Abstract
This case report highlights an uncommon sequelae of chest wall trauma that should be evaluated for patients presenting with similar history and symptoms. A 60-year-old man presented to the emergency department (ED) with swelling, fever, and chest wall pain two days after an assault with blunt chest wall trauma. On exam, there was a suspected chest wall abscess, verified on computed tomography (CT) with associated displaced midsternal fracture. This patient was admitted for abscess incision and drainage. While uncommon, chest wall abscess formation is an important condition that should be considered as a differential diagnosis in any patient presenting with chest wall pain post blunt trauma. With few reported similar presentations in the literature, this case is an important addition in a likely underreported phenomenon that requires prompt evaluation and treatment.
Topics
Blunt chest trauma, chest wall abscess, sternal fracture complication.
Brief introduction
Chest wall abscesses are a rare clinical phenomenon that arise secondary to tissue infection, osteomyelitis of the ribs, infection of the costochondral junction or sternoclavicular joint, or blunt chest trauma.1 Blunt chest trauma is a rare factor leading to chest wall abscess formation, seeing that very few case reports are currently published regarding this phenomenon. This case report reviews chest wall abscess as a complication of sternal fracture in the setting of a blunt chest trauma, including the different ways this phenomenon can be diagnosed and managed. Written consent was obtained for publishing the images as a case report.
Presenting concerns and clinical findings
A 60-year-old undomiciled male with a history of hypertension, tobacco use, and illicit fentanyl use presented to the ED with worsening midsternal chest pain and chest wall swelling status post an assault two days prior. He did not seek medical attention initially when the injury occurred. The patient reported someone stepped on his chest and denied any other symptoms. He had no significant family history. Physical examination revealed an 8-cm area of induration, erythema, and fluctuance in the mid-sternal chest wall (blue arrow) with chest wall tenderness but no crepitus or instability. His blood pressure was 167/102 mm Hg, and his other vitals were within normal limits. The rest of his exam was unremarkable.
Significant findings
On exam, we found a suspected chest wall abscess with surrounding erythema (blue arrow). The patient underwent CT of the chest which showed a comminuted displaced midsternal fracture (yellow arrow) with moderate fluid and air anteriorly (red arrow), consistent with an abscess. His laboratory results had no significant abnormalities.
Patient course
We consulted trauma surgery for further evaluation and management of the patient’s traumatic injuries. He was admitted for infection and pain control. The trauma surgery team performed an incision and drainage of the abscess and sent the fluid for cultures. The patient tolerated the procedure well without complications. He was started on vancomycin due to his risk factors for methicillin-resistant Staphylococcus aureus (MRSA), then was transitioned to oral sulfamethoxazole-trimethoprim. He was clinically improving and had no significant abnormalities in his subsequent laboratory results. He was discharged on admission day three with sulfamethoxazole-trimethoprim for seven days, wound care instructions and supplies, and plans for outpatient follow-up. Unfortunately, no further documentation was available in our electronic medical records regarding follow-up visits after discharge, and we were unsuccessful in contacting the patient to discuss patient-reported outcomes.
Discussion
In previous case reports of blunt chest trauma, abscesses were detected five days to two months after the initial trauma with or without the presence of a sternal wall fracture.2–11 Trauma, in general, is a risk factor for abscess formation in the body, along with immunosuppression and impaired circulation.12 Based on these case reports, no specific type of blunt chest trauma has been associated with increased risk of abscess formation.2–11 Though we do not believe that the abscess could have been prevented if patient presented at the time of injury, it would be interesting to see studies regarding whether certain patient risk factors or type of blunt trauma could warrant prophylactic antibiotic treatment for prevention of infection and abscess formation. Staphylococcus aureus is the most common causative organism.2–8
These abscesses are diagnosed by ultrasound (US) or CT.1–9 Ultrasound of any body part is able to detect abscesses with a sensitivity of 95–97% and specificity of 83–85%, while CT had a sensitivity of 77% and specificity of 91%.13–14 Though sensitivity and specificity of CT may be lower than US, CT has high sensitivity, with up to 100% in one study; therefore, CT may be more beneficial for evaluating chest wall infection or abscess in the setting of a sternal fracture.15–16
Treatment for chest wall abscesses varies depending on the severity of infection, including systemic antibiotics, bedside incision and drainage, and surgical debridement or chest wall reconstruction.2–11,17 In most of the reviewed case reports, patients recovered well with some cases having no recurrence in six months.1,8 Though we did not find specific case reports regarding complications from chest wall abscesses, fulminant infections can occur with delayed treatment especially in aged or immunocompromised patients; thus, prompt and appropriate management is important in treating chest wall abscesses.1
In conclusion, physicians should consider infectious etiologies, including cellulitis and abscess, in patients presenting with worsening chest pain following blunt chest trauma. A thorough physical exam and, if needed, diagnostic imaging with US or a CT scan of chest will allow a proper diagnosis of chest wall abscess. Initial treatment includes incision and drainage of the abscess in addition to systemic antibiotics covering for MRSA, with good prognosis if detected and treated in a timely manner.
Supplementary Information
Funding Statement
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.
Footnotes
Disclaimer Statement: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
References
- 1.Yamaoka Y, Yamamura J, Masuda N, et al. Primary chest wall abscess mimicking a breast tumor that occurred after blunt chest trauma: a case report. Case Rep Med. 2014;2014:620876. doi: 10.1155/2014/620876. Epub 2014 Feb 9. At: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Caruana V, Swayne LC. Gallium detection of Salmonella costochondritis. Journal of Nuclear Medicine. 1988;29(12):2004–2007. [PubMed] [Google Scholar]
- 3.Hananel JI, Hulbert TV, Larsen RA. Case report: recurrent Salmonella typhi chest wall abscess associated with a pituitary macroadenoma. The American Journal of the Medical Sciences. 1992;304(1):43–44. doi: 10.1097/00000441-199207000-00011. [DOI] [PubMed] [Google Scholar]
- 4.Gregory MW, Jacobsen WM. Closed blunt chest trauma causing mediastinal abscess. J Trauma. 1996;41(5):899–901. doi: 10.1097/00005373-199611000-00025. [DOI] [PubMed] [Google Scholar]
- 5.Jayle CP, Corbi PJ, Franco S, et al. Destructive sternitis 3 years after blunt chest trauma. Ann Thorac Surg. 2005;80(1):348. doi: 10.1016/j.athoracsur.2003.09.093. [DOI] [PubMed] [Google Scholar]
- 6.Gilart JF, Violán JS, de Castro FR. Multiple chest wall abscesses complicating blunt chest trauma. Archivos de Bronconeumologia. 2007;43(10):588–589. [PubMed] [Google Scholar]
- 7.Sakran W, Bisharat N. Primary chest wall abscess caused by Escherichia coli costochondritis. The American Journal of the Medical Sciences. 2011;342(3):241–246. doi: 10.1097/MAJ.0b013e31821bc1b0. [DOI] [PubMed] [Google Scholar]
- 8.Ichimura H, Ozawa Y, Sato T, et al. Sternal osteomyelitis and abscess caused by elbowing during a basketball game. Case Rep Med. 2012;2012(3):298187. doi: 10.1155/2012/298187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Fukuhara S, Sameshima T, Matsuo H, et al. Sternal fracture complicated by a subcutaneous abscess in a 5-year-old boy and diagnosed using point-of-care ulltrasound. J Emerg Med. 2019 May;56(5):536–9. doi: 10.1016/j.jemermed.2018.12.040. At: [DOI] [PubMed] [Google Scholar]
- 10.Philip MA, Mathew A, Pandyan MS, et al. Rare case of delayed presentation of chest wall abscess following blunt trauma. Indian J Thorac Cardiovasc Surg. 2006 Mar;22(86) At: s12055-006-06866. [Google Scholar]
- 11.Tatsura S, Ken-ichiro K, Masayuki O, et al. Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma. Chin J Traumatol. 2015 Dec;18(6):360–62. doi: 10.1016/j.cjtee.2015.12.002. At: [DOI] [PubMed] [Google Scholar]
- 12.Rehmus WE. Cutaneous Abscess. Merck Manual. 2023 Jun; Retrieved from: https://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/cutaneous-abscess. [Google Scholar]
- 13.Subramaniam S, Bober J, Chao J, et al. Point-of-care ultrasound for diagnosis of abscess in skin and soft tissue infections. Acad Emerg Med. 2016 Nov;23(11):1298–1306. doi: 10.1111/acem.13049. At: [DOI] [PubMed] [Google Scholar]
- 14.Gottlieb M, Avila J, Chottiner M, et al. Point-of-care ultrasonography for the diagnosis of skin and soft tissue abscesses: a systematic review and meta-analysis. Ann Emerg Med. 2020 Jul;76(1):67–77. doi: 10.1016/j.annemergmed.2020.01.004. Erratum in Ann Emerg Med 2022 Jan; 79(1):90. At: [DOI] [PubMed] [Google Scholar]
- 15.Gaspari R, Dayno M, Briones J, et al. Comparison of computerized tomography and ultrasound for diagnosing soft tissue abscesses. Crit Ultrasound J. 2012 Apr 17;4(1):5. doi: 10.1186/20367902-4-5. At: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Kim EY, Yang HJ, Sung YM, et al. Sternal fracture in the emergency department: diagnostic value of multidetector CT with sagittal and coronal reconstruction images. Eur J Radiol. 2011 Jun;81(5):708–11. doi: 10.1016/j.ejrad.2011.05.029. At: [DOI] [PubMed] [Google Scholar]
- 17.Locicero J. Infections of the chest wall. In: Shields TW, Reed CE, Fenis RH, editors. General Thoracic Surgery. 7th edition. Philadelphia, Pa, USA: Lippincott, Williams Wilkins; 2009. pp. 633–639. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.