Abstract

Musculoskeletal tuberculosis is one of the common form of extra-pulmonary tuberculosis. It is thought to be caused by the reactivation of mycobacteria lodged into bones during mycobacteremia which occurs at the initial stages of mycobacterium tuberculosis infection. The large joints and spine are commonly affected in tuberculous osteomyelitis because of their rich vascular supply. Extension of this osteomyelitis into adjacent joint may cause tuberculous arthritis. Another mechanism of skeletal spread is believed to be caused by extension of infection from lung to spine along with the Batson paravertebral venous plexus. Usually these tubercular infections are caused by Mycobacterium tuberculosis but with the epidemic of Acquired immunodeficiency syndrome (AIDS), cases of non-tuberculous mycobacterial skeletal infections are also on the rise. Tuberculosis of ribs is one of the common causes of destructive lesions of the ribs. The usual presenting complaints are fever, pain, swelling and discharging sinus. History of tuberculosis contact or past history of pulmonary Kochs may be present. Laboratory investigation may show positive montoux test and raised ESR. Imaging is important in the diagnosis. X-Ray may show expansile, osteolytic lesion with sclerosis. Computed tomography may show rib erosion and destruction with adjacent abscess formation. Zn staining of the discharging pus may show Acid fast bacilli. We present here a case of tubercular osteomyelitis of left 5th rib in a 10 year old girl who presented with history of recurrent chest wall abscesses. At the time of presentation she was found to be having ulcers adjacent to the left nipple with discharging sinus. ESR was raised and montoux was positive. Imaging by X-ray and Computed Tomography showed features of osteomyelitis. Patient was treated with IV antibiotics and antitubercular drugs (2HRZE + 10 RHE). She responded well to above treatment and ulcer and draining sinus healed. We present this case as the tubercular osteomyelitis usually involves large joints and spine. Involvement of ribs is uncommon. This case emphasizes that differential diagnosis of tubercular osteomyelitis of ribs should be kept in mind whenever these is history of recurrent abscess formation and discharging sinus in chest wall.