Painful thoracic swelling in a refugee teenager

Abstract

CaseA 14-year-old refugee, escaping from a Middle East war zone, was admitted with a 3-month history of chest pain and a 2-week history of sternal swelling. The patient had no previous medical history, but reported having been beaten by a policeman at a border at the beginning of his journey. He did not have the following symptoms: cough, wheezing fever, weight loss and sweating. When he was admitted to the hospital, he was afebrile; blood pressure was 120/70 mm Hg, pulse 95 beats per minute and oxygen saturation 97% while breathing ambient air. On physical examination, there was a 10 cm fluctuating swelling in the sternal region. The lesion was reddish, warm, tender and painful (figure 1). Digital clubbing was also noticed. The remaining examination was normal. White blood cell count was 9000 cells per mm3, haemoglobin 145 g/L, erythrocyte sedimentation rate and C reactive protein were normal as well as renal and liver function tests. ECG was regular.Figure 1Swelling in the sternal region.Question 1Based on the clinical picture, laboratory tests and history, what is the most likely diagnosis?Chest wall tuberculosisLymphomaThoracic actinomycosisInfected haematomaQuestion 2Which is the best diagnostic test to confirm this diagnosis?Ultrasound scanMRICTChest radiographQuestion 3What is the mainstay of the management of this condition?Drainage of the abscessAntitubercular chemotherapyAspiration of the abscess and antitubercular chemotherapyHyperbaric oxygen therapyAnswers can be found on page 02.