|Year : 2016 | Volume
| Issue : 2 | Page : 78-80
An unusual chest wall swelling mimicking tumorous growth
Manoj Meena, Ramakant Dixit, Jai Prakash Kewlani, Piyush Arora, Mukesh Goyal
Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan, India
|Date of Web Publication||10-Jun-2016|
Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
Chest wall swelling with underlying lung involvement is a rare phenomenon and it poses certain diagnostic challenges as well. It has to be differentiated from other swellings with different underlying etiology. We present a case where a 60-year-old man presented with a progressive chest wall swelling over right sterno-clavicular joint abutting the manubrium sterni. The origin of the swelling resulted from a leak of air from a tense tubercular cavity in the lung parenchyma that was diagnosed with the help of a contrast-enhanced computerized tomography thorax. The case was managed conservatively with antitubercular therapy and evacuation of air from the chest wall swelling by a nasogastric tube.
Keywords: Air leak, chest wall swelling, tense tubercular cavity, tumorous growth
|How to cite this article:|
Meena M, Dixit R, Kewlani JP, Arora P, Goyal M. An unusual chest wall swelling mimicking tumorous growth. J Assoc Chest Physicians 2016;4:78-80
| Introduction|| |
Chest wall swellings may not always originate from the constituents of chest wall, but sometimes they result from the extension of contents of underlying lung with pleura. A meticulous approach along with a high index of suspicion is needed to know the origin of these swellings as sometimes aneurysms of the ascending aorta can also present was chest wall swellings and unplanned interventions in these swellings can be disastrous and can lead to lethal complications. Investigations such as biopsy/fine-needle aspiration cytology (FNAC) and contrast-enhanced computerized tomography (CECT) should be performed only after careful examination of the swelling. We are reporting this case as there was no lung herniation nor there was any evidence of sub-cutaneous emphysema, pneumothorax, and this makes it worthy for reporting. Such cases certainly pose a challenge in making the diagnosis of the etiology as these are very rare presentations of rather very common disease entities such as tuberculosis and malignancy. Because of the wide variation in the origin of chest wall swellings, radiographic diagnosis can be challenging. A combination of location of origin of swelling along with imaging appearance and the clinical information is necessary to make the diagnosis rather than imaging alone.
| Case Report|| |
A 60-year-old man presented with a round swelling of approximately 4 cm × 4 cm in size at the lower neck over right sterno-clavicular joint abutting the lateral border of manubrium sterni [Figure 1]. Swelling was firm in consistency, nontender, and nonpulsatile in nature with some engorged veins overlying it. Appearance of swelling was preceded with a prodrome of cough with phlegm production and low-grade continuous fever since 2 weeks. Swelling was mimicking a tumorous growth arising from the chest wall. Pain is the most important symptom of any tumorous growth whether benign or malignant which was not there as the presenting complaint here nor there was any history of any trauma to the chest wall or intake of chronic immunosuppressive therapy by the patient in the form of steroids and other immunosuppresants.
|Figure 1: Swelling of approximately 4 cm × 4 cm in size at lower neck over right sterno-clavicular joint abutting the lateral border of manubrium sterni|
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Past history and family history were unremarkable. Routine hemogram was within normal limits except a raised erythrocyte sedimentation rate (80 mm at the end of the first hour). Mantoux test revealed induration of 20 mm at the end of 72 h. Chest X-ray postero-anterior view revealed a thin-walled cavity in right upper lobe, but X-ray was not sufficient to explain the origin and cause of the swelling. Color-Doppler and two-dimension (2D)-echocardiography and a CECT of the thorax were performed prior to biopsy and FNAC to rule out the possibility of aneurysm. Doppler study of heart was within normal limits, but CECT thorax revealed a cavity under tension in right upper lobe of lung with leakage of air from it which took an oblique path traversing the pleura and sub cutaneous planes to reach the right sterno-clavicular joint and protruded as a tumorous growth in the chest wall [Figure 2] and [Figure 3]. Following computed tomography (CT) confirmation that the underlying contents of the swelling is nothing but air a closed needle aspiration of the same was performed which revealed free flow of air and gradual disappearance of swelling which recurred after 1 h. Sputum for acid fast bacilli was positive on Zeihl–Neelsen staining.
|Figure 2: Contrast enhanced computerized tomography thorax revealing leakage of air from tense cavity which took an oblique path (red arrow) traversed the pleura and sub cutaneous planes to reach the right sterno-clavicular joint and protrude as a tumorous growth in the chest wall (blue arrow)|
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|Figure 3: Contrast enhanced computerized tomography thorax revealing air beneath the swelling (arrow) over the right sterno-clavicular joint|
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All the above findings with background of clinical features supported the diagnosis of cavitary pulmonary tuberculosis with subcutaneous swelling due to leakage of air from the cavity. A small thin chest drain (nasogastric tube) was inserted in right second intercostal space under water seal to release the tension created by leakage of air from the cavity. Prompt antitubercular therapy (ATT) (rifampicin 450 mg, isoniazid 300 mg, ethambutol 800 mg, and pyrazinamide 1000 mg) was started as per the weight band of the patient. Drain was removed after 5 days with no future recurrence of the swelling there after. Patient showed good response to ATT with no future recurrence of the swelling in subsequent follow-up.
| Discussion|| |
Chest wall swelling can result as a extention of intrathoracic or extrathoracic structures which can protrude out by contiguous spread by abutting the muscles and fascial planes or in some by breaching the overlying structures. Pulmonary and mediastinal neoplasms (benign or malignant) though are very common but seldom protrude as chest wall swellings. These swellings can arise from the skeletal or soft tissue structures of the thorax. Benign swellings like lipomas, chronic inflammatory granulomas and malignant swellings like sarcomas of thorax and chest wall, lung and mediastinal neoplasms and metastasis from other distant sites should be kept in differential diagnosis and have been reported in literature previously as well. Although chest wall swelling with underlying lung involvement is a rare presentation, and no such case was found with a similar presentation on Medline search. In this case air from the lung cavity probably traversed into the chest wall via the pleural symphysis that might have occurred due to continuous ongoing inflammation (originating from lung cavity) between the parietal and visceral pleura. The other probable reason for this swelling was the weakening of muscles in inter-costal space due to continuous ongoing inflammation and vigorous coughing by the patient that acted as a driving force for the air to bulge outwards. Another noticeable thing, in this case, was the location of the swelling that was exactly close to the costochondral junction that is the precise location that is anatomically weak due to the absence of external intercostal muscle. Subcutaneous emphysema secondary to tuberculosis may develop due to associated pneumothorax, pneumomediastinum, or following the chest tube insertion, but there was no evidence of pneumothorax and emphysema in this case due to the probable pleural symphysis. In case if there is a tear of this pleural symphysis than it can lead to the formation of subcutaneous emphysema. CT scan and magnetic resonance imaging are necessary to know the exact origin of chest wall swellings. 2D-echocardiography should always be performed in any pulsatile chest wall swellings to confirm the presence of underlying aneurysm. Once confirmed as a nonaneurysmal swelling biopsy can be taken from the same to know the histopathology of the underlying contents and plan further line of action. Protruding mediastinal tumors, aortic aneurysm, and lung herniation were other differential diagnosis in this case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]