Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 55, Num. 4, 2009, pp. 276-277

Journal of Postgraduate Medicine, Vol. 55, No. 4, October-December, 2009, pp. 276-277

Case Snippet

Sternal tuberculosis and gynecomastia

Gupta R, Gupta A¹ , Gupta KB, Sood S¹

Departments of Tuberculosis and Respiratory Medicine and ¹ Physiology, Pt B D Sharma PGIMS Rohtak, Haryana - 124 001, India

Correspondence Address: Dr. Rajesh Gupta, Department of Tuberculosis and Respiratory Medicine, Pt B D Sharma PGIMS Rohtak, Haryana - 124 001, India, drrajesh63@yahoo.co.in

Code Number: jp09088

PMID: 20083877

DOI: 10.4103/0022-3859.58934

A 20-year-old male presented with cough with scanty purulent sputum, low-grade fever with evening rise, loss of weight and appetite for the past six months. Within a month after the development of these symptoms, he developed a swelling of the size around 7 x 5 cm just below the xiphisternum that resulted in sinus formation. At presentation, this site showed some oozing with an induration of 5 x 6 cm. Another swelling, almost similar in size and shape, appeared in the right supra-mammary region within a month of the development of the first one, which was painful and had increased to 15 x 20 cm at presentation. He had bilateral enlargement of breast and gynecomastia [Figure - 1] of about four months duration with mild pain and tenderness. His external genitalia and secondary sexual characteristics were normal. He was neither a smoker nor an alcoholic. There was no history of prolonged medication. On investigation, the patient was found to be mildly anemic (Hb: 9.5 g%) with raised ESR (46 mm in first hour), and a negative HIV test. Various biochemical parameters were within normal limits as shown in the [Table - 1]. The three specimens of sputum smears were negative for AFB and the pus aspirated from abscess was sterile. Chest radiograph showed mediastinal widening more on right side with hilar prominence on both sides. USG abdomen was normal. USG-guided FNAC of the swelling demonstrated nonspecific inflammation with mammary tissue. In addition to confirming the chest radiographic findings, CT scan [Figure - 2] revealed erosion, irregularity and sclerosis of the right lateral aspect of the sternum. Multiple abscesses were present in the right anterior chest wall and in the retro-sternal region of the superior mediastinum. A diagnosis of tuberculosis was made on the basis of positive PCR of the pus aspirated from the abscess. He responded to four-drug anti tubercular treatment with disappearance of abscess. At three-month follow-up visit the patient is asymptomatic, and the gynecomastia has subsided partially with disappearance of local pain and tenderness. Sternal osteomyelitis of tubercular etiology is an uncommon entity. ^[1]

This association of tubercular osteomyelitis of the sternum and gynecomastia has not been hitherto reported in literature. However, chest wall injury has been listed as a cause of gynecomastia. ^[2] Puberty, endocrine disorders and drug therapy are the other common causes of gynecomastia. INH-induced gynecomastia has also been reported. ^[3] The exact mechanism by which tuberculous osteomyelitis could have caused gynecomastia is a matter of speculation. We think that it could either be related to a nerve injury due to tubercular erosion or to endocrinal dysfunction by an unknown mechanism. It is worthwhile noting that nerve injury was implicated in a case of gynecomastia associated with herpes zoster. ^[4]

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