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samples were taken for cultures&#44; and oral antibiotic therapy was started&#46; Culture results were negative&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The wound failed to heal and suppuration of purulent fluid persisted&#44; so a computed tomography &#40;CT&#41; scan of the chest was requested &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which revealed a soft tissue tumor located in the pre- and retrosternal region measuring 55<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>46<span class="elsevierStyleHsp" style=""></span>mm&#44; with heterogeneous uptake of contrast medium&#44; areas of necrosis&#44; and a pathological fracture of the sternum&#44; with no pulmonary parenchymal involvement&#46; On the basis of the tomographic findings&#44; a surgical biopsy was performed&#44; and specimens were sent for culture&#44; KOH&#44; PCR for tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41;&#44; and pathology studies&#44; all of which were negative&#46; The wound still failed to heal despite multiple attempts to close it&#44; and the patient developed fever &#40;38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; so intravenous broad-spectrum antibiotic treatment was started&#44; and the dose of prednisone was reduced &#40;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; with partial clinical outcomes &#40;resolution of fever&#44; but no closing of the wound&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Given the patient&#39;s lack of progress and the high suspicion of a malignant tumor of the sternum&#44; the CT was repeated&#44; showing an increase in the size of the lesion&#46; We performed a complete resection of the sternal tumor with reconstruction of the anterior chest wall with bilateral pectoralis major flaps&#46; The surgical specimen was sent to pathology&#44; and the report identified a granulomatous reaction with formation of caseifying granulomas and positive PCR for tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41;&#46; The results of the cultures confirmed the diagnosis of tuberculosis &#40;growth of 17 colonies&#41;&#44; sensitive to rifampicin &#40;R&#41;&#44; pyrazinamide &#40;Z&#41;&#44; ethambutol &#40;E&#41;&#44; and isoniazid &#40;H&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was treated with a 2 HREZ 4 HR regimen&#44; and her symptoms improved within a few weeks of starting&#46; The first phase of treatment has now been completed&#44; with good progress and complete closure of the wound&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Tuberculosis of the sternum is a rare entity&#44; with about 25 cases reported in the literature&#46; Twenty of these were in developing countries&#44; especially India&#44; and 5 cases in developed countries&#46; It is more common in men &#40;16 men compared to 9 women&#41; and 6 cases were associated with significant comorbidities&#46; The age of presentation was variable&#44; ranging from a child of 9 months to a patient of 74 years&#46; Most cases are associated with lung infections&#44; cardiac surgeries&#44; vaccination with BCG&#44; and immunosuppression&#44; as was the case with our patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Sternal involvement is believed to be due to hematogenous spread from a primary focus in the lung&#44; but only in 4 cases could another location in addition to the sternal site be identified&#46; In our patient&#44; it is possible &#40;although not confirmed&#41; that the etiology of her adrenal insufficiency was also tuberculous&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Most patients consult with a history of months of clinical symptoms&#44; characterized by a painful sternal tumor&#44; sometimes with the formation of fistulas&#44; fever&#44; profuse sweating&#44; weight loss&#44; or spontaneous sternal fracture&#44; as was the case with our patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest X-ray is generally not very useful&#44; whereas CT and magnetic resonance imaging &#40;MRI&#41; techniques are more useful for characterizing the lesion&#46; Cortical thickening with periosteal reaction&#44; osteomyelitis&#44; and heterogeneous tumors of soft tissues can be seen on CT&#44; in addition to inflammation of the medullary cavity of the sternum characterized by low intensity images in T2 on MRI&#46; The definitive diagnosis is performed by analyzing the sternal tissue&#44; but this tends to be complicated and more than 1 complementary method is often required&#46; In the published cases&#44; diagnosis was by histopathology in 11 cases&#44; by polymerase chain reaction in 5 &#40;90&#37; sensitivity and 80&#37; specificity&#41;&#44; by culture in 5&#44; and positive smears in 4&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The aim of treatment is to cure TB and prevent bone deformities&#46; It is based on the use of rifampicin &#40;R&#41;&#44; pyrazinamide &#40;Z&#41;&#44; ethambutol &#40;E&#41;&#44; and isoniazid &#40;H&#41; in a regimen of 2 HREZ plus 4&#8211;10 months of HR&#46; In general&#44; the regimen is the same as for pulmonary tuberculosis&#44; with or without surgical debridement of lesions &#40;only 7 published cases required surgery&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report the case of an immunosuppressed patient who presented tuberculosis of the sternum with no pulmonary focus&#46; This presentation is very rare&#44; but it must be taken into account among the differential diagnosis of sternal tumors&#46;</p></span>"
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