SUBMITTED 14 MAR 23 1

REVISIONS REQ. 1 MAY & 21 MAY 23; REVISIONS RECD. 5 MAY & 29 MAY 23 2

ACCEPTED 6 JUN 23 3

ONLINE-FIRST: JUNE 2023 4

DOI: https://doi.org/10.18295/squmj.6.2023.042 5

Supra-Sternal Notch Tuberculous Abscess in Child 7

Mohamed Bhairis,1 Massine El Hammoumi,1 Meryem Kabiri,2,3 8

*El Hassane Kabiri,1,3 9

1Department of Thoracic Surgery, Mohammed V Military Teaching Hospital, Rabat, Morocco; 11

2Department of Pediatrics, Rabat Children Hospital, Rabat, Morocco; 3Faculté de Médecine et de 12

Pharmacie, Université Mohammed V, Rabat, Morocco 13

*Corresponding Author’s e-mail: hassankabiri@yahoo.com 14

A 14-year-old student boy was referred to our thoracic surgery department at a university hospital 16

in Rabat, Morocco (November 2019) for a growing swelling of the suprasternal notch observed five 17

weeks prior to his admission to our department (Figure: 1A). The vaccination protocol was complete 18

including bacillus Calmette-Guérin (BCG). Clinical examination showed a well-limited, fluctuating 19

swelling, 10 cm in diameter, located in the suprasternal notch, without movement on swallowing, 20

and without associated cervical or axillary nodes. Blood tests were normal, except for an elevated 21

erythrocyte sedimentation rate (45 mm/h). An ultrasound of the neck revealed a collection of thick 22

fluid independent of the thyroid gland. Neck and thorax Computed tomography (CT) scan shows a 23

fluid collection with densification of anterior and superior cervicothoracic fat. 24

Anterior and superior cervicothoracic fat measuring approximately 125 × 71 × 52 mm (Figure 1 B). 26

Fine-needle aspiration and cytology (FNAC) were performed with pus aspiration; With negative 27

microbiologic evaluation and cultures, the patient underwent surgical debridement (Figure 1 C). 28

Histopathologic examination (Figure 1D) showed the presence of a giganto-cellular granuloma with 29

caseous necrosis; mycobacterium tuberculosis culture was negative and the diagnosis of tuberculosis 30

was confirmed by rapid PCR assay. 31

The patient received anti-tubercular treatment: 2 months of Rifampicin (R)-Isoniasid (H) - 33

Pyrazinamide (Z) and 4 months of Rifampicin - Isoniasid (2RHZ- 4RH) with a good clinical 34

response. 35

mailto:hassankabiri@yahoo.com

Written consent of the patient has been obtained for publication. 37

Comment 39

Tuberculosis can involve and disseminate all organs; chest wall tuberculosis is a rare extrapulmonary 40

localization and reaching 20-40% of all tuberculosis cases. 41

Chest wall tuberculosis is a rare extrapulmonary location and accounts for 1-5% of all 43

musculoskeletal involvement1. Isolated supra-sternal soft tissue tuberculous cold abscess is 44

exceptional. Differential diagnosis includes thyroid swelling2,3 vascular malformations, thyroglossal 45

duct cysts, dermoid cysts, or reactive and infectious lymphadenitis. 46

In the PubMed database Khalil4, Vijay2 and Asayama3 reported respectively three, one and one case 47

of suprasternal Notch2-4. it has been more described in immunocompetent individuals but 48

immunosuppression should be researched in all cases . The clinical expression is dominated by 49

swelling, sometimes there is sternal pain2. 50

Chest CT is the best examination to demonstrate the presence of costal or sternal lysis, 52

pleuropulmonary and mediastinal lesions. Confirmation of TB disease is obtained by bacteriological 53

and/or pathological data. 54

The geneXpert study is a rapid and efficient technique for the diagnosis of tuberculosis compared to 55

microscopy. 56

Therapeutic management combines anti-tubercular medical treatment (6 to 12 months) with fine 58

needle aspiration (FNA)2, 4 for diagnosis and small swalling but surgical debridement is mandatory 59

to reduce the risk of recurrence 1,3 in other cases. 60

The resolution is generally good with the combination of anti-bacillary treatment within 6 months 62

and complete surgical debridement can be performed to minimize local complications. 63

Authors’ Contribution 65

MB performed the observation. MEH and MK composed the manuscript. EHK edited the final draft. 66

All authors approved the final version of the manuscript. 67

References 69

1. Riahi, I., Fradi, R., Jaafoura, H. et al. A cervical tuberculous abscess mimicking a fourth branchial 70

cleft cyst in a child: PCR, the key to fast diagnosis. Egypt J Otolaryngol 2020 ;36:14. 71

https://doi.org/10.1186/s43163-020-00016- 72

2.Vijay V, Vaishya R. Tuberculous suprasternal notch abscess in a child. BMJ Case Rep 2016; 19: 73

bcr-2015-214269. https://doi: 10.1136/bcr-2015-214269 74

3. Asayama I, Ishikawa T, Yamada T, Kitagawa W, Shimizu K. A case of tuberculous granuloma 75

at the supra-sternal notch that was difficult to differentiate from a thyroid tumor. Med Sci Monit 76

2004;10: 37-40. PMID: 15278001 77

4. Khalil EA, Elsiddig KE, Elsafi ME, el-Hag IA, Elkhidir IM, Suleiman G, et al. Trans R Soc Trop 78

Med Hyg. 2000; 94:58-60. https://doi: 10.1016/s0035-9203(00)90440-1 79

Figure 1: (A): Large fluctuant swelling in the suprasternal notch. (B): CT scan of the neck and 82

chest showing a mass on suprasternal space. (C): Operative view debridement of the mass. (D): 83

Pathological micrograph (HE x 40): Giganto-cellular granuloma with caseous necrosis 84

https://pubmed.ncbi.nlm.nih.gov/27095807/?from_term=sternal+tuberculosis+in+children&from_sort=pubdate&from_pos=4
https://pubmed.ncbi.nlm.nih.gov/15278001/?from_term=Tuberculous+Suprasternal+&from_sort=pubdate&from_pos=7
https://pubmed.ncbi.nlm.nih.gov/15278001/?from_term=Tuberculous+Suprasternal+&from_sort=pubdate&from_pos=7