Chest wall tuberculosis (TB) is rarely reported in immunocompetent individuals and is usually a part of disseminated disease. A tuberculous abscess may mimic pyogenic abscess and unless strongly suspected, tuberculous etiology may be missed due to paucibacillary nature of extrapulmonary lesions. Molecular diagnostic tests can prove useful by providing a rapid and accurate diagnosis in such cases. We present here a case of chest wall tuberculous abscess without any evidence of immunosuppression or previous history of TB

Chander, Jagdish

Gupta, Menal

Singhal, Lipika

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 1 | Jan - Feb 2018 Indian J Case Reports 53
Case Report
Primary tuberculous abscess of chest wall in a young immunocompetent female
Menal Gupta, Lipika Singhal, Jagdish Chander
From Department of Microbiology, Government Medical College and Hospital, Chandigarh, Punjab, India
Correspondence to: Dr. Lipika Singhal, Department of Microbiology, Government Medical College and Hospital, Chandigarh, Punjab, 
India. Phone: +91-9988933566. E-mail: singhal.lipika@googlemail.com
Received - 15 December 2017 Initial Review - 06 January 2018 Published Online - 01 March 2018
India accounts for one-fourth of the global tuberculosis (TB) burden. It features among the high-burden country lists for TB, TB/HIV, and multidrug-resistant TB defined by the 
World Health Organization (WHO). As per the WHO Global 
Report on TB 2016, 16% of all freshly diagnosed cases in India 
are extrapulmonary [1]. Extrapulmonary TB (EPTB) is rarely 
smear-positive; it is generally accepted that the contagious 
potential of this form is negligible, and therefore, it has never 
been a priority in the campaigns undertaken by national TB 
control programs. The new Revised National TB Control 
Program (RNTCP) strategy to offer cartridge-based nucleic acid 
amplification technique (CBNAAT) upfront for the diagnosis of 
EPTB will improve the program’s capacity to diagnose EPTB 
patients [2]. Tuberculous abscess of the chest wall is usually 
a part of disseminated TB. Most cases present with soft tissue 
swelling (cold abscess) or discharging sinus over anterior chest 
wall [3]. Here, we report a case of primary tubercular chest 
wall abscess in an immunocompetent individual with no history 
of contact or previous antitubercular therapy, confirmed by 
CBNAAT.
CASE REPORT
A 25-year-old female presented with a lump on the anterior 
chest wall in the left paramedian region. It was preceded by 
pain and had gradually increased in size over a period of about 
4 weeks. There was no history of trauma or similar lesion in the 
past. There were no respiratory complaints, fever, and loss of 
appetite or weight. There was no history of TB or contact with 
a case of TB in the family. She had no chronic illness other than 
hypothyroidism for which she was being treated with thyroxine 
(50 mcg).
On examination, the patient was average built, afebrile. No 
abnormality was detected on systemic examination. A painless 
swelling was present in the left paramedian region, medial to the 
left breast. It was about 2–3 cm in size, soft, mobile, and tender. 
There was no redness, localized rise of temperature, or venous 
prominence over the swelling. There was no regional lymph node 
involvement. The differential diagnosis included cold abscess, 
pyogenic abscess, and costochondritis.
Laboratory investigations revealed: Hemoglobin 10.3 g/dl; 
total leukocyte count 8200/cu.mm with a differential count of 
67% neutrophils, 29% lymphocytes, 3% monocytes, and 1% 
eosinophils. Other biochemical investigations, including liver 
and kidney function tests, were within normal limits. Serology 
for HIV was non-reactive. Ultrasound evaluation revealed 
a hypoechoic area in the soft tissues superficial to the left 
costochondral junction (Fig. 1). Fine-needle aspiration from the 
swelling was done and yielded pus. Cytological examination 
showed dense neutrophilic infiltrate with few lymphocytes and 
macrophages in a background of extensive caseous necrosis. 
Aerobic bacterial culture of the pus was sterile, but acid-fast 
bacilli were detected on Ziehl–Neelsen staining (Fig. 2). 
CBNAAT confirmed the presence of Mycobacterium TB 
sensitive to rifampicin, while culture on Lowenstein–Jensen 
media was lost to contamination. Chest radiograph was normal 
with no evidence of hilar lymphadenopathy (Fig. 3). No clinical, 
radiological, or microbiological evidence of pulmonary TB 
could be established.
The patient was started on Category I antitubercular treatment 
with four drugs, namely, isoniazid, rifampicin, ethambutol, and 
pyrazinamide. On follow-up after 2 months, the abscess showed 
evidence of resolution and had decreased in size.
ABSTRACT
Chest wall tuberculosis (TB) is rarely reported in immunocompetent individuals and is usually a part of disseminated disease. 
A tuberculous abscess may mimic pyogenic abscess and unless strongly suspected, tuberculous etiology may be missed due to 
paucibacillary nature of extrapulmonary lesions. Molecular diagnostic tests can prove useful by providing a rapid and accurate 
diagnosis in such cases. We present here a case of chest wall tuberculous abscess without any evidence of immunosuppression or 
previous history of TB.
Key words: Chest wall abscess, Extrapulmonary, Tuberculosis
Gupta, et al. Tuberculous chest wall abscess 
Vol 4 | Issue 1 | Jan - Feb 2018 Indian J Case Reports 54
DISCUSSION
EPTB accounts for 10–20% of TB in immunocompetent 
patients and more than 40% of HIV-positive individuals. [4] 
Chest wall TB is rare form of EPTB and accounts for 1–5% of 
all musculoskeletal TB, which itself represents 1–2% of the total 
cases of TB. Sternum is the most common site to be involved 
though rib shaft and costochondral junction, and vertebral 
bodies can also be involved [5]. There are several reports of 
tuberculous subcutaneous abscesses of the thoracic wall [5-8]. 
Three mechanisms are described in the pathogenesis of chest wall 
abscess: Direct extension from pleural or pulmonary parenchymal 
disease, hematogenous dissemination of a dormant tuberculous 
focus, or direct extension from lymphadenitis of the chest wall [3].
In a study of tubercular chest wall abscesses by Keum et al., 
45.6% of cases had a past or current history of TB [7]. There are 
only few reports of tubercular abscesses without a history of TB 
[5,8]. Similarly, no primary focus of TB could be found in our 
patient.
Cold abscesses of the chest wall are generally solitary, but 
multiple lesions are possible. In a case series of 68 patients with 
chest wall cold abscesses, 64 were solitary [7]. Our patient also had 
solitary abscess. Cases have been reported of chest wall abscess 
with progression to a discharging sinus and ulcer formation [7,9]. 
Sometimes, abscesses make a fistulous tract to the pleural cavity 
and destroy underlying bone or cartilage [7,8]. In most cases, 
tubercular cold abscess has an insidious course with non-specific 
symptoms, and therefore, patients may remain undiagnosed for a 
long time and may present with complications. Swelling was the 
only presenting complaint in our case.
Biopsy and culture of mycobacteria are considered as the 
gold standard, though fine-needle aspiration cytology (FNAC) is 
the most commonly used technique for establishing a diagnosis 
[9]. In our case also, the pus sample after FNAC was used to 
achieve the microbiological diagnosis by Ziehl–Neelsen staining 
and CBNAAT. Culture, though highly sensitive and specific for 
TB diagnosis, requires 6–8 weeks to yield results, and hence, not 
useful for early diagnosis. In tropical countries like India, the 
rate of culture contamination is high, making novel diagnostic 
techniques such as CBNAAT all the more useful. Nucleic acid 
amplification technique provides rapid (2 h) and accurate 
diagnosis of TB by detecting M. tuberculosis and rifampicin 
resistance (rif gene). Under RNTCP, it was earlier used in cases 
of pulmonary TB only, but now it is used upfront in EPTB as 
well. In our patient, M. tuberculosis was confirmed by CBNAAT 
leading to early institution of therapy and prevention of possible 
complications such as ulceration, involvement of underlying 
structures as well as systemic dissemination.
Antitubercular therapy is the mainstay of management. 
Surgical intervention is secondary in the form of either 
ultrasonography or computerized tomography-guided aspiration 
or open drainage which is usually reserved for patients in whom 
medical treatment has failed [10].
CONCLUSION
Primary tubercular abscess of the chest wall in an 
immunocompetent patient without involvement of other 
structures is rare, and diagnosis requires a high index of suspicion 
Figure 1:Ultrasound showing hypoechoic area in the soft tissue 
superficial to left costochondral junction
Figure 2: Ziehl–Neelsen staining of aspirated pus showing acid-fast 
bacilli
Figure 3:  Chest X-ray showingnormal lung parenchyma and absence 
of hilar lymphadenopathy
Gupta, et al. Tuberculous chest wall abscess
Vol 4 | Issue 1 | Jan - Feb 2018 Indian J Case Reports 55
and microbiological examination to confirm M. tuberculosis. 
In a country like India, with a high burden of TB and limited 
availability of culture and molecular diagnostics, there is a 
possibility that EPTB may be missed or misdiagnosed.
REFERENCES
1. Global Tuberculosis Report; 2017. Available from: http://www.who.int/tb/
data. [Last accessed on 2017 Nov 08].
2. TB India. Revised National Tuberculosis Control Programme Annual Status 
Report; 2017. Available from: http://www.tbcindia.gov.in. [Last accessed on 
2017 Nov 06].
3. Rajput AK, Rajan KE, Gupta RK, Muttagikar MP. Tuberculosis of sternum. 
Med J Armed Forces India 2001;57:330-2.
4. Lombardi R, Pelusi S, Airaghi L, Fargion S. Extra pulmonary tuberculosis: 
An unusual Presentation in an immunocompetent patient. BMJ Case Rep 
2015. Available from: http://www.dx.doi.org/10.1136/bcr-2014-207146. 
[Last accessed on 2017 Nov 06].
5. Sharma S, Mahajan RK, Myneedu VP, Sharma BB, Duggal N. 
Primary tubercular chest wall abscess in a young immunocompetent 
male. Case Rep Pulmonol 2014. Available from: http://www.dx.doi.
org/10.1155/2014/357456. [Last accessed on 2017 Oct 27].
6. Deng B, Tan QY, Wang RW, He Y, Jiang YG, Zhou JH, et al. Surgical 
strategy for tubercular abscess in the chest wall: Experience of 120 cases. 
Eur J Cardiothorac Surg 2012;41:1349-52.
7. Keum DY, Kim JB, Park CK. Surgical treatment of a tuberculous abscess of 
the chest wall. Korean J Thorac Cardiovasc Surg 2012;45:177-82.
8. Sonhaye L, Amadou A, Gnandi-Piou F, Assih K, Tchaou M, Kolou B, et al. 
Tuberculous abscess of the chest wall simulate pyogenic abscess. Case Rep 
Radiol 2015. Available from: http://www.dx.doi.org/10.1155/2015/195412. 
[Last accessed on 2017 Oct 30].
9. Khaira A, Khaira DD, Gupta A, Bhowmik D, Kalra OP, Tiwari SC, et al. 
Tuberculosis of sternum: Three cases with different presentations. J Assoc 
Physicians India 2009;57:595-6.
10. Malhotra MK. Cold abscess of the anterior abdominal wall: An unusual 
primary presentation. Niger J Surg 2012;18:22-3.
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Gupta M, Gautam L, Chander J. Primary tuberculous 
abscess of chest wall in a young immunocompetent female. Indian J Case 
Reports. 2018;4(1):53-55.


Primary tuberculous abscess of chest wall in a young immunocompetent female

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Primary tuberculous abscess of chest wall in a young immunocompetent female

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