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What causes lytic lesions in right 2nd and 3rd rib with pain?

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Posted on Sat, 16 May 2015
Question: Hi,

My sister was experiencing pain in the right 2nd and 3rd ribs since last 10 years. The inflammation of the 2nd and 3rd ribs on the right have been there since last 10 years but the pain used to be very sporadic like once every month. We did consult doctors in the past and nobody could definitely give a solution.
However since last December 2014 the pain increased after which we visited a top hospital where she was suggested Xray, CT Scan and MRI. Subsequent xray, ct scan and mri were done which suggested lytic lesions due to infectious etiology.After the results were out CRP and ESR test was suggested and it was found that the levels were above normal.
The ortho specialist then came to the conclusion that this is Bone TB and prescribed AKT4. Since then 2 months have passed and she has been on this medication. When we followed up again our ortho specialist suggested that since the pain is still there this is not Bone TB. We did a FNAC test but no malignant cells were found. Now a biopsy is being suggested to determine the root cause of bone pain which is being suspected either as a bacterila infection or a benign tumor.. However a second opinion with another ortho specialist suggested for complete removal of the 2nd and 3rd ribs rather than have 2 different surgeries as no one is definitely able to identify the root cause of bone swelling.
Please advice.
doctor
Answered by Dr. Praveen Tayal (2 hours later)
Brief Answer:
Continue AKT4 for one more month and then do a repeat MRI scan.

Detailed Answer:
Hello,
Thanks for posting your query.
A lytic lesion in the 2nd and 3 rd rib with pain can be due to infectious cause like tuberculosis. If the FNAC was negative for malignant cells then an infection is the most likely cause. Rather than going for a major surgery to remove the two ribs it is better to continue with AKT4 for one more month and get a repeat MRI scan to see any progress of the lesion. In case the lesion is decreasing gradually then there is no need to worry. The pain will also gradually improve with time.
I hope this answers your query.
In case you have additional questions or doubts, you can forward them to me, and I shall be glad to help you out.
Wishing you good health.
Regards.
Dr. Praveen Tayal.
For future query, you can directly approach me through my profile URL http://bit.ly/Dr-Praveen-Tayal
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Praveen Tayal (1 hour later)
Hello Sir,

Thanks for the reply. I am sharing the exact reports details for Xray, MRI, CT Scan and FNAC below.
Please note that AKT4 was suggested based on Xray, MRI, CT Scan and ESR and CRP tests only.
FNAC was done recently as the pain was not diminishing.

XRAY REPORT:
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Right 2nd and 3rd ribs shows ill defined sclerotic lesions in antero lateral aspect.
Small lytic area are noted within.
No other focal lesion in the visualized bones
No evidence of fracture
Lungs are clear
Hila are normal
CP angles are clear
Domes of Diaphragm are normal

Impression:
Recommended clinical correlation and further evaluation

CT CHEST/RIBS FINDINGS:
==================
Anterior chest wall deformity is noted on the right.
The 2nd and 3rd right anterior ribs are expanded and demonstrate multiple lytic foci with evidence of cortical erosion.
There is associated soft tissue thickening and stranding in the intercostal regions.
Rest of the ribs, sternum and the other visualised bones are within normal limits.
Dependent changes are seen in the lungs.
No focal lung lesion is seen.No pleural abnormality.
No significant upper abdominal abnormality.

MRI OF THE CHEST FINDINGS:
===================
Correlation is made with the CT performed on the same day.
MRI confirms the presence of expansile lytic lesions in the right 2nd and 3rd anterior ribs with associated soft tissue components.
Unremarkable appearances of the sternoclavicular joints.

IMPRESSION:
Expansile, lytic lesions in the right sided 2nd and 3rd anterior ribs with associated soft tissue thickening/oedema. Appearances are suggestive of an infectious etiology. Suggest biopsy for confirmation.


FNAC Report
========
US guided FNA of right anterior chest wall swelling involving 2nd and 3rd ribs
Smears are predominantly haemorrhagic consisting of few muscle fragments and few inflammatory cells. Epithelioid cell granuloma or malignant cells are not present.


My questions are:
1. Why did the pain appear only sporadically over the last 10 years
2. Why did the pain increase abnormally after AKT4 medication started
3. Are there any blood tests that can definitely confirm Bone TB ?
doctor
Answered by Dr. Praveen Tayal (2 hours later)
Brief Answer:
Details below.

Detailed Answer:
Hello.
Thanks for writing again.
I have seen the attached reports.
1. The pain gradually increased as TB is a chronic infection. It spreads slowly. If not treated it causes intermittent pain that later on becomes a continuous pain.
2. Initially after starting the treatment there can be aggravation of symptoms like pain. After taking the medicine for a few weeks as the infection is controlled the symptoms gradually decrease.
3. TB gold test is done to detect TB. To confirm bone TB bone biopsy and culture is the only sure test.
Hope my answer is helpful.
Do accept my answer in case there are no further queries.
Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Praveen Tayal (11 hours later)
Hi,

Thanks for the advice.
Few more questions:
The intensity of the pain was almost the same in the last 10 years. The only difference was that it used to happen intermittently. Since AKT4 medication started the pain increased a lot and it did not stop even after 2 months of continuous dose. The swelling of the bone did not get better as well.
What should be done now ? Should we go for bone biopsy ?
Anything to worry about ?
doctor
Answered by Dr. Praveen Tayal (2 hours later)
Brief Answer:
Bone biopsy will confirm diagnosis.

Detailed Answer:
If the pain has not decreased at all and is gradually increasing then it is best to go for a bone biopsy and reach a definitive diagnosis so that specific therapy can be started. Meanwhile continue taking AKT-4. She can take mild pain killers and do a hot compress in the area to help with the pain.
Regards.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Praveen Tayal (42 minutes later)
Hi,

What sort of bone biopsy should we do ? Will incision biopsy be good enough in which case she does not need to go through surgery procedure ?
Our doctor has suggested not to use AKT4 right now as he explained that AKT4 medication might not help the biopsy process of determining infection.
Finally by looking at the reports do you feed that there are any tumors ?
doctor
Answered by Dr. Praveen Tayal (7 hours later)
Brief Answer:
Tumor is not likely.

Detailed Answer:
Incision biopsy should be sufficient. Any tumor does not look likely. She can stop taking AKT-4 for biopsy as it will help in detecting tubercle bacilli if there are any.
Regards.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Praveen Tayal (18 hours later)
Hi,

Thanks for following up.
Is it possible for AKT4 to increase pain in case there is no Bone TB ?
We kind of want to know why the pain increased so much after the AKT4 medication started. Now even after it has been stopped for 6 days the pain remains normal throughout the day and gets worse at night.
doctor
Answered by Dr. Praveen Tayal (5 hours later)
Brief Answer:
Details below.

Detailed Answer:
AKT 4 will aggravate the pain only in case of TB and not in case of tumor. The increase in pain can be due to spread of the lesion. The pain will not subside immediately after stopping AKT4. The flare up of the disease has to be controlled to reduce the pain.
Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Praveen Tayal (17 hours later)
Hi,

We found the X-ray report from 10 years before. It says fibrous dysplasia noted in right 3rd rib.
Can you please co relate this report with the current reports that I shared above.
doctor
Answered by Dr. Praveen Tayal (6 hours later)
Brief Answer:
Can be fibrous dysplasia.

Detailed Answer:
If fibrous dysplasia was detected 10 years ago then this could have spread to the second rib. It is a benign tumor. Since the area is painful it is best to get it removed. The MRI appearance that has been described can be related to fibrous dysplasia. Excision biopsy will help in confirmation.
Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Dr. Praveen Tayal

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What causes lytic lesions in right 2nd and 3rd rib with pain?

Brief Answer: Continue AKT4 for one more month and then do a repeat MRI scan. Detailed Answer: Hello, Thanks for posting your query. A lytic lesion in the 2nd and 3 rd rib with pain can be due to infectious cause like tuberculosis. If the FNAC was negative for malignant cells then an infection is the most likely cause. Rather than going for a major surgery to remove the two ribs it is better to continue with AKT4 for one more month and get a repeat MRI scan to see any progress of the lesion. In case the lesion is decreasing gradually then there is no need to worry. The pain will also gradually improve with time. I hope this answers your query. In case you have additional questions or doubts, you can forward them to me, and I shall be glad to help you out. Wishing you good health. Regards. Dr. Praveen Tayal. For future query, you can directly approach me through my profile URL http://bit.ly/Dr-Praveen-Tayal