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IJCRR - 6(2), January, 2014

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AN EXTREMELY RARE REPORT OF TUBERCULOUS COLD ABSCESS OF THE RIGHT ANTERIOR CHEST WALL PRESENTING AS AN EXTREMELY HARD AND IMMOBILE LUMP MIMICKING CARCINOMA BREAST

Author: Govindarajalu Ganesan, Krishnapillai Ayyappan

Category: Healthcare

Abstract:Tuberculous cold abscess usually presents as soft swelling and occurs commonly in the neck, axilla and inguinal regions due to the presence of lymph nodes in these regions. But tuberculous cold abscess of the anterior chest wall is quite rare. Also tuberculous cold abscess of the anterior chest wall presenting as an extremely hard and immobile lump is extremely rare and is so far not reported in the literature and hence is reported here. Due to the extremely hard and immobile lump, the lesion was initially thought to be due to carcinoma breast. But after detailed investigations, the lump was finally diagnosed to be due to tuberculous cold abscess. The exact reasons for the extreme hardness and immobility of the lump are discussed here in detail. The role of ultrasonography in distinguishing between solid and fluid filled lesions of the anterior chest wall and in showing clearly the exact anatomical relation of the fluid filled lesion to the breast and ribs is discussed here. The importance of doing incisional biopsy before starting antituberculous drugs and its role in excluding malignancy is discussed here. The importance of doing prompt surgical drainage and complete evacuation of the cold abscess inorder to prevent the disastrous complication of rupture of the cold abscess into the underlying pleural cavity and lungs is also discussed here.

Keywords: Tuberculous cold abscess, anterior chest wall, extremely hard and immobile lump, ultrasonography, incisional biopsy, prompt surgical drainage.

Full Text:

INTRODUCTION

Tuberculous cold abscess of the chest wall is quite rare. Tuberculous cold abscess can occur in the anterior chest wall or lateral chest wall or in the posterior chest wall (1,11). Tuberculous cold abscess of the anterior chest wall is commonly reported to occur in association with tuberculosis of the underlying ribs (6,27) or tuberculosis of the underlying lungs (5,.6,7,10,11,21,29). But in the patient reported below the cold abscess of the anterior chest wall was neither associated with tuberculosis of the underlying ribs nor associated with tuberculosis of the underlying lungs. Tuberculous cold abscess of the anterior chest wall lying parasternally is reported to occur mainly due to tuberculous caseation of the internal mammary lymph nodes (3,8,10,18,21,22). Hence the most probable cause of the cold abscess which was lying parasternally in this patient was tuberculous caseation of the internal mammary lymph nodes. Tuberculous cold abscess of the anterior chest wall occurring without tuberculosis of the underlying ribs or lungs is very rare and is hence reported here.

Case report:

A 55 year old female patient presented with history of painless lump of the right breast, gradually increasing in size for two months. There was no history of fever, loss of appetite or loss of weight. She was non diabetic, human immunodeficiency virus (HIV) negative immunocompetent patient. Local examination revealed an extremely hard, immobile, nontender, smooth lump measuring about 6x3cms in the region of right upper medial quandrant of the right breast (fig 1). Due to the extremely hard and immobile lump, the lesion was initially thought to be due to carcinoma breast and the patient was immediately subjected to ultrasound examination of the right breast. But very interestingly ultrasound examination revealed normal right breast and an abundant amount of collection of dense fluid deep to the right breast (fig 2) extremely close to the ribs (fig 3 ). The collection was also seen to extend in between the ribs by ultrasound examination (fig 4) Mantoux test revealed 29x24mm induration at the end of 48hours. Hence the patient was strongly suspected to have tuberculous cold abscess. But X-ray chest was normal without erosion of the underlying ribs and also revealed normal lung fields. While doing fine needle aspiration cytology (FNAC), aspiration showed pus like material and microscopic examination revealed neutrophils, macrophages and degenerated cells in a necrotic background and the smear for acid fast bacilli was also negative. Despite very strong Mantoux test, since X-ray chest and Fine needle aspiration cytology were inconclusive of tuberculosis, it was decided to do incisional biopsy inorder to get accurate tissue diagnosis. Hence under short general anaesthesia, an incision was made deep into the lesion. About 250 ml of pus was found deep to the right breast and deep to the pectoralis major and minor muscles extremely close to the ribs. After complete evacuation of the pus, an incisional biopsy was done from the wall of the abscess. Histopathological examination revealed epitheloid cell granuloma with langhans giant cells, caseating necrosis and lymphocytes indicating tuberculosis (fig 5,6). Epitheloid cell is identified under light microscope by its lightly stained pale elongated or oval nucleus, lightly stained eosinophilic (pink) cytoplasm and indistinct cell border (fig 5). Due to the indistinct cell border, the outline of one epitheloid cell appears to merge with the outline of the adjacent epitheloid cell (fig 5) (29 to32). Langhans giant cells are huge cells with multiple nuclei arranged as horseshoe pattern in the periphery of the cell (fig 5) (29to32). Caseating necrosis is identified by acellular pink areas of necrosis under light microscope (fig 6) (29). Lymphocytes are cells almost completely filled with haemotoxylin stained blue coloured nucleus. Hence a final diagnosis of tuberculous cold abscess of the right anterior chest wall was made for the patient. The patient was immediately started on 6 months daily course of antituberculous drugs with daily dose of Isoniazid 300mg, Rifmpicin 450mg, Ethambutol 800mg and Pyrazinamide 1500mg for an intial period of two months followed by daily dose of Isoniazid 300mg and Rifmpicin 450mg for the next four months. After completion of three months of antituberculous treatment, the operative wound has healed completely, the patient has become completely asymptomatic and has recovered completely

DISCUSSION

Tuberculous cold abscess of the anterior chest wall usually presents as soft and mobile swelling (1,2,3,9,13,14,16,18,20,32) . But tuberculous cold abscess of the anterior chest wall presenting as an extremely hard and immobile swelling, as in this patient, is extremely rare. The cold abscess of this patient was lying between the strong pectoral muscles in front and the bony ribs behind and was extremely hard and immobile. The exact reasons for the extreme hardness and immobility of this cold abscess are discussed here in detail. Tuberculous cold abscess is a type of false cyst. A cyst is a swelling having fluid inside it. A cyst is of two types- true cyst and false cyst. A true cyst has fluid inside it and is lined by epithelium. A false cyst has fluid inside it but is not lined by epithelium. An abscess is a false cyst as it has pus inside it but is not lined by epithelium. Both pyogenic abscess and tuberculous cold abscess are examples of false cyst. Tuberculous cold abscess is a false cyst as it has caseating material or tuberculous pus inside it but is not lined by epithelium. A false cyst like tuberculous cold abscess has all the clinical features of a true cyst except for the fact that it is not lined by epithelium. A cyst is soft, firm or hard depending upon the tension of the fluid present inside the cyst. A cyst will be hard in consistency if the fluid inside the cyst is under tremendous tension. Being a false cyst, tuberculous cold abscess will also be hard in consistency if the tuberculous pus inside the cold abscess is under tremendous tension. The cold abscess of this patient was filled with abundant amount of tightly packed collection of dense caseating material or tuberculous pus. As the disease progresses, the extent of caseation increases and the tuberculous pus also increases in amount. But this increasing amount of tuberculous pus of this patient could not expand freely both anteriorely and posteriorely due to the highly unyielding extremely strong pectoralis major muscle present anteriorely and the strong bony ribs present posteriorely producing tremendous tension of the tuberculous pus inside the cold abscess. Since the tuberculous pus inside the cold abscess of this patient was under tremendous tension due to the highly unyielding strong pectoralis major muscle present anteriorely and the strong bony ribs present posteriorely, the cold abscess was extremely hard in consistency. Any deep swelling arising from bone or attached to bone is immobile. The cold abscess of this patient was lying extremely close to the ribs and was also seen to extend in between the ribs both by ultrasound examination and during the operation and hence it was immobile. Ultrasonography, with its advantages of being radiation-free, is an extremely useful diagnostic tool for evaluation of chest wall lesions (16) Ultrasonography is a cost-effective and an extremely useful modality to demonstrate rib destruction in a chest wall cold abscess. Ultrasonography shows abscesses as hypoechoic areas and bone fragments due to rib destruction appears as echogenic foci within these hypoechoic collections (15). But in this patient ultrasonography did not show any evidence of rib destruction. Thus ultrasonography shows chest wall cold abscess as hypoechoeic collection (28, 29). Hence ultrasonography in this patient also has shown an hypoechoeic collection deep to the right breast adjacent to the ribs (fig 2,3). Thus ultrasonography is extremely useful to distinguish between solid and fluid filled lesions of the anterior chest wall, shows the exact anatomical relation of the fluid filled lesion and its relation to the breast and ribs (fig 2,3) and can also show clearly the extension of the fluid filled lesion in between the ribs (fig 4). Incisional biopsy is generally avoided in tuberculous cold abscess of cervical, axillary and inguinal lymph nodes due to the fear of occurrence of non-healing sinus or ulcer (33). But in most cases of cold abscess of the anterior chest wall, fine needle aspiration cytology is inconclusive of tuberculosis (2,7,8,9,11,19,24,34). Hence incisional biopsy from the wall of the cold abscess is absolutely mandatory inorder to get accurate tissue diagnosis and to rule out any underlying malignancy(1,2,8,9,18, 20,23,24,29,32). Incisional biopsy is also absolutely necessary since rare organisms other than Mycobacterium tuberculosis like Burkholderia pseudomallei causing melioidosis and even Staphylococcus aureus were reported to cause cold abscess of the anterior chest wall (33,35) Biopsy and histopathological examination facilitates prompt diagnosis of chest wall cold abscess (20). Histologic proof by biopsy facilitates prompt treatment of chest wall cold abscess (20). Such prompt diagnosis and treatment is extremely important to prevent serious bone and joint destruction underlying the chest wall cold abscess (1,18). In this patient, within one week of her clinical presentation, X-ray chest, Mantoux test, ultrasonography and fine needle aspiration cytology was done immediately followed by incisional biopsy from the wall of the abscess after complete surgical evacuation of the abscess. Within few days after doing incisional biopsy, histopathological examination revealed tuberculous granuloma and the patient was immediately started on antituberculous drugs. Hence within two weeks of her clinical presentation, complete surgical drainage of the cold abscess was done, histological diagnosis of tuberculosis was made and antituberculous drugs was started for the patient. Because of such prompt diagnosis and treatment, serious complications like destruction of the adjacent ribs and rupture of the cold abscess into the underlying pleural cavity and lungs was avoided in this patient. Hence prompt histological diagnosis and prompt surgical and medical treatment of the cold abscess of the anterior chest wall is extremely important to avoid the above mentioned serious complications. Tuberculous cold abscess of cervical, axillary and inguinal lymph nodes are generally managed by antigravity or non-dependent wide bore needle aspration along with antituberculous drug treatment (33). But wide bore needle aspration is not adequate for the deep seated cold abscess of the anterior chest wall as it has high risk of incomplete evacuation of the cold abscess. But complete evacuation of the cold abscess of the anterior chest wall is extremely important as the cold abscess can easily rupture into the underlying pleural cavity or lungs with disastrous consequences if not completely evacuated. However complete evacuation of this cold abscess is possible only through open surgical drainage and not by wide bore needle aspration. Cold abscess of the anterior chest wall cannot rupture anteriorely due to the highly unyielding extremely strong pectoralis major muscle present anteriorely. Hence the only way for the cold abscess to rupture is through the space between the ribs into the underlying pleural cavity or lungs with disastrous consequences (24,27). Hence prompt open surgical drainage and complete evacuation of the cold abscess without any undue delay is extremely important inorder to avoid the disastrous consequences of rupture of the cold abscess into the underlying pleural cavity and lungs. The cold abscess of the anterior chest wall of this patient was not associated with tuberculosis of the underlying ribs or lungs. The cold abscess was located deep to the right upper medial quadrant of the right breast just by the side of sternum which is the exact location of the internal mammary lymph nodes. Tuberculous cold abscess of the anterior chest wall lying parasternally is reported to occur due to tuberculous caseation of the internal mammary lymph nodes (3,8,10,18,21,22). Since the underlying ribs and lungs were normal and due to its parasternal location the most probable cause of the cold abscess of this patient was tuberculous caseation of the internal mammary lymph nodes.

CONCLUSION

Six extremely important features of tuberculous cold abscess of the anterior chest wall of this patient are highlighted in this article 1. The cold abscess was extremely hard due to the tremendous tension of tuberculous pus inside the cold abscess due to the highly unyielding strong pectoral muscles in front of it and the bony ribs behind it. 2. The cold abscess was immobile since it was lying extremely close to the ribs and was also extending in between the ribs. 3. Ultrasonography is extremely useful to distinguish between solid and fluid filled lesions of the anterior chest wall and shows clearly the exact anatomical relation of the fluid filled lesion to the breast and ribs. 4. Incisional biopsy from the wall of the cold abscess is absolutely mandatory inorder to get accurate tissue diagnosis and to rule out any underlying malignancy. 5. Prompt open surgical drainage and complete evacuation of the cold abscess without any undue delay is extremely important inorder to avoid the disastrous consequences of rupture of the cold abscess into the underlying pleural cavity and lungs. 6. Since the underlying ribs and lungs were normal and due to its parasternal location the most probable cause of the cold abscess of this patient was tuberculous caseation of the internal mammary lymph nodes

ACKNOWLEDGEMENT

Both the authors gratefully acknowledge with utmost respect Professor Dr. N. Anantha Krishnan, the greatest guru for both of us, whose constant guidance, encouragement and advice has helped us to publish this manuscript. Both the authors also acknowledge with extreme thankfulness Professor Dr.Thirupurasundari, Head of the dept of gynaecology, Aarupadai Veedu Medical College And Hospital, Puducherry for doing thorough gynaecological examination of the patient and ruling out gynaecological pathology in the patient.

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A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07

A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness

A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06

A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia

A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05

A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04

A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03

A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02

A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01

A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24

A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23

A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22

A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21

A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20

A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19

A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18

A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16

A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15

A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020

A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"

A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13

A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for Vol 12 issue 12

A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for Vol 12 issue 11

A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for Vol 12 issue 10

A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for Vol 12 issue 09

A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for Vol 12 issue 08

A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for Vol 12 issue 07

A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20

A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR

A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13

A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR

A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR.

A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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