Ann Thorac Surg 2005;79:964-967
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Surgical Treatment of Tuberculous Abscess in the Chest Wall
Motoki Sakuraba, MD*,
Yuzo Sagara, MD,
Hikotaro Komatsu, MD
Department of Thoracic Surgery, National Hospital Organization Tokyo Hospital, Tokyo, Japan
Accepted for publication September 2, 2004.
* Address reprint requests to Dr Sakuraba, Tokyo Women's Medical University, School of Medicine, Department of Surgery I, Kawadacho 8–1 Shinjuku-ku, Tokyo, Japan, 162–8666 (E-mail: bt3m-skrb{at}asahi-net.or.jp).
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Abstract
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BACKGROUND: We reviewed surgical cases of tuberculous abscess in the chest wall and analyzed the indications and methods of surgery, results, perioperative complications, and postoperative treatment.
METHODS: We retrospectively reviewed the records of 13 patients who underwent surgical treatment of tuberculous abscess in the chest wall between January 1994 and December 2003 at National Hospital Organization Tokyo Hospital.
RESULTS: There was a past history of tuberculosis in 3 patients, concomitant active pulmonary tuberculosis in 5, concomitant active tuberculosis in the neck lymph node in 1, and no antecedent tuberculosis in 4. The locations of the tuberculous abscesses were right chest wall in 8 patients, left chest wall in 3, and anterior chest wall in 2. All of the patients underwent surgical treatment. In all patients, postoperative antituberculous treatments were administered. The combination regimens consisted of isoniazid (400 mg/d), rifampicin (450 mg/d), ethambutol (750 mg/d), pyrazinamide (1,500 mg/d), or some combination of these, and the duration ranged more than 6 months. Postoperative complications were not seen, and there was no recurrence.
CONCLUSIONS: We recommend a complete resection of the abscess with rib resection, and postoperative treatment by tuberculous chemotherapy regimen. We consider that these treatments reduce postoperative recurrence.
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Introduction
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The incidence of tuberculosis has shown a declining trend with advances in chemotherapy [1]. By this trend, skeletal localization is not frequent and tuberculous abscess in the chest wall is rare [2]. However, medical treatment often fails with tuberculous abscess in the chest wall [3]. As the diagnosis of tuberculous abscess in the chest wall is obviously difficult, it is important to differentiate the diagnosis of chest wall tumors. We reviewed 13 cases treated by surgical resection of tuberculous abscess in the chest wall and analyzed the indications and methods of surgery, results, perioperative complications, and postoperative treatment.
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Material and Methods
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In the Department of Thoracic Surgery, National Hospital Organization Tokyo Hospital, we retrospectively reviewed the records of 13 patients who underwent surgical treatments of tuberculous abscess in the chest wall between January 1994 and December 2003. The diagnosis of tuberculous abscess was made by either a positive case of acid-fast bacilli, polymerase chain reaction or culture of the pus, or postoperative specimens showing giant cells and caseous necrosis. A case with pure rib caries was excluded from this study.
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Results
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There were 4 men and 9 women, with ages ranging from 26 to 86 years (mean, 57.2 years). There was a past history of tuberculosis in 3 patients. Five patients had concomitant active pulmonary tuberculosis, and 1 had concomitant active tuberculosis in the neck lymph node. Four patients had no antecedent tuberculosis (Table 1). In these 4 patients, chest computed tomography revealed a pleural thickness near the tuberculous abscess in the chest wall (Fig 1).
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Fig 1. Chest computed tomography showing a right pleural thickness near the tuberculous abscess in the chest wall.
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Needle aspiration was performed in 4 patients, surgical biopsy and drainage of the abscess was performed in 8 patients, and 1 patient had a ruptured abscess surface. Preoperative specimen by needle aspiration or surgical drainage revealed acid-fast bacilli in 10 patients. Polymerase chain reaction for Mycobacterium tuberculosis was positive in 5 patients, and culture for M tuberculosis was positive in 6 patients (Table 2).
The duration of surgical treatment from the symptom of tuberculous abscess in the chest wall ranged from 1 to 7 months (mean, 3.8 months). The locations of tuberculous abscess were right chest wall in 8 patients, left chest wall in 3 patients, and anterior chest wall in 2 patients (Table 1).
All patients underwent surgical treatment. After open drainage, many cases underwent radical surgery. In 4 patients, radical surgery was performed first. Debridement of the abscesses and costal resection were performed in 10 patients, debridement, costal resection, and partial resection of the sternum in 1 patient, and only debridement in 2 patients. The duration required for the open wounds to close and be covered with skin ranged from 13 to 241 days (mean, 79.9 days) in 9 patients (Table 3). The debrided specimen revealed acid-fast bacilli in 6 patients. Polymerase chain reaction for M tuberculosis was positive in 2 patients, and culture for M tuberculosis was positive in 2 patients. Histologic findings of the debrided specimens showed typical lesions of tuberculosis, giant cells, and caseous necrosis in 8 of the 13 patients (Table 2).
Preoperative antituberculous treatments were administered in 11 of the 13 patients. In all patients, postoperative antituberculous treatments were administered. Combination regimens consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months followed by 4 months of isoniazid, rifampicin, and ethambutol, or isoniazid, rifampicin, and ethambutol for 6 months, as in the treatment of lung tuberculosis, were used. Postoperative complications were not seen, and there was no recurrence (Table 3).
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Comment
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Cases of tuberculous abscess in the chest wall are rare. It has been reported that they constitute less than 10% of skeletal tuberculous abscesses [4–7]. It is considered an important matter that tuberculous abscesses in the chest are related to pleuritis by tuberculosis. Twenty of 49 cases with a proven state of tuberculosis had had a pleuritis in the past. Of these, 12 cases had an ipsilateral tuberculous abscess in the chest [8]. In our study, in 4 patients who had no antecedent tuberculosis, a pleural thickness was indicated in the same side as the tuberculous abscess in the chest wall. It is not considered that M tuberculosis invaded the soft tissue of the chest wall by way of the blood and formed an abscess. By the results, the pleurae were thickened, because no patients had evidence of a tuberculous lesion. It is a reasonable supposition that M tuberculosis reached from pleuritis by a localized tuberculous lesion to the soft tissue of the chest wall. Faure and colleagues [2] reported that in tuberculous abscess of the chest wall, there was a past history of tuberculosis in 15 of 18 patients (83%), and cases of concomitant active tuberculosis that had been medicated comprised 17.4% to 62.5%. In our study, there was a past history of tuberculosis in 3 of the 13 patients (23%), and 6 patients (46%) had concomitant active pulmonary tuberculosis.
There are four mechanisms in the pathogenesis of tuberculous abscess in the chest wall. First, there is a pleural thickening, and a visceral pleura adheres to a parietal pleura by the tuberculous pleural lesions. Lymphatics are developed by the inflammation and anastomose with the lymphatic network in the chest wall. Mycobacterium tuberculosis flows into the lymphatics, constructs caseous necrosis and fistula in the new lymphatics, and reaches the soft tissue of the chest wall. It then constructs caseous necrosis in the regional lymph nodes involving the surrounding soft tissue. Second, a chest wall abscess develops by means of a localized empyema from the tuberculous pleuritis and ruptures the soft tissue of the chest wall. Third, M tuberculosis in the thoracic cavity disseminates the soft tissue of the chest wall at the time of puncture in the tuberculous pleural effusion and empyema. Fourth, M tuberculosis infiltrates by means of blood the soft tissue of the chest wall by miliary tuberculosis, and constructs the abscess [8]. In our study, we supposed the first or second pathogenesis in the cases with no antecedent tuberculosis.
The diagnosis of tuberculous abscess in the chest wall is made by bacteriologic examinations for detecting acid-fast bacilli, polymerase chain reaction, or culture of aspiration specimens or postoperative specimens. Faure and associates [2] reported only a 36.3% (4 of 11 patients) success rate of diagnosis by needle aspiration. Nonaka and coworkers [9] reported that the positive rate of acid-fast bacilli was 35% and the positive rate of culture was 60%. In our study, of the 4 patients in whom needle aspiration was performed, all were positive in acid-fast bacilli, 2 were positive in polymerase chain reaction, and 1 was positive in culture. It is difficult to distinguish subcutaneous tuberculous abscess in the chest wall. In our hospital, we perform incisional biopsy for the subcutaneous mass under localized anesthesia. When it is an abscess we try to drain it at the same time. However, after drainage, it is not always cured by antituberculous treatment only; therefore, it is often necessary to perform surgical treatment. Seven of the 13 cases were positive cases of acid-fast bacilli, 3 were positive cases of polymerase chain reaction, and 5 were positive cases of culture.
The treatment of tuberculous abscess in the chest wall is controversial. A few studies have reported successfully treating patients with a current chemotherapy regimen [1, 10, 11]; however, the total number of patients treated by the preceding authors was small, and the follow-up was sometimes too short. Faure and associates [2] and other authors have reported recurrence of tuberculosis by the antituberculous treatment only. The combination of surgical and antituberculous treatments is recommended for reducing the recurrence of tuberculosis. We use indigo carmine for injection into the abscess cavity to define the lesion, and resect all of the stained tissue. When we resected the involved ribs or sternum and performed debridement of the abscess, there was no postoperative recurrence at our hospital. In the basic treatment in our hospital, a radical resection is done after antituberculous treatments at the diagnosis of tuberculous abscess in the chest wall or the suggestion of it.
The postoperative treatment has been considered to be a tuberculous chemotherapy regimen comprising isoniazid, rifampicin, and ethambutol for 6 months, and often pyrazinamide was added. Paik and colleagues [3] recommended a 6-month regimen comprising isoniazid, rifampicin, and pyrazinamide for 2 months followed by isoniazid and rifampicin for 4 months.
In conclusion, we recommend complete resection of the abscess with rib resection, and postoperative treatment by tuberculous chemotherapy regimen. We consider that these treatments reduce postoperative recurrence.
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References
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Abstract
Introduction
