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Self-assessment
corner
245
Pulmonary
infiltrates
and
skin
lesions
I
Avivi,
S
Vulfsons,
R
Finkelstein,
T
Hayek,
JG
Brook
Department
of
Internal
Medicine
D,
Rambam
Medical
Center,
Haifa
31096,
Israel
I
Avivi
S
Vulfsons
R
Finkelstein
T
Hayek
JG
Brook
Accepted
28
February
1996
A
60-year-old
man,
a
heavy
smoker,
was
hospitalised
because
of
a
three-month
history
of
pleuritic
chest
pain,
dry
cough
and
weight
loss.
He
had
lost
20
kg
in
weight
and
suppurative
skin
lesions
began
appearing
on
the
chest
wall.
His
medical
history
was
unremarkable.
On
examination
he
was
cachectic
(44
kg)
and
pale.
His
temperature
was
37.8°C.
Important
physical
findings
of
the
chest
and
neck
are
shown
in
figure
1.
The
axillary
and
neck
nodes
were
enlarged
and
tender.
Clubbing
was
present.
Chest
auscultation
disclosed
decreased
breath
sounds
bilaterally,
with
no
rales
or
ronchi.
Non-tender,
soft,
small
skin
masses
were
observed
and
palpated
on
the
chest
wall.
A
chest
X-ray
and
computed
tomography
(CT)
scan
were
performed
(figures
2
and
3).
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2
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Figure
3
Questions
1
What
are
the
most
prominent
physical
findings
shown
in
figure
1?
2
Describe
four
radiologic
findings
shown
in
figures
2
and
3.
3
Name
the
two
most
likely
differential
diagnoses
in
this
case.
246
Avivi,
Vulfsons,
Finkelstein,
Hayek,
Brook
Answers
QUESTION
1
In
the
middle
of
the
left
clavicle
a
small
mass
can
be
observed.
On
palpation,
it
was
soft
and
non-tender.
Such
a
finding
can
fit
the
descrip-
tion
of
'cold
abscess'.
Furthermore,
multiple
sinuses
on
the
anterior
chest
wall
and
neck
can
be
observed.
The
sinus
on
the
sternum
is
covered
by
dried
crusted
secretions.
QUESTION
2
The
chest
X-ray
shows
a
right
upper
lung
infiltrate
and
an
osteolytic
lesion
of
the
ninth
rib
(arrow).
On
CT
scan,
a
left
pleural
effusion
and
a
sinus
communicating
the
pleural
space
and
anterior
soft
tissue
infiltrate
of
the
chest
wall
(arrow)
can
be
observed.
QUESTION
3
The
osteolytic
lesion
of
the
ninth
rib
makes
the
diagnosis
of
malignancy
very
appealing.
How-
ever,
the
presence
of
a
lung
infiltrate,
pleural
effusion,
skin
sinuses
and
'cold
abscesses'
should
suggest
an
infectious
process.
Although
uncommon
in
the
present
day,
the
particular
association
of
pleuropulmonary
disease
with
chest
sinuses
spontaneously
draining
an
em-
pyema,
or
a
soft
tissue
mass,
may
be
quite
typical
of
both
tuberculosis
and
actinomyco-
sis."
2
In
addition,
bone
involvement
may
be
a
manifestation
of
localised
or
disseminated
disease
found
in
both
entities.
Nocardiosis,
mucormycosis
and
blastomycosis
are
other
rare
diseases
in
which
these
clinical
manifesta-
tions
have
been
described.'5
Discussion
The
diagnosis
in
this
case
was
reached
easily
by
needle
puncture
of
one
of
the
'cold
abscesses'
which
revealed
several
acid-fast
bacilli,
later
identified
as
Mycobacterium
tuberculosis.
The
patient
was
treated
with
isoniazid,
rifampicin
and
pyrazinamide,
and
after
a
two-year
follow-
up
period,
he
is
doing
well.
The
protean
manifestations
of
tuberculosis
have
been
well
appreciated
for
centuries.
Two
particular
pre-
sentations
of
disease
in
this
case
are
note-
worthy.
The
first
was
the
osteolytic
lesion
of
the
ninth
right
rib,
initially
considered
to
be
of
neoplastic
origin.
Skeletal
tuberculosis
accounts
for
1-2%
of
all
cases
of
tuberculosis
and,
particularly
when
manifesting
as
a
multifocal
disease,
it
may
mimic
malignant
disease
both
clinically
and
radiologically.4
The
second
unusual
presenta-
tion
was
empyema
burrowing
through
the
parietal
pleura
and
spontaneously
discharging
its
content.
This
is
consistent
with
what
was
previously
described
as
'empyema
necessitatis',
a
well-known
complication
of
chronic
empye-
ma
before
the
antibiotic
era."
7-1"
In
the
1940s
M
tuberculosis
was
responsible
for
73%
of
empyema
necessitatis.'
In
the
past
10
years,
tuberculosis
has
resurged
as
one
of
the
most
important
communicable
diseases
and
is
re-
sponsible
for
about
27%
of
preventable
deaths
worldwide."
Clinically,
it
should
suffice
to
say
that
in
the
1990s,
as
in
the
1890s,
any
puzzling
multisystem
disease
may
turn
out
to
be
tuberculosis.
Final
diagnosis
Tuberculosis.
Keywords:
empyema
necessitatis,
tuberculosis,
scro-
fula
1
Bhatt
GH,
Austin
HM.
CT
demonstration
of
empyema
necessitatis.
J
Comput
Assist
Tomogr
1985;
9:
1108-9.
2
Felson
B.
The
extrapleural
space.
Semin
Roentgenol
1977;
12:
327-33.
3
Sindel
EA.
Empyema
necessitatis.
Bull
Sea
View
Hosp
1940;
6:
1-49.
4
Bernstein
A,
White
FZ.
Unusual
findings
in
pleural
effusion:
intrathoracic
manometric
studies.
Ann
Intern
Med
1952;
37:
733.
5
Hochberg
LA.
A
study
of
300
cases
of
acute
empyema
thoracis.
J
Thorac
Surg
1941;
10:
354.
6
Muradali
D,
Gold
WL,
Vellend
H,
Becker
E.
Multifocal
osteoarticular
tuberculosis:
Report
of
four
cases
and
review
of
management.
Clin
Infect
Dis
1993;
17:
204-9.
7
Glicklich
M,
Mendeison
DS,
Gendal
ES,
Teirson
AS.
Tuberculous
empyema
necessitatis:
computed
tomographic
findings.
Clin
Imag
1990;
14:
23-5.
8
Haddad
CJ,
Sim
WK.
Empyema
necessitatis.
Am
Fam
Physician
1989;
40:
149
-
52.
9
Peterson
MW,
Austin
JH,
Yip
CK,
McManus
RP,
Jaretzki
A
3rd.
CT
findings
in
transdiaphragmatic
empyema
necessitatis
due
to
tuberculosis.
J
Comput
Assist
Tomogr
1987;
11:
704-6.
10
Eschelman
DJ,
Gibbens
DT,
et
al.
Chest
case
of
the
day.
Acta
Radiol
1991;
156:
1295-
1300.
11
Sepkowitz
KA,
Raffalli
J,
Riley
L,
Kiehn
TE,
Armstrong
D.
Tuberculosis
in
the
AIDS
era.
Clin
Microbiol
Rev
1995;
8:
180-99.
