Isolated primary cold abscess of the sternum: a case report.

BACKGROUND: Musculoskeletal tuberculosis forms 10-25% of extrapulmonary tuberculosis which mainly involves the spine or weight-bearing joints. Tuberculous involvement of the sternum is a rare clinical entity even in countries where tuberculosis has high prevalence. Primary tuberculous sternal osteomyelitis accounts for approximately 0.3% of all types of tubercular osteomyelitis and the probable source appears to be extension from paratracheal or hilar lymph nodes. Despite tuberculosis being a common disease in endemic countries and worldwide, a thorough literature search of the PubMed database for keywords "primary tuberculosis of sternum" and "primary tuberculous osteomyelitis of sternum" yielded 30 and 22 articles, respectively. CASE PRESENTATION: We present an unusual case of a large dumb-bell-shaped cold abscess arising due to infection of the sternum. A 23-year-old immunocompetent Asian woman presented with a gradually progressing painless swelling on anterior chest wall for the last 5 months. She had a large visible swelling on anterior chest wall which was 12.5 cm in diameter, soft, non-tender, temperature was not raised, and fluctuant. Magnetic resonance imaging showed a large dumb-bell-shaped hyperintense collection in upper anterior chest wall with marrow edema and cortical irregularity in left side of manubrium. Pus was positive for nucleic acid testing (cartridge-based nucleic acid amplification test) for Mycobacterium tuberculosis and later culture was also positive. She was started on anti-tubercular therapy and aspirated twice. Currently, she has completed 6 months of therapy and the swelling has now disappeared. DISCUSSION: Swelling, pain localized to sternum, or ulceration of the skin with discharging sinus along with or without constitutional symptoms are the usual presentation. A high element of suspicion is needed for early diagnosis and treatment to prevent its complications. Sternal mycobacterial infections are categorized as primary, secondary, and/or acquired postoperatively. Although radiological investigations aid in diagnosis, the diagnosis is established by positive culture or histopathological examination. Anti-tubercular therapy is the mainstay of treatment with standard four-drug regimen for 6-9 months. Surgical drainage of the abscess should be considered only if it does not resolve by aspiration and anti-tubercular therapy.

Validation of a scoring system to predict difficult laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures being performed by general surgeons all over the world. Preoperative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. The purpose of our prospective study was to analyze various risk factors and to predict difficulty and degree of difficulty preoperatively by the use of a scoring system. MATERIALS: This prospective study was conducted in the department of surgery, Lady Hardinge Medical College and associated Dr Ram Manohar Lohia Hospital, Delhi, India. The parameters considered in the preoperative scoring method were old age, male sex, history of hospitalization, obesity, previous abdominal surgery scar, palpable gall bladder, wall thickness of gall bladder, pericholecystic collection and impacted stone. A total of 210 patients were included in the study. RESULTS: We found that history of hospitalization, palpable gall bladder, impacted stone and gall bladder wall thickness were statistically significant factors for prediction of difficult laparoscopic cholecystectomy. Sensitivity and specificity of this preoperative scoring method were found to be 95.74% and 73.68% respectively. Positive predictive values of this scoring method were 90% and 88% for easy and difficult cases respectively. Area under ROC curve was 0.86. Conversion rate from laparoscopic to open cholecystectomy was found to be 4.28%. CONCLUSION: With the help of accurate prediction, high risk patient may be informed before hand regarding the probability of conversion and hence they may have a chance to make arrangements accordingly. On the other hand, surgeons also may have to schedule the time and team for the operation appropriately. Surgeons can also be aware about the possible complications that may arise in high risk patients.

Extraosseous Ewing's tumor of lateral abdominal wall.

Extraosseous Ewings tumor (EES) is a rare entity. Few cases have been reported in literature. There are no specific guidelines for management of this disease. We are reporting a case of EES arising from left lateral abdominal wall. We did wide excision of tumor followed by chemoradiation. Patient is asymptomatic after 8 months of follow up.