title: "Caught by the Eye of Sound" - Epigastric Swelling due to Xiphisternal Tuberculosis.
abstract: BACKGROUND
  Common causes of an epigastric mass include hepatomegaly, pancreatic pseudocyst and epigastric hernia, less common causes being carcinoma of the stomach or pancreas, whereas diseases of the sternum presenting as an epigastric swelling is extremely uncommon. We report a case of tubercular infection of the sternum located in the xiphoid process resulting in its presentation as an epigastric swelling.
  
  
  METHODS
  A 30-year-old immunocompetent woman with complaints of an epigastric swelling and undocumented pyrexia for four months was referred for sonographic evaluation with a clinical suspicion of an incompletely treated liver abscess. The patient was examined with ultrasound, sternal radiographs, CT and MRI. Ultrasound revealed a heterogeneous epigastric collection with linear echogenic components suggestive of bone fragments. These appearances suggested chronic infective osteomyelitis of the xiphoid process of the sternum. Lateral chest radiograph demonstrated lytic destruction of the xiphisternum. Tubercular etiology was considered and further evaluation with Multidetector Computed tomography (MDCT) and Magnetic Resonance Imaging (MRI) demonstrated erosive osteomyelitis of the xiphoid process with enhancing inflammation and collection in the adjoining soft tissue. Ultrasound-guided aspiration, PCR and Amplified Mycobacterium tuberculosis DNA test confirmed tubercular infection.
  
  
  CONCLUSIONS
  We report a new case of osteo-articular tuberculosis localized to the xiphisternum, a rare clinical entity with an extremely unusual clinical presentation as an epigastric mass. The role of ultrasound in primary diagnosis and as an interventional diagnostic modality for guided aspiration is highlighted.
authors.affiliation: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
authors.forename: Shabnam Bhandari
authors.initials: SB
authors.lastname: Grover
authors.affiliation: At the time of study: Department of Orthopaedic Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India; Presently, Department of Orthopaedic Surgery, Maulana Azad Medical College, New Delhi, India.
authors.forename: Sumit
authors.initials: S
authors.lastname: Arora
authors.affiliation: At the time of study: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India; Presently: MR Centre, Green Park, New Delhi, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Kumar
authors.affiliation: At time of study: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Deputed from Institute of Nuclear Medicine and Allied Sciences, Delhi, India; Currently, Department of Neuro Radiology, New York Medical University, New York, NY, U.S.A.
authors.forename: Hemal
authors.initials: H
authors.lastname: Grover
authors.affiliation: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Katyan
authors.affiliation: Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
authors.forename: Deepthi Mohan
authors.initials: DM
authors.lastname: Nair
keywords: Magnetic Resonance Imaging; Multidetector Computed Tomography; Osteoarticular, Tuberculosis; Sternum; Ultrasonography; Xiphoid Bone