the chest wall: the treatment of costal chondritis and sternal osteomyelitis. Ann Surg 1952;135: Ward AS. Superficial abscess formation: an usual presenting feature of tuberculosis. Br J Surg 1971;58: Chen CH, Shih JF, Wang LS, Perng RP. Tuberculous subcu-

5 1178 FAURE ET AL Ann Thorac Surg COLD ABSCESS OF THE CHEST WALL 1998;66: taneous abscess: an analysis of seven cases. Tubercle Lung Dis 1996;77: Blunt SB, Harries MG. Discrete pleural masses without effusion in a young man: an unusual presentation of tuberculosis. Thorax 1989;44: Chang JH, Kim SK, Kim SK, et al. Tuberculosis of the ribs: a recurrent attack of caries. Yonsei Med J 1992;33: Frouge C, Miquel A, Cochan-Priollet B, Adrien C, Bléry M. Breast mass due to rib tuberculosis. Eur J Radiol 1995;19: Kaufmann R. Quelques considérations sur l abcès froid thoracique. J Chir 1931;37: Wiebe ER, Elwood RK. Tuberculosis of the ribs: a report of three cases. Respir Med 1991;85: INVITED COMMENTARY Faure and associates have presented considerable experience with a complication of tuberculosis that is rarely seen nowadays. Infection of the chest wall by tuberculosis occurs by hematogenous dissemination or by chest wall lymphadenitis; it rarely occurs by extension from an adjacent lung or pleura. The radiologic picture is variable. Tuberculosis may appear as cystic lesions in bony structures, which may be easily confused with neoplasms, either primary or metastatic. The lesions appear as areas of low density and may show points of increased radionuclide activity [1, 2]. Although tuberculosis of the sternum and ribs is rare, it is still the most common inflammatory disease that affects the ribs, resulting in well-demarcated areas of destruction [3]. The margins of destruction are often sclerotic, which helps in diagnosis. The psoas abscesses are a direct extension of advanced thoracolumbar osteomyelitis and are characterized by a classic radiographic presentation. In addition, radiograms may show a posterior mediastinal mass or a soft tissue mass. Reduced intervertebral disc space and calcifications within the psoas abscess are highly suggestive of tuberculosis [2]. Because of the difficulties in diagnosis, acute clinical awareness is of great importance, particularly in immunocompromised patients and in intravenous narcotic addicts who present with chest wall masses or sinuses. Computed tomography is particularly useful in the evaluation of these lesions and was well used by Faure and associates. Tuberculous lesions of the chest wall are best treated with antimicrobials and drainage, with debridements and excision reserved for the most extensive ones. Dov Weissberg, MD Tel Aviv University Sackler School of Medicine and the E. Wolfson Medical Center Holon Israel References 1. Mulloy EMT. Tuberculosis of the sternum presenting as metastatic disease. Thorax 1995;50: Cordova F, Criner GJ. A 25-year-old man with back pain and an abnormal chest radiograph. Chest 1996;109: Schaefer PS, Burton BS. Radiographic evaluation of chest wall lesions. Surg Clin N Am 1989;69: by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)