Case reports
1992, The British Journal of Radiology, 65, 822-824
Case reports Tuberculosis of the ribs: computed tomographic findings By R. FitzGerald, FRCR and *C. E. Hutchinson, BSc, FRCR, FFRRCSI Department of Radiology, New Cross Hospital, Wolverhampton, UK (Received 10 September 1991 and in revised form 9 January 1992, accepted 11 February 1992) Keywords: Osseous tuberculosis, Computed tomography, Mediastinal lymphadenopathy Tuberculosis (TB) is still endemic in Britain, 5474 cases being notified in England and Wales during 1989 (9:100000). Eighty-one new cases of TB were notified in Wolverhampton during that year (31:100000). Despite the introduction of preventative and curative treatment, this is little less than half the 195 new cases of TB in Wolverhampton notified during 1947 (Report of the Director of Public Health, Wolverhampton, 1990). The ethnic minorities in Britain are overrepresented amongst the patients with tuberculosis (Davies etal, 1984). Wolverhampton has a rate three times the national average, and this is considered to be due to the social and ethnic structure of its population. In the USA the incidence of tuberculosis, which had been previously declining over decades, has since 1985 shown an increase (Buckner etal, 1991). This is considered to be due to the HIV epidemic. Clinical manifestations of tuberculosis in patients with AIDS are often atypical. In approximately 15% of patients without HIV infection TB occurs at extrapulmonary sites, whereas this is seen in 40% of patients who are HIV positive (Goldsmith, 1990). Bony tuberculosis is classically described in about 1 % of patients with tuberculosis (Davidson & Horowitz, 1970). The rib is an uncommon site of osteoarticular tuberculosis. We present two cases of rib tuberculosis which demonstrate the computed tomographic (CT) appearances and the role of CT in its diagnosis.
Figure 1. Case 1. Dynamic CT, 100 ml iohexol (300mgI/ml). Chest wall and pleural soft tissue lesion with rim enhancement and low attenuation centre. Aspiration of this lesion yielded pus which grew tuberculous bacilli.
Case reports Case 1 An 80-year-old male Indian farmer presented with lower left chest pain for 6 months. He had smoked until 3 years prior to his admission. Chest radiograph showed a destructive lesion in the left 5th rib with associated soft tissue shadowing. The mediastinum was unremarkable on the chest film. The lesion was initially thought to be malignant, CT was performed and showed right paratracheal, carinal and sub-carinal lymph node enlargement. There was an area of low attenuation with rim enhancement seen deep to serratus anterior and contiguous with a similar lesion in the pleural space (Fig. 1). On bone settings there was destruction of the associated rib. CT attenuation reading of this lesion suggested it to be a fluid density.
Case 2 A 39-year-old male Indian solicitor was referred with a three month history of pain in the left parasternal region and also interscapular pain. He had a pyrexia, weight loss, anorexia and was experiencing night sweats. On his chest film there was suspicion of right paratracheal nodal enlargement. CT was performed 6 days later in an effort to confirm this. On PA and lateral chest radiographs there was no evidence of chest wall abnormality. CT showed right paratracheal, carinal and sub-carinal nodal enlargement. The sub-carinal nodes showed peripheral enhancement with central low density (Fig. 2). In the left posterior upper thorax there was a lesion involving the chest wall, rib and pleural space (Fig. 3). Again the CT attenuation suggested fluid density. Biopsy confirmed the presence of tuberculosis bacilli. Neither patient was thought to be at risk for HIV infection.
*Present address: University of Manchester, Department of Diagnostic Radiology, Stopford Building, Oxford Road, Manchester, M13 9PT, UK.
Discussion The ribs are unusual sites for osteo-articular tuberculosis, occurring in none of 36 patients described by
822
The British Journal of Radiology, September 1992
Case reports
Figure 3. Case 2. Post-contrast CT, 50 ml bolus iohexol (300mgI/ml). Fluid density lesion involving chest wall,riband pleura! space seen in upper left thorax posteriorly.
Figure 2. Case 2. Post-contrast CT, 50 ml bolus iohexol (300 mgl/ml). Subcarinal lymph node enlargement exhibiting peripheral enhancement and lower attenuation centre.
Foley-Nolan et al (1991) nor in any of 71 patients reported by Rathakrishnan & Mohd (1989) and in only two of 499 cases described by Goldblatt & Cremin (1978). Newton cited one case of 'chest wall' TB in his series of 74 Manchester patients (Newton et al, 1982) and Nicholson found that 14 of their 176 patients had TB involving 'ribs, manubrium and sternum' (Nicholson, 1974). Brown in Bradford was able to identify and describe seven cases of tuberculosis of the ribs (Brown, 1980). In the largest series reported, the shaft was the site of infection in the majority of the 23 cases of rib tuberculosis (Tatelman & Drouillard, 1953). Costovertebral involvement was the next most common presentation invariably associated with tuberculous spondylitis. In our first case, CT images on bone settings demonstrated irregular bone destruction that was not shown on plain radiographs. In our second case, CT demonstrated bony destruction and the associated soft tissue lesion, neither of which were apparent on the plain films. The nature of bone destruction shown on CT was as one would expect from descriptions in a conventional radiology text (Thijn & Sheensma, 1990), or in previous Vol. 65, No. 777
reports of skeletal tuberculosis demonstrated with CT (Coppola et al, 1987; Ip et al, 1989). The associated soft tissue lesions in our patients had similar features of central low attenuation with rim enhancement which Coppola et al (1987) described in a review paper of CT in musculoskeletal tuberculosis. Similar appearance of TB of the chest wall was shown by Eschelman et al (1991). However, one should be aware of other imaging findings in rib tuberculosis not seen in our patients. Ip et al (1989) described two patients with rib tuberculosis whose associated soft tissue component did not have a low attenuation centre, and relative high attenuation rim. Such an appearance could obviously mimic a tumour and indeed tumour-like tuberculous lesions of bone have been described at other sites (Abdelwahab etal, 1987). The differential diagnosis of an irregular destructive rib lesion associated with an adjacent soft tissue mass with or without low attenuation change would include metastasis, multiple myeloma, Ewing's and invasive peripheral lung cancer, as well as infective pathology such as actinomycosis and other indolent infections. Im et al (1987) found the presence of low density areas within enlarged mediastinal nodes to be very helpful in differentiating tuberculosis from other causes of mediastinal lymphadenopathy (22/23 patients). They demonstrated a marked preponderance of enlarged tuberculous mediastinal nodes to be in the right paratracheal, right tracheobronchial and the sub-carinal areas. Our two patients conformed to this pattern. Low attenuation change in enlarged mediastinal nodes is recognized in lymphoma (North et al, 1990) and metastatic disease, if somewhat unusual (Im et al, 1987). There is overlap in the distribution of enlarged mediastinal nodes in tuberculosis versus neoplastic disease with lymphoma often involving the right paratracheal area. However, sparing of the prevascular and hilar areas is very suggestive of mediastinal TB. Coloured patients have been shown to exhibit 823
Case reports
changes of sclerosis and/or florid periosteal reaction associated with their tuberculous bone destruction on plain radiography (Jacobs, 1964; Chapman et al, 1979). Although this was not seen in our patients nor in those of Coppola et al (1987) or Ip et al (1989), one would expect in due course to see such CTfindingsdescribed. Because of the AIDS epidemic and the associated increase in the incidence of TB, this is a diagnosis that needs to be considered more frequently than in the recent past. Moreover, given the high rate of extrapulmonary involvement (Goldsmith, 1990), radiologists will need to be attentive to the skeletal manifestations of tuberculosis. Firooznia etal (1973) in a report of 21 cases of disseminated extrapulmonary tuberculosis associated with heroin addiction found that the ribs were the most common site of infection in this group of patients. Tuberculosis has been shown to occur earlier in the course of HIV infection than other opportunistic infections such as pneumocystic carinii (Goodman, 1990). Delays of many months in the diagnosis of skeletal tuberculosis are well recognized (Newton et al, 1982) but they still occur (Foley-Nolan et al, 1991), but early CT of the thorax and recognition of the features described here may expedite the diagnosis. In conclusion, the CT findings or irregular rib destruction, with an associated soft tissue lesion which exhibits a low attenuation centre and exhancing rim combined with right-sided mediastinal node enlargement should alert the radiologist to a diagnosis of rib tuberculosis and, if the patient is not of a social group predisposed to tuberculosis, consideration should be given to the possibility of drug abuse or HIV infection. Acknowledgments We would like to thank Dr S. J. Connellan and Dr J. S. Mann for their permission to report their patients. References ABDELWAHALE, I., PRESENT, D. A., ZWASS, A., KLEIN, M. J. &
MAZZRA, J., 1987. Tumour-like tuberculous granulomas of bone. American Journal of Roentgenology, 149, 1207-1208. BROWN, T. S., 1980. Tuberculosis of the ribs. Clinical Radiology, 31, 681-684. BUCKNER, C. B., LEITHISER, E., WALKER, C. W. & ALLISON,
J. W., 1991. The changing epidemiology of tuberculosis and other mycobacterial infections in the United States: implications for the radiologists. American Journal of Roentgenology, 156, 255-264. CHAPMAN,
M.,
MURRAY,
R. O.
Tuberculosis of the bones Roentgenology, 14, 266-282. COPPOLA,
J.,
MULLER,
N. L.
&
STOKER,
and joints.
D. J.,
1979.
Seminars in
DAVIDSON, P. T. & HOROWITZ, J., 1970. Skeletal tuberculosis
—a review with patient presentations and discussions. American Journal of Medicine, 48, 77-84. D A VIES, P. D. O., HUMPHRIES, M. J., BYFIELD, S. P., NUNN, A. J., DARYSHIRE, J. H., CITRON, K. M. & Fox, W., 1984.
Bone and joint tuberculosis; a survey of notifications in England and Wales. Journal of Bone and Joint Surgery, 66B, 326-330. ECHELMAN, D . J., GlBBENS, D . T., FIELDING, J. R., ROMO, L. V., PARKER, D. R., ARGY, N. & O'CONNOR, J. F., 1991.
Chest case of the day. American Journal of Roentgenology, 156, 1295-1300. FIROOZNIA, H., SELINGER, G., ABRAMS, R. M., VALENSI, V. &
SHAMOUN, J., 1973. Disseminated extrapulmonary tuberculosis in association with heroin addiction. Radiology, 109, 291-296. FOLEY-NOLAN, D . , DEEGAN, R. I., FOLEY-NOLAN, A . A . , BARRY, C , COUGHLAN, R. J. & HONE, R., 1991. Skeletal
tuberculosis. Irish Medical Journal, 84, 72-73. GOLDBLATT,
M.
&
CREMIN,
B. J.,
1978.
Osteo-articular
tuberculosis: its presentation in coloured races. Radiology, 29, 669-677. GOLDSMITH, M. F., 1990. Fogotten (almost) but not gone, tuberculosis suddenly looms large on domestic scene. Journal of the American Medical Association, 264, 165-166. GOODMAN, P. C , 1990. Pulmonary tuberculosis in patients with acquired immunodeficiency syndrome. Journal of Thoracic Imaging, 5, 38-45. IM, J. G., SONG, K. S., KANG, H. S., PARK, J. H., YEON, K. M.,
HAN, M. C. & KIM, C. W., 1987. Mediastinal tuberculosis lymphadenitis: CT manifestations. Radiology, 164, 115-119. IP, M., CHEN, N. K., SO, S. Y., CHIEI, S. W., & LAM, W. K.,
1989. Unusual rib destruction in pleuropulmonary tuberculosis. Chest, 95, 242-244. JACOBS, P., 1964. Osteo-articular tuberculosis in coloured immigrants: a radiological study. Clinical Radiology, 15, 59-69. NEWTON, P., SHARP, J. & BARNES, K. L., 1982. Bone and joint
tuberculosis in Greater Manchester, 1969-1979. Annals of the Rheumatic Diseases, 41, 1-6. NICHOLSON, R. A., 1974. Twenty years of bone and joint tuberculosis in Bradford. Journal of Bone and Joint Surgery, 56B, 760-765. NORTH, L. B., LIBSHITZ, H. I. & LORIGAN, J. G., 1990. Thoracic
lymphoma. Radiologic Clinics of North America, 28 (4), 745-762. RATHAKRISHNAN, V. & MOHD, T. H., 1989. Osteo-articular
tuberculosis. Skeletal Radiology, 18, 267-272. REPORT OF DIRECTOR OF PUBLIC HEALTH, WOLVERHAMPTON,
1990. Chapter 12, pp. 51-53. TATELMAN, M. & DROUILLARD, E. J. P., 1953. Tuberculosis of
the ribs. American Journal of Roentgenology, 70, 923-935. THIJN, C. J. P., & SHEENSMA, J. T., 1990. Tuberculosis of the
&
CONNELL,
D. G.,
1987.
Computed tomography of musculoskeletal • tuberculosis.
824
Journal of the Canadian Association of Radiologists, 38, 199-203.
Skeleton. Focus on Radiology (Springer-Verlag, Heidelberg), p. 144.
The British Journal of Radiology, September 1992
1992, The British Journal of Radiology, 65, 822-824
Case reports Tuberculosis of the ribs: computed tomographic findings By R. FitzGerald, FRCR and *C. E. Hutchinson, BSc, FRCR, FFRRCSI Department of Radiology, New Cross Hospital, Wolverhampton, UK (Received 10 September 1991 and in revised form 9 January 1992, accepted 11 February 1992) Keywords: Osseous tuberculosis, Computed tomography, Mediastinal lymphadenopathy Tuberculosis (TB) is still endemic in Britain, 5474 cases being notified in England and Wales during 1989 (9:100000). Eighty-one new cases of TB were notified in Wolverhampton during that year (31:100000). Despite the introduction of preventative and curative treatment, this is little less than half the 195 new cases of TB in Wolverhampton notified during 1947 (Report of the Director of Public Health, Wolverhampton, 1990). The ethnic minorities in Britain are overrepresented amongst the patients with tuberculosis (Davies etal, 1984). Wolverhampton has a rate three times the national average, and this is considered to be due to the social and ethnic structure of its population. In the USA the incidence of tuberculosis, which had been previously declining over decades, has since 1985 shown an increase (Buckner etal, 1991). This is considered to be due to the HIV epidemic. Clinical manifestations of tuberculosis in patients with AIDS are often atypical. In approximately 15% of patients without HIV infection TB occurs at extrapulmonary sites, whereas this is seen in 40% of patients who are HIV positive (Goldsmith, 1990). Bony tuberculosis is classically described in about 1 % of patients with tuberculosis (Davidson & Horowitz, 1970). The rib is an uncommon site of osteoarticular tuberculosis. We present two cases of rib tuberculosis which demonstrate the computed tomographic (CT) appearances and the role of CT in its diagnosis.
Figure 1. Case 1. Dynamic CT, 100 ml iohexol (300mgI/ml). Chest wall and pleural soft tissue lesion with rim enhancement and low attenuation centre. Aspiration of this lesion yielded pus which grew tuberculous bacilli.
Case reports Case 1 An 80-year-old male Indian farmer presented with lower left chest pain for 6 months. He had smoked until 3 years prior to his admission. Chest radiograph showed a destructive lesion in the left 5th rib with associated soft tissue shadowing. The mediastinum was unremarkable on the chest film. The lesion was initially thought to be malignant, CT was performed and showed right paratracheal, carinal and sub-carinal lymph node enlargement. There was an area of low attenuation with rim enhancement seen deep to serratus anterior and contiguous with a similar lesion in the pleural space (Fig. 1). On bone settings there was destruction of the associated rib. CT attenuation reading of this lesion suggested it to be a fluid density.
Case 2 A 39-year-old male Indian solicitor was referred with a three month history of pain in the left parasternal region and also interscapular pain. He had a pyrexia, weight loss, anorexia and was experiencing night sweats. On his chest film there was suspicion of right paratracheal nodal enlargement. CT was performed 6 days later in an effort to confirm this. On PA and lateral chest radiographs there was no evidence of chest wall abnormality. CT showed right paratracheal, carinal and sub-carinal nodal enlargement. The sub-carinal nodes showed peripheral enhancement with central low density (Fig. 2). In the left posterior upper thorax there was a lesion involving the chest wall, rib and pleural space (Fig. 3). Again the CT attenuation suggested fluid density. Biopsy confirmed the presence of tuberculosis bacilli. Neither patient was thought to be at risk for HIV infection.
*Present address: University of Manchester, Department of Diagnostic Radiology, Stopford Building, Oxford Road, Manchester, M13 9PT, UK.
Discussion The ribs are unusual sites for osteo-articular tuberculosis, occurring in none of 36 patients described by
822
The British Journal of Radiology, September 1992
Case reports
Figure 3. Case 2. Post-contrast CT, 50 ml bolus iohexol (300mgI/ml). Fluid density lesion involving chest wall,riband pleura! space seen in upper left thorax posteriorly.
Figure 2. Case 2. Post-contrast CT, 50 ml bolus iohexol (300 mgl/ml). Subcarinal lymph node enlargement exhibiting peripheral enhancement and lower attenuation centre.
Foley-Nolan et al (1991) nor in any of 71 patients reported by Rathakrishnan & Mohd (1989) and in only two of 499 cases described by Goldblatt & Cremin (1978). Newton cited one case of 'chest wall' TB in his series of 74 Manchester patients (Newton et al, 1982) and Nicholson found that 14 of their 176 patients had TB involving 'ribs, manubrium and sternum' (Nicholson, 1974). Brown in Bradford was able to identify and describe seven cases of tuberculosis of the ribs (Brown, 1980). In the largest series reported, the shaft was the site of infection in the majority of the 23 cases of rib tuberculosis (Tatelman & Drouillard, 1953). Costovertebral involvement was the next most common presentation invariably associated with tuberculous spondylitis. In our first case, CT images on bone settings demonstrated irregular bone destruction that was not shown on plain radiographs. In our second case, CT demonstrated bony destruction and the associated soft tissue lesion, neither of which were apparent on the plain films. The nature of bone destruction shown on CT was as one would expect from descriptions in a conventional radiology text (Thijn & Sheensma, 1990), or in previous Vol. 65, No. 777
reports of skeletal tuberculosis demonstrated with CT (Coppola et al, 1987; Ip et al, 1989). The associated soft tissue lesions in our patients had similar features of central low attenuation with rim enhancement which Coppola et al (1987) described in a review paper of CT in musculoskeletal tuberculosis. Similar appearance of TB of the chest wall was shown by Eschelman et al (1991). However, one should be aware of other imaging findings in rib tuberculosis not seen in our patients. Ip et al (1989) described two patients with rib tuberculosis whose associated soft tissue component did not have a low attenuation centre, and relative high attenuation rim. Such an appearance could obviously mimic a tumour and indeed tumour-like tuberculous lesions of bone have been described at other sites (Abdelwahab etal, 1987). The differential diagnosis of an irregular destructive rib lesion associated with an adjacent soft tissue mass with or without low attenuation change would include metastasis, multiple myeloma, Ewing's and invasive peripheral lung cancer, as well as infective pathology such as actinomycosis and other indolent infections. Im et al (1987) found the presence of low density areas within enlarged mediastinal nodes to be very helpful in differentiating tuberculosis from other causes of mediastinal lymphadenopathy (22/23 patients). They demonstrated a marked preponderance of enlarged tuberculous mediastinal nodes to be in the right paratracheal, right tracheobronchial and the sub-carinal areas. Our two patients conformed to this pattern. Low attenuation change in enlarged mediastinal nodes is recognized in lymphoma (North et al, 1990) and metastatic disease, if somewhat unusual (Im et al, 1987). There is overlap in the distribution of enlarged mediastinal nodes in tuberculosis versus neoplastic disease with lymphoma often involving the right paratracheal area. However, sparing of the prevascular and hilar areas is very suggestive of mediastinal TB. Coloured patients have been shown to exhibit 823
Case reports
changes of sclerosis and/or florid periosteal reaction associated with their tuberculous bone destruction on plain radiography (Jacobs, 1964; Chapman et al, 1979). Although this was not seen in our patients nor in those of Coppola et al (1987) or Ip et al (1989), one would expect in due course to see such CTfindingsdescribed. Because of the AIDS epidemic and the associated increase in the incidence of TB, this is a diagnosis that needs to be considered more frequently than in the recent past. Moreover, given the high rate of extrapulmonary involvement (Goldsmith, 1990), radiologists will need to be attentive to the skeletal manifestations of tuberculosis. Firooznia etal (1973) in a report of 21 cases of disseminated extrapulmonary tuberculosis associated with heroin addiction found that the ribs were the most common site of infection in this group of patients. Tuberculosis has been shown to occur earlier in the course of HIV infection than other opportunistic infections such as pneumocystic carinii (Goodman, 1990). Delays of many months in the diagnosis of skeletal tuberculosis are well recognized (Newton et al, 1982) but they still occur (Foley-Nolan et al, 1991), but early CT of the thorax and recognition of the features described here may expedite the diagnosis. In conclusion, the CT findings or irregular rib destruction, with an associated soft tissue lesion which exhibits a low attenuation centre and exhancing rim combined with right-sided mediastinal node enlargement should alert the radiologist to a diagnosis of rib tuberculosis and, if the patient is not of a social group predisposed to tuberculosis, consideration should be given to the possibility of drug abuse or HIV infection. Acknowledgments We would like to thank Dr S. J. Connellan and Dr J. S. Mann for their permission to report their patients. References ABDELWAHALE, I., PRESENT, D. A., ZWASS, A., KLEIN, M. J. &
MAZZRA, J., 1987. Tumour-like tuberculous granulomas of bone. American Journal of Roentgenology, 149, 1207-1208. BROWN, T. S., 1980. Tuberculosis of the ribs. Clinical Radiology, 31, 681-684. BUCKNER, C. B., LEITHISER, E., WALKER, C. W. & ALLISON,
J. W., 1991. The changing epidemiology of tuberculosis and other mycobacterial infections in the United States: implications for the radiologists. American Journal of Roentgenology, 156, 255-264. CHAPMAN,
M.,
MURRAY,
R. O.
Tuberculosis of the bones Roentgenology, 14, 266-282. COPPOLA,
J.,
MULLER,
N. L.
&
STOKER,
and joints.
D. J.,
1979.
Seminars in
DAVIDSON, P. T. & HOROWITZ, J., 1970. Skeletal tuberculosis
—a review with patient presentations and discussions. American Journal of Medicine, 48, 77-84. D A VIES, P. D. O., HUMPHRIES, M. J., BYFIELD, S. P., NUNN, A. J., DARYSHIRE, J. H., CITRON, K. M. & Fox, W., 1984.
Bone and joint tuberculosis; a survey of notifications in England and Wales. Journal of Bone and Joint Surgery, 66B, 326-330. ECHELMAN, D . J., GlBBENS, D . T., FIELDING, J. R., ROMO, L. V., PARKER, D. R., ARGY, N. & O'CONNOR, J. F., 1991.
Chest case of the day. American Journal of Roentgenology, 156, 1295-1300. FIROOZNIA, H., SELINGER, G., ABRAMS, R. M., VALENSI, V. &
SHAMOUN, J., 1973. Disseminated extrapulmonary tuberculosis in association with heroin addiction. Radiology, 109, 291-296. FOLEY-NOLAN, D . , DEEGAN, R. I., FOLEY-NOLAN, A . A . , BARRY, C , COUGHLAN, R. J. & HONE, R., 1991. Skeletal
tuberculosis. Irish Medical Journal, 84, 72-73. GOLDBLATT,
M.
&
CREMIN,
B. J.,
1978.
Osteo-articular
tuberculosis: its presentation in coloured races. Radiology, 29, 669-677. GOLDSMITH, M. F., 1990. Fogotten (almost) but not gone, tuberculosis suddenly looms large on domestic scene. Journal of the American Medical Association, 264, 165-166. GOODMAN, P. C , 1990. Pulmonary tuberculosis in patients with acquired immunodeficiency syndrome. Journal of Thoracic Imaging, 5, 38-45. IM, J. G., SONG, K. S., KANG, H. S., PARK, J. H., YEON, K. M.,
HAN, M. C. & KIM, C. W., 1987. Mediastinal tuberculosis lymphadenitis: CT manifestations. Radiology, 164, 115-119. IP, M., CHEN, N. K., SO, S. Y., CHIEI, S. W., & LAM, W. K.,
1989. Unusual rib destruction in pleuropulmonary tuberculosis. Chest, 95, 242-244. JACOBS, P., 1964. Osteo-articular tuberculosis in coloured immigrants: a radiological study. Clinical Radiology, 15, 59-69. NEWTON, P., SHARP, J. & BARNES, K. L., 1982. Bone and joint
tuberculosis in Greater Manchester, 1969-1979. Annals of the Rheumatic Diseases, 41, 1-6. NICHOLSON, R. A., 1974. Twenty years of bone and joint tuberculosis in Bradford. Journal of Bone and Joint Surgery, 56B, 760-765. NORTH, L. B., LIBSHITZ, H. I. & LORIGAN, J. G., 1990. Thoracic
lymphoma. Radiologic Clinics of North America, 28 (4), 745-762. RATHAKRISHNAN, V. & MOHD, T. H., 1989. Osteo-articular
tuberculosis. Skeletal Radiology, 18, 267-272. REPORT OF DIRECTOR OF PUBLIC HEALTH, WOLVERHAMPTON,
1990. Chapter 12, pp. 51-53. TATELMAN, M. & DROUILLARD, E. J. P., 1953. Tuberculosis of
the ribs. American Journal of Roentgenology, 70, 923-935. THIJN, C. J. P., & SHEENSMA, J. T., 1990. Tuberculosis of the
&
CONNELL,
D. G.,
1987.
Computed tomography of musculoskeletal • tuberculosis.
824
Journal of the Canadian Association of Radiologists, 38, 199-203.
Skeleton. Focus on Radiology (Springer-Verlag, Heidelberg), p. 144.
The British Journal of Radiology, September 1992
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