The British Journal of Radiology, 77 (2004), 449457

DOI: 10.1259/bjr/82634045

2004 The British Institute of Radiology

Pictorial review

Chest wall tuberculosis: a review of CT appearances

B S MORRIS, DMRD, MD, M MAHESHWARI, MD and A CHALWA, DMRD
Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai 400 012, India

Abstract. Tuberculous abscesses of the chest wall, though uncommon are not infrequently encountered in
countries endemic to the disease. This pictorial review of 14 patients highlights the varied appearance of
tuberculosis (TB) of the chest wall on CT. The patients ranged in age from 9 to 55 years (a mean of 25 years)
with a preponderance of chest wall lesions in young adults and in females (male to female ratio of 2:5). Cases in
which there was no involvement of the chest wall other than of the spine have been excluded. In all cases CT
demonstrated peripherally enhancing chest wall collections some of which were accompanied by changes in
adjacent bone. Enlargement of intrathoracic lymph nodes with comparatively lesser involvement of lung
parenchyma and pleura was also seen.

Tuberculosis (TB) of the chest wall constitutes 1% to 5%

of all cases of musculoskeletal TB [15] which in turn is far
less frequently encountered than pulmonary infection
alone and represents between 1% and 2% of TB overall
[68]. A resurgence of TB throughout the world can
largely be attributed to widespread HIV infection [9]. TB is
considered second only to metastasis as a cause of rib
destruction [10] and is thought to be the most commonly
encountered inflammatory lesion of the ribs [11]. The
endemic nature of TB accounts for the concurrence of lung
infection in nine of 14 patients with chest wall abscesses.
TB of bone is thought to result from either lymphatic or
haematogenous dissemination of bacilli from a site of
primary infection a Ghon focus, in the lungs. Erosion of
bone in TB results from pressure necrosis by granulation
tissue and also by the direct action of invading organisms.
Faure et al [12] hypothesized that infection of lymph nodes
in the chest results from pleuritis caused by invasion of the
tubercle bacilli. The extraparenchymal (subpleural) collections made up of caseous material from the necrosed
lymph nodes are termed cold abscesses. These can
burrow through the chest wall to form visible swellings on
the exterior without erythema or tenderness. This explains
the contiguity of chest wall collections with enlarged and
caseous intrathoracic lymph nodes in half the patients.
Internal mammary nodes are found to be the most commonly involved.
Tuberculous abscesses of the chest wall can involve the
sternum, costochondral junctions, rib shafts, costovertebral joints and the vertebrae. They are most frequently

found at the margins of the sternum and along the rib shafts
[13]. A predilection for the rib shaft is seen in nine cases. The
parasternal region (Figures 13, 11, 13, 14), costovertebral
junction (Figures 5, 9, 13, 14), and vertebra (Figures 5 and 9)
are involved less frequently. Multiplicity of the chest wall
lesions seen in half the cases could be the result of a
suppressed immunological response by host tissue.
Destruction of bone adjacent to TB abscesses though a
common finding, is not always seen [12, 1416]. It can take the
form of disruption of the cortical margin or of an osteolytic
lesion, which could be expansile in nature [15]. Of 10 patients
with lesions along the rib shaft, erosion of the ribs is seen in
5 patients and a periosteal reaction in 4. Bone erosions are
identified in only two of eight patients with lesions at or near
the sternum (Figures 1 and 13). Frank rib destruction as in
Figure 6 is a less common finding. Extensive destruction of
bone can often raise a differential of other pathologies, e.g.
infective (pyogenic/fungal) and neoplastic. However, necrosis even if present in such lesions is unlikely to simulate the
appearance of tuberculous caseous collections.
Pleural thickening at sites remote from chest wall lesions,
parenchymal infiltrates and pericardial thickening (Figures 1
and 11) were each seen in two of the 14 patients. Cold
abscesses on the inner surface of the parietal wall indented the
contour of the liver in four patients (Figures 3, 4, 7 and 10).
On initial ultrasound evaluation, the encapsulated collection
in two of these patients mimicked a diseased gallbladder
(Figure 7). An extension of the paravertebral abscess into the
spinal canal was seen in two patients (Figures 9 and 13);
neither patient had a neurological deficit.

Received 28 October 2002 and in final form 1 December 2003 and

accepted, accepted 3 February 2004.

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449

B S Morris, M Maheshwari and A Chalwa

(a)

(b)

Figure 1. A 40-year-old lady presented with a painful swelling on the right side of the chest over a period of 3 months. (a) A section
through the mid-thorax reveals sternal erosion by a lesion in the chest wall. An extrapleural component is seen to abut the pericardium. (b) A section 10 mm caudal to the previous image reveals uniform thickening of the pericardium, which is a striking finding in
this patient.

Figure 2. CT of a 15-year-old boy with a painful swelling in

the parasternal region of about 10 months shows a peripherally
enhancing necrotic lesion at the right costochondral junction.

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Pictorial review: CT appearance of chest wall TB

(a)

(b)

Figure 3. A fluctuant swelling of several months duration on the sternum of a 17-year-old woman prompted need for a chest radiograph.
Superior mediastinal widening coupled with bilateral hilar prominence suggested extensive adenopathy. There was subtle notching of the posterolateral aspect of the left fifth rib. (a) An encapsulated low attenuation collection anterior to the sternum is seen to communicate with coalescent and necrotic pre-vascular lymph nodes. Pre-tracheal, tracheobronchial and carinal nodes are also noted. (b) A cold abscess along the
lateral parietal wall displaces the contour of the liver. There are enlarged necrotic epiphrenic lymph nodes and multiple discrete granulomas
(23 mm in size) within a mildly enlarged spleen. Sections through the upper abdomen (not shown) revealed multiple, necrotic coeliac and
peripancreatic lymph nodes.

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B S Morris, M Maheshwari and A Chalwa

Figure 4. The larger of two chest wall swellings in a 25-year-old

man located on the posterolateral aspect of the rib cage appears
contiguous with an intrathoracic component, which confers a scalloped configuration to adjacent liver contour. Drainage of the
smaller lesion on the anterior chest wall had led to the formation
of a discharging sinus. A lung abscess was present within the upper
lobe of the right side.

Figure 6. A plain radiograph of a 47-year-old woman who

presented with a painful swelling in the lower rib cage on the
left side suggested malignancy. CT shows irregular rib expansion and destruction with a break in continuity of the posterior
aspect of the sixth and seventh ribs. Fine nodular opacities
(,1 mm in diameter) are disseminated throughout the lung
fields. CT repeated 10 months later showed dramatic resolution
of the lesion, though residual bone deformity with a minimal
pleural reaction was found to persist.

(a)

(b)

Figure 5. (a) An extrapleural soft tissue mass in an 18-year-old man is seen adjacent to the anterolateral chest wall at the mid-thoracic
level. (b) A section through the lower thorax, at bone window settings reveals scalloping of the inner margin of the ribs by the extrapleural mass. Erosion of the pedicle and body of D8 with bilateral paravertebral abscesses was the cause of pronounced tenderness
along the spine.

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Pictorial review: CT appearance of chest wall TB

Figure 8. A 17-year-old woman came with a protuberant and

fluctuant swelling of 8 months duration over the upper chest. CT
reveals an encapsulated and peripherally enhancing low attenuation collection in the infraclavicular region contiguous with
enlarged and necrotic paratracheal lymph nodes. Drainage of the
chest wall abscess was later undertaken for cosmetic reasons.

Figure 7. A 27-year-old woman who was treated for pulmonary tuberculosis 5 years earlier came for evaluation of a swelling on the parietal wall. A low attenuation, encapsulated,
extraperitoneal collection along the inner aspect of the anterior
parietal wall displaces the adjacent capsule of the liver, which
otherwise appears unremarkable. This collection was mistaken
for a mucocoele of the gall bladder on preliminary ultrasound.

(a)

(b)

Figure 9. Multiple lesions in the thoracic cage were detected on a CT of a 15-year-old girl who presented with painless cervical adenopathy, anorexia, weight loss and an evening rise in body temperature. (a) Loculated, low attenuation collections are seen along the
inner aspect of the left fifth rib, which is expanded by irregular periosteal reaction. An abscess within the back muscles is seen at the
same level. (b) reveals a paravertebral abscess adjacent to an excavating lesion along the margin of the sixth dorsal vertebra. Despite
demonstrable epidural extension into the spinal canal, the girl had no neurological manifestations. A CT done 12 weeks later showed
a significant reduction in size of the lesions despite an absence of reparative bone changes in the affected rib and vertebra.

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B S Morris, M Maheshwari and A Chalwa

(a)

(b)

Figure 10. Over 100 ml of caseous material was aspirated from a subcostal swelling of a 35-year-old woman in whom a preliminary
ultrasound examination suggested an amoebic liver abscess. Past tuberculosis of the ribs on the right side of the chest however suggested the probability of resurgent infection. (a) Axial and (b) parasagittal reformatted images show an encapsulated collection tracking along the inner surface of the thoracic cage up to the costal margin. The liver though displaced appears otherwise normal.

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Pictorial review: CT appearance of chest wall TB

(a)

(b)

Figure 11. Ill-defined haziness over the heart border on a plain radiograph of the chest of a 55-year-old man with a parasternal
swelling suggested an extraparenchymal lesion. (a) A section through the mid-thorax shows a low attenuation peripherally enhancing
lesion with intrathoracic and extrathoracic components. (b) A section taken a few centimetres caudal shows pericardial thickening
and indentation of cardiac contour by the cold abscess.

Figure 13. A 9-year-old girl came with anorexia and weight

Figure 12. A 20-year-old woman who had received treatment
for pulmonary tuberculosis 4 years earlier was investigated for
secondary infertility. A plain radiograph of the chest revealed a
giant emphysematous bulla with atelectasis of the left lower
lobe. CT reveals an extrapleural mass with a small nodular
focus of calcification adjacent to the inner aspect of the upper
rib cage. There is no evidence of bone erosion.

The British Journal of Radiology, May 2004

loss. Painful swellings on the forehead, chest wall and palm

were noticed over a period of 2 months. A section through the
upper thorax shows large, encapsulated low attenuation collections in the chest wall, encircling the upper half of the sternum
contiguous with necrotic superior mediastinal lymph nodes.
The sternum and the costochondral junctions mainly on the
left side appear eroded. A pre-vertebral abscess with epidural
extension at the mid-dorsal level was not associated with a
neurological deficit.

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B S Morris, M Maheshwari and A Chalwa

(a)

(b)

Figure 14. CT was done for an 11-year-old girl with fever and chest pain. (a) An axial image just below the carina shows linear
periosteal reaction at the vertebral end of the left 5th rib adjacent to a large extrapleural collection which is contiguous with necrotic
mediastinal and left hilar lymph nodes. Caseous collections in the anterior chest wall partially encircle the sternum without evidence
of bone erosion. Florid periosteal reaction was seen along the posterior aspect of the 4th to 8th ribs on the left side. (b) A reconstructed image in the coronal plane shows the extent of the thoracic paravertebral abscess from the level of D1 to D10. Periosteal
reaction is seen to cause expansion of the vertebral ends of the adjacent ribs.

Conclusion
CT is ideal for evaluating tuberculous chest wall lesions
as it demonstrates the nature and extent of soft tissue
collections, and accompanying intrathoracic adenopathy
and bone erosion. Hitherto unsuspected lesions in lung
parenchyma and the upper abdomen are also detected.

Acknowledgment
The authors would like to thank the editorial board of
the Journal of the International Skeletal Society for permitting them to incorporate a case report and other
material from the article Multifocal musculoskeletal tuberculosis in children: appearances on computed tomography (Skeletal Radiol 2002;31:18) [13].

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