Sternum Tuberculosis Osteomyelitis in an Adolescent Patient: A Case Report and Review of Children’s Literature

Hindu writings mentioned the disease, signifying “consumption” (or destruction by virtue of body deterioration, by progression of body condition). Hippocrates (460-337 BC) popularized the word for tuberculosis phthisis in ancient Greek, which has numerous connotations including: “to consume”, “to spit”, and “to waste away” [1]. John Schoenlein (1793-1864) reported, in 1839, the term tuberculosis derived from the Latin word tubercula (the diminutive of tuber), which indicates a small lump [1]. Robert Koch (1882) a German physician, bacteriologist and researcher (1843-1910) had Mycobacterium tuberculosis isolated [1].


Introduction
Tuberculosis (TB) continues as a multi-systemic worldwide infection unchanged in countries where it is endemic. Sternum TB in children is one of the incredibly uncommon sites for flat bone to be infected. Sternum incidence involvement constitutes approximately less than 1% of all cases of Mycobacterium tuberculosis osteomyelitis [5][6][7][8][9]. Only a limited number of articles of sternum TB in children's literature have been reported [3,4,7,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. In view of this, a representative case of sternum tuberculosis osteomyelitis in an immunocompetent adolescent male patient is described. A patient aged 15-year-10-month-old, with a cutaneous sinus formation over the anterior chest wall was ascertained on. The aim of this manuscript was to present an unusual case of tuberculous osteomyetilis of the sternum body area in a young patient with a secondary type (form) and multifocal sternum TB infection categorized [23]. The compelling diagnosis by image examinations and histopatology lesions of infected tissues was confirmed. An anti-tuberculous chemotherapy treatment consisting of rifampicin (RIF), isoniazid (INH), pyrazinamide (PZA) and ethambutol (EMB) was prescribed.

Case Presentation
A 15-year -10-month-old male adolescent patient (PHFS) from a low socioeconomic level family, with foot symptoms, was admitted from another hospital. Careful clinical history revealed initial symptoms 4 months ago after trauma to his left ankle with cast immobilization plus treatment with antibiotics (oxacillin) for 32 days, without any benefit. Past medical history was collaborative, comprising a positive history of Bacillus-Calmette-Guérin (BCG) vaccination. At admission as an inpatient at our hospital, physical examination revealed tenderness on the left foot over the medial malleolus and a purulent secretion (abscess) fistulous lesion were detected. His gait needed auxiliary crutches in conformity with his difficulty of performing flexion-extension of the ankle joint, which was limited. In the thorax over the sternum flat bone an ulcer on the middle portion was evidenced. An open chronic sinus formation or cold abscess (a skin fistula overlying the bone) with drainage of purulent material was noted.
Following informed approval by the mother, a battery of investigations to confirm the diagnosis of tuberculosis was performed. Following informed consent, HIV testing method was requested. The laboratory complementary exams asked for blood count with erythrocyte sedimentation rate (ESR), anteroposterior and lateral chest radiographs as well as routine views for left ankle X-rays, ultrasonography and tomography of the chest were requested. Bone biopsies for microscopic examination of the ankle as well as of the sternum bone were required. On histopathological examination, granulomatous inflammation composing of epithelioid histiocytes, Langhans' type giant cells and typical caseous necrosis were observed. Diagnosis of TB was corroborating upon the other histopathological macroscopic findings. A standard four-drug regimen at our center, an antituberculous chemotherapy combination consisting of rifampicin (10mg/kg per day), isoniazid (10mg/kg per day), pyrazinamide (35mg/kg per day) and ethambutol (30mg/kg per day) for two months as an intensive phase patient was received. Subsequently for order seven months rifampicin (10mg/kg per day) and isoniazid (10mg/kg per day) following the national government's (World Health Organization-WHO) guidelines were used. The patient was regularly followed by visiting the outpatient department at two-month intervals until the disease healed. The tuberculous lesions of the ankle and the sternum were completely relieved after four months of medications employed. The patient satisfactory response to treatment was demonstrated. During the follow-up period there have been no recurrences of the symptoms. Full treatment duration in our patient took nine months. The authors present after six years clinical evaluations (photograph) of the patient (PHFS), aged 21-years-10-month-old, demonstrating, that a sinus over the sternum had healed.

Orthopedics and Rheumatology Open Access Journal (OROAJ)
which was elevated; C-reactive protein (CRP) was positive (over 20,0 mg/dl); human immunodeficiency virus (HIV) testing was negative (nonreactive). Abnormalities in urinary findings were not evident. Purified protein derivative (PPD) was observed 11 mm (positive) 48 hours after administration.

Roentgenographic Findings (Figures 2-7)
Ultrasonography Figure 4 Ultrasonography of the chest wall hypoechoic collection (low echogenicity) tracts communicating to the skin surface (cutaneous fistula) around the fourth rib arch is evidenced.

Orthopedics and Rheumatology Open Access Journal (OROAJ) Discussion
In Brazil, bone tuberculosis is more common in children and corresponds to 10% to 20% of the extrapulmonary lesions in childhood [24]. Sternum tuberculosis osteomyelitis is a rare form of flat bone afflictions among pediatric populations such as in this case [20]. Sternum TB commonly occurs by reactivation of latent focuses formed throughout the course of hematogeneous or lymphatic dissemination primary tuberculosis. Classically the disease is seen in young adults, although cases in children have been reported [11,16]. A few cases in countries where TB is endemic are described [16]. Sternum TB in pediatric patients is uncommon in the literature; a small number of articles is reported [3,4,7,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Patients with pain and swelling in the sternum bone, tuberculosis should be considered [25].
Pinheiro reported a study of the records of a series of 94 child patients diagnosed with osteoarticular TB, with only one case of sternum TB observed [22]. McLellan reviewed 20 cases of sternum TB and only two cases to be from the pediatric age group found [25]. Khan et al. [9] in his work about sternum TB, three cases in children were found. Sternum TB osteomyelitis in children, comprises less than 1% of all skeletal TB cases [5][6][7][8][9].
It is hard to understand making a final diagnosis without a histological examination of the sternum tissue [20,26]. It is mandatory, for diagnosis, to secure important histological samples to certify diagnosis and provide drug sensitivity data [18]. The gold standard for diagnosis of osseous tuberculosis comprises of histological examination verification. A needle aspiration or excisional biopsy for histopathological diagnosis of sternum TB is obligatory [27]. Histopatology is the key suitable differential diagnosis to be confirmed [18]. In our case biopsy by an open excisional from the foot and the sternum bone has been done to ratify the diagnosis.

Conclusion
In conclusion, in the case of any child patient with a nonhealing ulcer or abscess in the sternum bone, reliance on physicians involved with the musculoskeletal system (infection) tuberculosis disease should be kept in mind (Figure 11).

Acknowledgement
The authors wish to tank Paulo Vinicius Valladão Pinheiro, Angela Marta Marquini and Carlos Brown Scavarda for their review, advice, encouragement, and help in preparing the manuscript.

Ethical Approval
The procedures in this study involving human participants was in accordance with the ethical standards of the Institutional Jesus Children Hospital Rio de Janeiro, Brazil, and with the 1964 declaration of Helsinki (DoH) and its later amendments/ clarifications have been performed. This study with under protocol nº 172/11, CAAE (Presentation Certificate for Ethical Appreciation) number 0070.0.314.000-11, approved the Research about "Skeletal tuberculosis in children".

Consent
Written informed consent from parents/guardians for publication of this report and accompanying images was obtained. Written consent on the patient´s chart registration number 73777 and 127915, Departments of orthopedic, and Radiologic Services of Jesus Children's Hospital, Rio de Janeiro, Brazil is available.

Disclosure
None of the authors received payments or services, either directly or indirectly, i.e., via his or her institution of any aspect of this work. None of the authors, or their intuition(s), have had any financial relationship, prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this article. Also, no author has had any other relationships, or has engaged in any other activities, that could perceive to influence or have the potential to influence what is written in this work.