Case presentation:
A 24-year-old male patient, who was previously healthy, presented to the
Hamad general hospital complaining of progressive left-sided pleuritic
chest pain lasting for a few weeks. He noticed two large lumps in front
of his chest, precisely at the same site of the pain slowly increasing
in size over the last four months. He experienced a loss of appetite and
weight of eight kilograms over the same duration. The patient denied any
history of cough, shortness of breath, fever, or night sweats. He was a
lifelong nonsmoker, with no contact with sick people and no recent
travel, with unremarkable family history. On examination, he was
afebrile, maintaining normal oxygen saturation on ambient air. There
were two anterior chest wall masses: the first above the left second
rib, measuring 7x7 cm, and the second over the left costal margin
measuring 10x10 cm. The covering skin of both masses appeared normal
with no draining sinus or tract. The lumps were mobile, cold,
non-pulsatile, and not tender. Chest auscultation and examination of
other relevant systems were unremarkable. His laboratory investigations
showed hemoglobin of 11.4 g/dl, C-reactive protein of 65 mg/L, positive
Quantiferon TB gold plus, and normal kidney and liver function tests
(Table 1).
A chest x-ray showed airspace opacity noted in the left perihilar region
(Figure 1). Chest computed tomography (CT) showed two lenticular-shaped
collections noted in the left anterior chest wall. One is noted along
the internal surface of the left third rib measures 19 x 53 mm causing
bone destruction. The other one is in the subcutaneous tissue measures
60 x 33 mm, with an enlarged left hilar lymph node showing peripheral
enhancement and central hypodense necrotic area (Figure 2 A, B).With
associated underlying third rib destruction (Figure 3). Ultrasound
examination of the lesion in the lower chest wall showed well defined
hypoechoic area, with varying degrees of internal heterogeneity (Figure
4).
The patient failed to produce any sputum even after induction. The
acid-fast bacilli smear (AFB) of the aspirated fluid from the chest wall
swelling came negative, but the Polymerase Chain Reaction (PCR) came
positive. The aspirated fluid culture grew a pan-sensitive Mycobacterium
tuberculosis complex (MTB). We diagnosed him with primary chest wall
tuberculosis and therefore started on first-line anti-tuberculosis
medications. The patient traveled back to his home country and lost
follow up with us.