Ann Thorac Surg 2006;81:1220-1226
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Current Surgical Therapy for Patients with Tuberculous Abscess of the Chest Wall
Kyu Do Cho, MD
a
,
*
,
Deog Gon Cho, MD
a
,
Min Seop Jo, MD
a
,
Myeong Im Ahn, MD
b
,
Chan Beom Park, MD
c
a Departments of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
b Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
c Departments of Thoracic & Cardiovascular Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Accepted for publication October 31, 2005.
* Address correspondence to Dr Cho, Department of Thoracic & Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6, Ji-dong Paldal-gu, Suwon, Gyeonggi-do, 442-723 Korea (Email: kyudias{at}cvnet.co.kr).
 |
Abstract
|
|---|
BACKGROUND: Although anti-tuberculosis medication is essential for the treatment of tuberculous abscess of the chest wall, surgical treatment also plays an important role. We report our surgical experience for patients with tuberculous abscess of the chest wall.
METHODS: The series was comprised of 16 patients with tuberculous abscess of the chest wall, and they were treated from May 1996 to June 2003 at St. Vincent's Hospital, Suwon, Korea. The data were retrospectively reviewed.
RESULTS: Tuberculous abscesses were managed by combined anti-tuberculosis medication and surgery of either abscess excision with rib resection (11 abscesses) or abscess excision alone (7 abscesses). The overall rate of rib involvement for abscess was 44.4 % (8 abscesses in 7 patients), and the rate of rib involvement was not much different according to the extent of the chest wall involvement. The incidence of performing a second surgical procedure was higher in the following groups: (1) the group with pathologic evidence of bone involvement (3 of 7 patients vs 1 of 9 patients), (2) the group that was not given preoperative anti-tuberculosis medication (4 of 7 patients vs none of 9 patients).
CONCLUSIONS: In managing tuberculous abscess of the chest wall, extensive abscess excision with rib resection is considered to be important. Preoperative anti-tuberculosis medication may play an important role in reducing the postoperative complication, including abscess recurrence.
|
Introduction
|
|---|
Although the incidence of tuberculosis has shown a decline with the advent of effective anti-tuberculosis drugs, it is still high in some areas of the world. Whereas the lungs are the main target in primary infection, extrapulmonary tuberculosis has been reported to constitute 15% to 20% of all the tuberculosis cases [1]. Bone and joint involvements are rare findings, and they account for only 2% of all cases [1]. In Korea, the new tuberculosis case notification rate (incidence) was 65.4 per 100,000 people in 2004 and the rate of extrapulmonary tuberculosis was 11.3% [2]. Tuberculous abscess of the chest wall (TACW) has many names according to the prominent clinical feature or pathologic finding; tuberculous sinuses of the chest wall [3, 4], rib tuberculosis [5–7], tuberculous osteomyelitis of the ribs and sternum [8, 9], rib caries [10], cold abscess [11, 12], tuberculous subcutaneous abscess [13], and more simply, chest wall tuberculosis [14, 15]. Yet all these terms mean the same disease entity (ie, tuberculous abscess of the chest wall with or without rib involvement). The purpose of this study is to report our experience with 16 patients for whom their TACW was surgically managed in combination with anti-tuberculosis medication, and discuss the clinical characteristics and outcomes.
|
Patients and Methods
|
|---|
Patients
We undertook a retrospective review of 16 patients with TACW who were surgically managed at St. Vincent's Hospital from May 1996 to June 2003. The patients who presented with chest wall abscess from tumor, pyogenic abscess, fungal abscess, and empyema necessitatis were excluded. For the management of chronic unhealing fistula of the chest wall, 2 patients were referred to our hospital after their first operations, and they were included in this study. Informed consents were obtained from all the patients.
Radiologic Features
In 14 patients, preoperative chest computed tomographic (CT) scanning was performed prior to the first operation at our hospital. The 2 referred patients also underwent chest CT scanning prior to their second operation at our hospital. The preoperative roentgenogram and chest CT findings were examined to identify active tuberculosis, bone involvement, and the extent of the chest wall involvement. The extent of the chest wall involvement was categorized as followings: (1) lesion confined to the chest wall (ie, chest wall epi-parietal pleural lesion [CWEP] [Fig 1]), (2) lesion confined to the inner chest wall beneath the ribs and also protruding into the pleural space (ie, peri-parietal and pleural space lesion [PPPS] [Fig 2]), (3) lesion involving most of the chest wall and also protruding into the pleural space (ie, chest wall and pleural space lesion [CWPS] [Figs 3, 4]).
View larger version (108K):
[in this window]
[in a new window]
|
Fig 1. A chest computed tomographic scan section through the lower thorax shows a peripherally enhancing necrotic lesion at the right lateral chest wall. This lesion was defined as the chest wall epi-parietal lesion, which is a lesion confined to the chest wall and the epi-parietal pleural.
|
|
View larger version (95K):
[in this window]
[in a new window]
|
Fig 2. A chest computed tomographic scan section through the upper thorax shows a peripherally enhancing necrotic lesion at the right anterior chest wall. This lesion was defined as peri-parietal pleural lesion, which is a lesion confined to the inner chest wall beneath the ribs, and also protrudes into the pleural space.
|
|
View larger version (83K):
[in this window]
[in a new window]
|
Fig 3. A chest computed tomographic scan section through the mid-thorax shows a peripherally enhancing necrotic lesion at the right lateral chest wall. This lesion was defined as a chest wall epi-parietal lesion, which is a lesion involving the chest wall, and also protrudes into the pleural space.
|
|
View larger version (118K):
[in this window]
[in a new window]
|
Fig 4. A chest computed tomographic scan section through the lower thorax shows the chest wall epi-parietal lesion involving the chest wall, and it also protrudes into the pleural space at the right posterior chest wall. Rib destruction is also noted.
|
|
Pathologic Diagnosis
The pathologic diagnosis was established if one or any combination of the following conditions was present: caseous granulomatous necrosis with Langhan's giant cells on the surgical specimens, identification of tuberculosis bacilli by Erlich–Ziehl–Neelsen staining, or growth of bacilli on Lowenstein–Jensen culture media.
Postoperative Management and Follow-Up
After their first operations, most patients were managed with anti-tuberculosis medication for 6 to 12 postoperative months. After completion of the anti-tuberculosis medication, they were regularly followed-up at the outpatient clinic every 3 months for 6 months, and every 6 months thereafter for a total of 2 years. The end-point of the follow-up was June 30, 2005. The routine follow-up included a physical examination and chest roentgenogram, and chest CT scanning was added if needed. The mean follow-up period was 55.8 months.
|
Results
|
|---|
Past History and Present Illness
All the patients were immunologically healthy. Eleven patients were recently diagnosed to have tuberculosis or they were found to have concomitant active lung lesion. Three of them also had a remote past history of tuberculosis. One patient had only a remote past history of tuberculosis. None of the patients had active pleural effusion when TACW developed. Only 4 patients were free from a history of tuberculosis or from the radiologic findings of active tuberculosis (Table 1).
Abscess Location and Tuberculous Lesion
Eighteen abscesses developed in 16 patients. In all the patients whose radiologic finding of active pulmonary tuberculosis or sites of recent pleurisy were confined to one side of the chest, TACW developed in the thoracic cage of the corresponding side. Among the 4 patients who had active pulmonary lesions in both lungs, TACW developed in the left thoracic cage in 2 patients, in the right thoracic cage in 1 patient, and in both sides in 1 patient. Among the remaining 7 patients with neither active pulmonary lesion nor recent anteceding pleurisy, 3 patients had TACW in the left thoracic cage and 4 patients had TACWs in the right-sided thoracic cage (Table 1).
Preoperative Diagnosis
Needle aspiration of the abscess was performed preoperatively in 7 patients. Although the criteria was not strictly applied to every patient, the indications for preoperative aspiration study were as followings: (1) absence of both a recent history of tuberculosis and any concomitant active pulmonary lesion, (2) a poorly demarcated mass, and (3) preoperative study for the planned nephrectomy. The diagnosis of tuberculosis was confirmed in only 2 patients by positive AFB staining of the abscess fluid. The cause was presumed to be tuberculosis in the remaining 7 patients according to the concomitant pulmonary tuberculosis or the recent past history of tuberculosis. For the two referred patients (patient 7 and 15), no preoperative aspiration or biopsy was performed before their first operation (Table 2).
Radiologic Findings of Bone Involvement and Extent of Chest Wall Involvement
There was mostly a solitary lesion in 14 patients; 3 patients had a CWEP lesion, and 11 had a CWPS lesion. Each of 2 patients had two abscesses (CWEP and CWPS lesions in 1 patient; PPPS and CWEP lesions in another patient). Preoperatively, bone involvement was evident on the chest CT scanning in a total of 4 patients. In one of them, rib involvement was noted on the chest CT scanning taken before her second operation. The sternum and the clavicle were also noted to be involved in 1 patient (Table 3).
Preoperative Anti-Tuberculosis Medication
Six patients were on anti-tuberculosis regimens when their TACW developed and their medications were continued until the operation (mean medication period, 16.3 weeks). Three patients were given preoperative anti-tuberculous medication for 2 to 3 weeks according to presumptive diagnosis of a tuberculosis lesion. Thus in total, 9 patients were taking anti-tuberculosis medication when they were operated on (Table 2).
Surgery and Pathologic Diagnosis
No patient was treated with anti-tuberculosis medication alone. The surgical indications were as follows: (1) findings of bone involvement on the preoperative CT scanning, (2) abscess developed during the administration of anti-tuberculosis medication or soon after completion of the anti-tuberculosis medication, (3) to diagnosis patients who had negative results on their preoperative studies, (4) a rapidly growing mass and pain in spite of anti-tuberculosis medication, and (5) treatment failure after the first operation. The surgical procedures performed were excision of the abscess, the abnormal looking surrounding tissues, and the tract of the fistula. The bone, mostly rib, was segmentally resected when the bone was suspected to be involved by noting any destruction or periosteal granulation tissue. The rib was also resected when it overlaid the fistulous tract or if it was largely exposed to the abscess even when it did not look involved. A small-sized catheter was then placed for a few days. Fourteen ribs were segmentally resected during the initial operations for 11 abscesses in 10 patients. In one of them, partial resection of the sternum and the clavicle was also performed in addition to the segmental rib resection. The pathologic findings confirmed the cause of tuberculosis in all the patients, and there was bone involvement in 5 patients. The pathologic finding of the ribs that were resected at the second operation was positive for tuberculosis in 2 patients and negative in the other 2 patients (Table 3).
Follow-Up and Complication
The 2 referred patients presented to us with unhealed fistulas of their chest walls. The time interval from the operation to the presentation was 2 months for both of them. Chest CT scanning revealed the abscess focuses deep in the chest wall in these 2 patients. In another 2 patients of ours, the abscess recurred during the course of the postoperative anti-tuberculosis medication. The time interval from the operation to the recurrence was 3 months and 4 months for each patient, respectively. All of these 4 patients were successfully managed by repeated abscess excision with rib resection.
|
Comment
|
|---|
Tuberculous lesions located in the chest wall are not frequent findings, and these account for less than 10% of the skeletal tuberculosis [16, 17]. Tuberculous cold abscesses of the chest wall are generally solitary, but multiple lesions are possible [11]. Fourteen of our 16 patients (87.5%) had a single location. Many patients are reported to have a past history of tuberculosis or they have concomitant tuberculosis; this was seen in 83% of the patients in Faure and associates' [11] study, and in 69.2% of the patients in Sakuraba and associates' [18] study. In our series, 12 patients (75 %) had a past history of tuberculosis or concomitant tuberculosis. Active pulmonary tuberculosis was present in 8 of 16 patients (50%). This association was variable in the other previous series, and it ranged from 17.4% to 62.5% [5, 19, 20]. Many authors first performed needle aspiration or biopsy of the lesion to establish the diagnosis of tuberculosis, and second to exclude other diagnoses [10, 13, 21, 22]. But needle aspiration alone is often not so reliable, and surgical biopsy is often needed to establish the definite diagnosis [11, 21]. In our cases, needle aspiration was performed in 7 patients with positive results in 2 patients, and the cause of the abscess was presumed to be tuberculosis in many patients according to their past history or present illness.
A tuberculous chest wall abscess occurs by one of three mechanisms of spread: (1) direct extension from the underlying pleural or pulmonary parenchymal disease [21], (2) hematogenous dissemination that is associated with the activation of a dormant tuberculous focus [23, 24], and (3) direct extension from lymphadenitis of the chest wall [18, 25–27]. According to the previous authors, the steps in the evolution of a TACW 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, and these become caseous. The necrotic and caseous material burrows externally to form a TACW. In our study, TCACW occurred at the corresponding hemithorax in 5 patients when the antecedent or present tuberculous lesions were confined to one hemithorax (100%). We believe this finding favors the suggested mechanisms of direct extension from the underlying pleural and parenchymal disease or from lymphadenitis of the chest wall. The mechanism of hematogenous dissemination was believed to be responsible for the development of TACW in at least 1 patient (patient 2) of this series.
Anti-tuberculosis medication alone has been regarded an optimal treatment for TACW by some authors [13, 21, 28, 29]. However, Chen and associates' [13] series was mostly comprised of patients with subcutaneous abscess, and only 3 of their 7 patients had chest wall abscess. The mechanism of abscess occurrence in most of those patients could be different from the mechanism of a typical TACW. Furthermore, the total number of patients treated by the preceding authors was rather small [21, 29], and the follow-up period was sometimes too short (2 months for Blunt and Harries [29]). In Hsu and associates' [21] series, only 1 patient was successfully treated by medication alone, and more than 2 operations were performed in half of the remaining 6 patients. Faure and associates [11] have reported that only 1 of their 18 patients could be successfully managed by instituting only anti-tuberculosis regimens. Hence, medical treatment alone is not suitable and many authors recommend a combination of medical and surgical management [11, 14, 18, 22]. As for the surgical method, when the abscess is left open, the wound healing could be markedly prolonged as this favors chronic sinus formation. The wound should be primarily closed and obliterating the dead space is essential [3, 11]. Sakuraba and associates [18] reported that the duration required for the wounds to close and be covered with skin ranged from 13 to 241 days (mean, 79.9 days) in 9 patients among their 13 patients. Segmental rib resection generally has been considered an essential procedure to reduce the surgical complication, including recurrence, by eradicating all the infected tissue and unroofing the dead space that resulted from abscess excision [11, 25, 30]. Regarding the extent of rib resection, however, Gale and Kergin [26] stated that in the era of antimicrobial therapy, if the healthy bone or cartilage exposed in the wound can be covered with muscle or with a sheath of perichondrium and the wound can be closed, then such a radical procedure as was done in the past is not necessary. Kuzucu and associates [14] reported that 5 patients were managed by abscess excision alone, whereas only 1 patient was managed by abscess excision with rib resection, and all their patients did not need a second operation. But in a large series of 89 patients with cold abscess of chest wall, the recurrence rate was different between the group that underwent abscess excision only and the group that underwent abscess excision with rib resection, 16% vs 1.6%, respectively [12]. Faure and associates [11] reported that 1 of 2 patients who underwent abscess excision only needed a second operation due to abscess recurrence at the same location; one of 16 patients who were managed by abscess excision with rib resection experienced a recurrence, and this patient refused to take postoperative anti-tuberculosis medication. We could find only one report that commented on any preoperative anti-tuberculous medication [12]. Although the authors recommended preoperative anti-tuberculosis medication, there was no difference in the complication rate between the 39 patients who were given preoperative medication and the 50 patients who were not given anti-tuberculosis medication.
Recurrent abscess can be clinically manifested as either a cutaneous fistula or a fresh abscess. In all of our 4 patients who needed a second operation, chest CT scanning disclosed the finding of abscess, which was a peripherally enhancing necrotic lesion located deep in the chest wall. The rate of recurrence that needs repeated operation is generally reported to be low after combined surgical and medical treatment, which was 6.3% for Faure and associates' study [11], and 7.8% for Paik and associates' [12] study. However, when a chronic fistula is counted as a major complication that needs repeated operation, the incidence of performing a second surgical procedure could be far more frequent [18]. When excluding the 2 patients who were referred to us due to their nonhealing fistulas, abscess recurred in 2 patients among our 14 patients with a recurrence rate of 14.3%. We have noted that complications and recurrences occurred more frequently in patients with rib involvement (ie, 3 of 7 patients with rib involvement vs 1 of 9 patients without rib involvement) for a total of 16 patients. We tried to find whether the incidence of rib involvement was different according to the extent of the chest wall involvement. The incidence of rib involvement was 46.2% in the peri-parietal pleural and CWPS abscesses, and 40% in the CWEP abscesses, for a total of 18 abscesses in 16 patients. It seemed that the more superficial location of abscess did not exclude the risk of rib involvement. Two of our 14 patients needed a second operation due to recurrent abscess, and the resected rib from the second operation was not found to be involved by the tuberculosis. It is considered that rib resection was not enough for unroofing the dead space that resulted from abscess excision and approximating the healthy tissues in these 2 patients. Regarding these findings, it is considered that rather radical rib resection should be performed in most patients, if not in all, irrespective of the extent of the chest wall involvement. However, it was interesting to find that none of the 9 patients who were preoperatively treated with anti-tuberculosis medication needed a second operation, whereas 4 of the 7 patients who were not given preoperative medication needed a second operation. We suspect that the absence of preoperative anti-tuberculosis medication could have also resulted in abscess recurrence in at least 2 of our patients.
In conclusion, we believe TACW should be treated by combination of surgical and medical therapy. We regard extensive abscess excision with rib resection to be the basis of proper surgical therapy. We consider that preoperative anti-tuberculosis medication may play an important role in reducing any complication, including the possibility of abscess recurrence. However, further study with statistical analysis will be needed to confirm our findings.
|
Requirements for Recertification/Maintenance of Certification in 2006
|
|---|
Diplomates of the American Board of Thoracic Surgery who plan to participate in the Recertification/Maintenance of Certification process in 2006 must hold an active medical license and must hold clinical privileges in thoracic surgery. In addition, a valid certificate is an absolute requirement for entrance into the recertification/maintenance of certification process. if your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations.
The American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified in the American Board of Medical Specialties directories. The Diplomate's name will be published upon successful completion of the recertification/maintenance of certification process.
The CME requirements are 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to application. SESATS and SESAPS are the only self-instructional materials allowed for credit. Category II credits are not allowed. The Physicians Recognition Award for recertifying in general surgery is not allowed in fulfillment of the CME requirements. Interested individuals should refer to the Booklet of Information for a complete description of acceptable CME credits.
Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed.
Candidates for recertification/maintenance of certification will be required to complete all sections of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS individually because it will be sent to candidates after their application has been approved.
Diplomates may recertify the year their certificate expires, or if they wish to do so, they may recertify up to two years before it expires. However, the new certificate will be dated 10 years from the date of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation.
Recertification/maintenance of certification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate.
The deadline for submission of applications for the recertification/maintenance of certification process is May 10 each year. A brochure outlining the rules and requirements for recertification/maintenance of certification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, 633 N St. Clair St, Suite 2320, Chicago, IL 60611; telephone: (312) 202-5900; fax: (312) 202-5960; e-mail: mailto:info{at}abts.org. This booklet is also published on the website: www.abts.org.
|
References
|
|---|
- Iseman MD. Extrapulmonary tuberculosis in adultsIn: Iseman MD, editor. Clinician's guide to tuberculosis. Philadelphia: Lippincott; 2000. pp. 145-197.
- Annual report on the notified tuberculosis patients in Korea (based on Korean tuberculosis surveillance system. 20041–2004.12 http://tbnet.nih.go.kr..
- Gale GL, Kergin FG. Tuberculous chest wall sinuses Am Rev Tuberc 1952;66:732-743.[Medline]
- Payne WS, Cardoza F, Weed LA. Chronic draining sinuses of the chest wall Surg Clin Nor Am 1973;53:927-936.
- Lee G, Im J-G, Lim JS, Kang HS, Han MC. Tuberculosis of the ribsCT appearance. J Comput Assist Tomogr 1993;17:363-366.[Medline]
- Haijar W, Logan AM, Belcher PR. Primary sternal tuberculosis treated by resection and reconstruction Thorac Cardiovasc Surgeon 1996;44:317-318.[Medline]
- Asnis DS, Niegowska A. Tuberculosis of the rib Clin Infec Dis 1997;24:1018-1019.[Medline]
- Bishara J, Gartman-Israel D, Weinberger M, Maimon S, Tamir G, Pitlik G. Osteomyelitis of the ribs in the antibiotic era Scand J Infect Dis 2000;32:223-227.[Medline]
- McLellan DGJ, Philips KB, Corbett CE, Bronze MS. Sternal osteomyelitis caused by mycobacterium tuberculosiscase report and review of the literature. Am J Med Sci 2000;319:250-254.[Medline]
- Chang JH, Kim SK, Kim SK, Chung KY, Shin DH, Choe KO. Tuberculosis of the ribsa recurrent attack of rib caries. Yonsei Med J 1992;33:374-378.[Medline]
- Faure E, Souilamas R, Riquet M, et al. Cold abscess of the chest walla surgical entity?. Ann Thorac Surg 1998;66:1174-1178.[Abstract/Free Full Text]
- Paik HC, Chung KY, Kang JH, Maeng DH. Surgical treatment of cold abscess of the chest wall Yonsei Med J 2002;43:309-314.[Medline]
- Chen CH, Shih JF, Wang LS, Perng RP. Tuberculous subcutaneous abscessan analysis of seven cases. Tubercle Lung Dis 1996;77:184-187.[Medline]
- Kuzucu A, Soysala Ö, Gu
en H. The role of surgery in chest wall tuberculosis Interact CardioVasc Thorac Surg 2004;3:99-103.[Abstract/Free Full Text] - Ueno T, Yoshioka T, Satoh H, Yamashita YT, Ohtsuka M, Sekizawa K. Chest wall tuberculosis Respiration 2001;68:87.[Medline]
- Lafond EM. An analysis of adult skeletal tuberculosis J Bone Joint Surg 1958;40A:346-364.[Abstract/Free Full Text]
- Goldblatt M, Cremin BJ. Osteo-articular tuberculosisits presentation in coloured races. Radiol 1978;29:669-677.
- Sakuraba M, Sagara Y, Komatsu H. Surgical treatment of tuberculous abscess in the chest wall Ann Thorac Surg 2005;79:964-967.[Abstract/Free Full Text]
- Tatelman M, Drouillard EJP. Tuberculosis of the ribs Am J Roentgenol 1953;70:923-935.
- Burke HE. The pathogenesis of certain forms of extrapulmonary tuberculosisspontaneous cold abscesses of the chest wall and Pott's disease. Am Rev Tuberc 1950;62:48-67.[Medline]
- Hsu HS, Wang LS, Wu YC, Fahn HJ, Huang MH. Management of primary chest wall tuberculosis Scand J Thorac Cardiovasc Surg 1995;29:119-123.[Medline]
- Ward AS. Superficial abscess formationan usual presenting feature of tuberculosis. Br J Surg 1971;58:540-543.[Medline]
- Wiebe ER, Elwood RK. Tuberculosis of the ribsa report of three cases. Respir Med 1991;85:251-253.[Medline]
- Bishara J, Gartman-Israel D, Weinberger M, Maimon S, Tamir G, Pitlik S. Osteomyelitis of the ribs in the antibiotic era Scand J Infect Dis 2000;32:223-227.[Medline]
- Kaufmann R. Quelques conside'rations sur l'abce‘s froid thoracique J Chir 1931;37:829-841.
- Gale GL, Kergin FG. Tuberculous chest wall sinus Am Rev Tuberc 1952;66:732-743.[Medline]
- Prasoon D. Tuberculosis of the intercostal lymph nodes Acta Cytol 2003;47:51-55.[Medline]
- Newton P, Sharp J, Barnes KL. Bone and joint tuberculosis in greater Manchester Ann Rheum Dis 1982;41:1-6.[Abstract/Free Full Text]
- Blunt SB, Harries MG. Discrete pleural masses without effusion in a young manan unusual presentation of tuberculosis. Thorax 1989;44:436-437.[Abstract/Free Full Text]
- Brown RB, Trenton J. Chronic abscesses and sinuses of the chest wallthe treatment of costal chondritis and sternal osteomyelitis. Ann Surg 1952;135:44-51.[Medline]
Top
Abstract
Introduction
