Cold Abscess Research Articles

Challenges in Diagnosis and Management of Atlantoaxial Tuberculosis: A Case Report

Background and Objectives: Atlantoaxial tuberculosis (TB) is rare, and its diagnosis is difficult. Herein, we present a rare case with a challenging diagnostic journey of atlantoaxial TB spanning over two years. Materials and Methods: A 70-year-old immunocompetent female patient presented with a four-week history of nuchal pain, stiffness, and headache. She did not have any TB-associated constitutional symptoms. The result of the initial biopsy indicated only a nonfermenting Gram-negative bacillus and the histopathological report revealed concurrent acute and chronic inflammation. Posterior fusion with bilateral C1 lateral mass and C2 transpedicular screw fixation was performed after a five-week course of antibiotics. Results: However, the atlantoaxial abscess progressed and led to myelopathy two years later. Tuberculous spondylitis was not confirmed until the second biopsy. We chose the transoral approach for prompt abscess evacuation and to prevent unnecessary damage to the nearby vital neurovascular structures. The sputum culture and chest radiograph did not reveal concurrent pulmonary TB. Conclusions: Spinal TB has a greater likelihood of presenting with a cold abscess without the typical constitutional symptoms of pulmonary TB. Distinctive magnetic resonance imaging (MRI) features, such as a thin and smooth abscess wall, subligamentous spread, severe vertebral body destruction, and heterogenous vertebral wall enhancement, might help to differentiate between tuberculous and pyogenic spondylitis. We hope to offer meaningful insights to clinicians facing similar intricate scenarios, including subtle clues that may lead to a quicker diagnosis and the considerations we made while designing a treatment plan.

Abnormal T Cells Function Associated With Intraspinal Cold Abscess Caused by Macrolide-resistant Mycoplasma pneumoniae in a Patient With X-linked Agammaglobulinemia.

Intraspinal cold abscesses caused by macrolide-resistant Mycoplasma pneumoniae in patients with X-linked agammaglobulinemia have not yet been described to our knowledge. Here we describe a patient with X-linked agammaglobulinemia who developed an intraspinal cold abscess caused by macrolide-resistant M. pneumoniae . Genetic analysis revealed a hemizygous c.1566 + 1G > C (IVS15 + 1G > C) mutation in BTK gene. The patient showed relatively naive T cells and a significant proliferative defect.

Hyper IgE Syndromes.

The Hyper IgE Syndromes are rare primary immunodeficiencies characterized by eczema, recurrent skin and respiratory infections and elevated serum IgE levels. Nowadays a geneticmolecular characterization is possible and allows the distinction in various monogenic pathologies, which share some clinical characteristics but also important differences. In addition to long-known STAT3 and DOCK8 gene mutations, in fact, also ZNF341, CARD11, ERBB2IP, IL6R and IL6ST genes mutations can cause the disease. The main clinical manifestations are represented by newborn rash, eczema similar to atopic dermatitis, bacterial and viral skin infections, cold abscesses, respiratory infections with possible pulmonary complications, allergies, gastrointestinal manifestations, malignancies and connective tissue abnormalities. Diagnosis is still a challenge because, especially in the early stages of life, it is difficult to distinguish from other pathologies characterized by eczema and high IgE, such as atopic dermatitis. Several scores and diagnostic pathways have been developed, but it is essential to seek a genetic diagnosis. Treatment is based on prevention and early treatment of infections, meticulous skincare, intravenous immunoglobulins and HSCT, which, in some HIES subtypes, can modify the prognosis. Prognosis is related to the affected gene, but also to early diagnosis, timely treatment of infections and early HSCT.

“Lumbar swelling: And up into the lungs…” A radiology case report of spinal tuberculosis

Spinal tuberculosis is one form of extra-pulmonary tuberculosis which usually has delayed presentation with spinal deformities in most cases. The para-spinal soft-tissue involvement can lead to a cold abscess which can present as swellings, mainly in the neck and lumbar regions. Here, a case of a young man is being presented, who had lumbar swelling which on computed tomography evaluation showed para-spinal collection, vertebral lytic foci, and lung parenchymal lesions suggestive of infection.

Pott’s disease and scrofuloderma as presentation of clinically extrapulmonary tuberculosis in 15 years old girl: a case report

Backgrounds: Extrapulmonary tuberculosis (TB) accounts for 15–20% of all tuberculosis cases, with the lymph node being the most commonly affected organ. Spinal tuberculosis and scrofuloderma are rare manifestations of extrapulmonary TB and constitute less than 5% of the cases. Establishing the diagnosis is a challenge. Eradication and prevention of sequelae complicate further management of the disease. This study aims to describe the clinical manifestation and the management of spondylitis tuberculosis and scrofuloderma in a child. Case presentation: A 15-year-old girl came with a chief complaint of lower extremities weakness for a week following monthly chronic low back pain. She also reported a painless lesion on her back with no sign of acute inflammation. She also complained of intermittent fever with night sweats and lost 3 kilos of body weight in the last two months. From physical examination, we found a kyphotic posture and severe malnutrition. Skin examination revealed an open wound on her right lower back, size 4x3 cm, with no sign of inflammation. The tuberculin skin test was positive with 15 mm induration. The spinal magnetic resonance imaging revealed destruction of the vertebral corpus thoracal segment, hyperintense sacrum, and right ileum bone with a cold abscess, suggesting spondylitis TB. A wound biopsy with hematoxylin-eosin stain concluded chronic granulomatous inflammation and showed multinucleated giant cell Langhans-type, suggestive of cutaneous tuberculosis. Microbiology examination (PCR GeneXpert) from wound biopsy and ziehl neelsen stain failed to detect Mycobacterium tuberculosis. The patient was diagnosed with Pott’s disease and scrofuloderma. Anti-tuberculous therapy commenced, and the patient responded well after several months of treatment. Conclusions: The diagnosis of extrapulmonary TB manifests as spinal tuberculosis, and scrofuloderma could be made from clinical manifestation and imaging.

A Rare Presentation - Case Report on Tubercular Cold Abscess

Tuberculosis is a chronic granulomatous infection that is quite common and a threat to many developing countries. However, extrapulmonary cases involving tubercular skin and soft tissue abscess formation are rare, accounting for 1 or 2% of cases of Mycobacterium TB infections with skin and soft tissue involvement. The typical extrapulmonary tuberculosis symptoms and indications are nonspecific, making diagnosis difficult and time-consuming. We present a case of right arm tubercular cold abscess in a child related to mycobacterium tuberculosis, which was diagnosed by Ziehl- Neelson stain FNAC (Fine needle Aspiration cytology) and Mantoux test (18mm) induration. Due to its rare manifestation, it often gets misdiagnosed or overlooked. A proper diagnosis will ensure a proper treatment plan. Our case further depicts the collaborative effort of healthcare professionals. The patient came back complaining about the increased swelling in his right arm.
 Keywords: Tubercular Cold Abscess, Ziehl- Neelson, Fine needle Aspiration cytology, Mantoux test, Mycobacterium Tuberculosis

Multiple Cold Abscesses of a Chest Wall with Ribs Destruction in a Hemodialysis Patient

Cold abscess of the chest wall is an uncommon disease that is mainly caused by tuberculous infection. Staphylococcal cold abscesses of the chest wall are extremely rare and usually clinically occult, frequently leading to a delay in diagnosis and consequently severe infectious complications. We report an 88-year-old woman with end-stage renal disease, who presented with an exit site infection of a cuffed tunneled dialysis catheter caused by methicillin-resistant Staphylococcus aureus (MRSA). Despite the removal of the catheter and administration of antibiotics, she developed refractory MRSA bacteremia. Computed tomography (CT) of the chest revealed septic thrombophlebitis with metastatic cold abscesses of the chest wall and ribs destruction. Although CT-guided drainage and vancomycin therapy eliminated MRSA bacteremia, the chest wall abscesses did not resolve. Patients fitted with a central venous dialysis catheter are at risk of septic thrombophlebitis with metastatic cold abscesses of the chest wall that are resistant to antibiotic therapy. Early identification is based on serial blood cultures and prompt CT scans. Surgical management coupled with antibiotic therapy can eradicate the source of infection and improve patients’ outcomes.

Hyper-IgE syndrome: a case report

Introduction and importance: Hyper-IgE syndrome (HIES), also known as Job syndrome, is a rare primary immunodeficiency disorder characterized by elevated serum IgE levels, recurrent infections, and various clinical features. Early diagnosis, prompt management of infections, and supportive care are essential in improving outcomes for individuals with HIES. Genetic testing, including STAT3 gene sequencing, plays a crucial role in confirming the diagnosis. Further research is needed to enhance our understanding of HIES and develop targeted therapies to improve the quality of life for affected individuals. Case presentation: This case report presents the clinical features and management of a 37-year-old male with HIES, diagnosed at the age of 2 due to recurrent cold abscesses caused by Staphylococcal infections. Clinical discussion: The patient exhibited typical symptoms of HIES, including recurrent eczema, frequent bacterial infections, mucocutaneous candidiasis, and various physical abnormalities. Diagnostic markers such as elevated IgE levels and eosinophilia supported the HIES diagnosis, which was further confirmed by the identification of a STAT3 gene mutation. Treatment primarily involved supportive measures and antibiotics for infections. The patient’s blood test results and imaging findings revealed abnormalities such as low red blood cell count, elevated erythrocyte sedimentation rate, and pulmonary nodules. Conclusion: This case report highlights the importance of early diagnosis, prompt management of infections, and the need for ongoing research to improve our understanding and treatment of HIES.

Changing trends in the management of posttransplant ureteric stricture

Abstract Introduction: Chronic kidney disease (CKD) is a common disease now. Diabetes and hypertension are the main cause. Renal transplant is a gold standard treatment. Posttransplant stricture is also common, and changing trends in management are emerging. Materials and Methods: It is a retrospective observational study in a tertiary care hospital in East India. The study duration was from January 2019 to December 2021. In total, 140 patients were studied, including both live and cadaveric transplants. A patient who developed posttransplant hydronephrosis or presented with acute kidney injury was evaluated with ultrasonography, intravenous urography, contrast-enhanced computerized tomography, and magnetic resonance imaging. Management was done with double J (DJ) stenting, percutaneous nephrostomy (PCN) insertion, or surgical intervention. Results and Analysis: Twelve (8.6%) patients out of 140 developed posttransplant ureteric stricture. Five (41.7%) out of 12 patients were managed with long dura DJ stenting, and five (41.7%) were managed with PCN insertion and serial follow-up. Only two (16.7%) required ureteric reimplantation. Discussion: Posttransplant ureteric stricture is a common complication following renal transplantation. Common causes are increased cold ischemia time, ureteral edema, clots, tumors, calculi, lymphocele, abscess, and hematoma. Other causes include kinking of the ureter and previously unrecognized pelviureteric junction obstruction. In the literature, the incidence of posttransplant ureteric stricture ranges from 2% to 10% in one study; and in another study, it is 1% to 9%. In our study, it is 8.6%. Conclusion: Diagnosis of the posttransplant ureteric stricture should be prompt, and management should be given as early as possible for better graft survival.

Tubercular cold abscess: uncommon location of a common disease

Musculoskeletal tuberculosis is not rare to find, but presence of the disease and such extensive involvement at an unusual site without much of bone involvement is rare. Reporting a case of isolated cold abscess in a 60-year-old male with evening rise of temperature, weight loss and diffuse swelling in his leg involving almost entire anterior aspect of leg. Magnetic resonance imaging (MRI) was advised to investigate further and revealed large focal intra medullary heterogenous collection and large lobulated juxtacortical collection in tibialis anterior muscle. Hematoma/organised abscess, incision and drainage was done and sent for Z-N staining which showed acid-fast bacilli. Anti-tubercular treatment was administered- isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z). Outcome was favourable and patient become symptomatic better. Drainage of the cold abscess and antitubercular coverage produced good results in this rare presentation of tuberculosis.

Presternal Scrofuloderma in a HIV Infected Patient Case Report and Discussion of the Literature Data

Scrofuloderma is a cutaneous extension of Mycobacterium tuberculosis (and rarely Mycobacterium bovis or Calmette-Guerin bacillus) from a local focus. It is a rare form of extra-pulmonary tuberculosis, starting as a painless skin cold abscess that progresses to fistulisation and ulceration. This article presents a case of presternal scrofuloderma in a non-adherent to treatment HIV-infected patient with disseminated tuberculosis.

Disseminated Cryptococcosis in an Immunocompetent Patient: A Case Study

Cryptococcosis is the fungal infection caused by the yeast that belongs to the cryptococcus species which is divided into two broad categories, Cryptococcus neoformans and Cryptococcus gattii. Cryptococcosis is the opportunistic infection in the immunocompromised individual, particularly in HIV infected individual. In immunocompetent individuals, there may be serological evidence of cryptococcal infection, but cryptococcal disease is very rare in the absence of impaired immunity. Here we are reporting a case of disseminated cryptococcosis (multiple cold abscesses, sacroiliitis and asymptomatic pulmonary nodules) in an immunocompetent patient, which was initially thought to be mycobacterium tuberculosis infection.

A series of tuberculous cold abscesses at uncommon anatomic sites.

A series of tuberculous cold abscesses at uncommon anatomic sites.

Unusual presentation of Pott disease and diagnostic challenges in a resource-limited setting: a case report

BackgroundPott disease is rare and responsible for only 1%–2% of all tuberculosis cases. It poses diagnostic challenges in resource-limited settings due to unusual presentation and limited investigative capacity, resulting in debilitating sequelae if diagnosed late.Case presentationWe present a case of severe Pott disease of the lumbar spine, with a large paravertebral abscess tracking down to the gluteal region in a 27-year-old Black African Ugandan woman living with human immunodeficiency virus, whose main complaint was right lower abdominal pain. She was initially misdiagnosed from the peripheral clinics as a case of lumbago and later with a psoas abscess. The diagnosis of severe Pott disease was established at the regional referral hospital following an abdominal computed tomography scan, and the patient was appropriately initiated on anti-tuberculosis drugs. However, only abscess drainage and provision of a lumbar corset were possible, with no neurosurgical intervention done on the spine due to financial constraints. Clinical review at 2, 6, and 12 months revealed improvement.ConclusionsPott disease may present with non-specific symptoms such as abdominal pain resulting from pressure effects of an expansile cold abscess. This, coupled with limited diagnostic capacity in resource-limited settings; results in significant morbidity and possible mortality. Hence, there is need to train clinicians to increase their index of suspicion and equip health units with basic radiological equipment, such as x-ray, for timely detection and subsequent management of Pott disease.

Extrapulmonary Tuberculosis: A Retrospective Study in Eastern India Based on Diagnostic Modalities

Background: The most common site of tubercular infection is lungs, but various extrapulmonary sites also can be affected by tuberculosis (TB). Very few fine-needle aspiration-based studies supplemented by cartridge-based nucleic acid amplification test (CBNAAT) and radiology have been conducted in any center of tribal-based area situated in Eastern India. Materials and Methods: Sixty extrapulmonary TB cases (28 males and 32 females) received during 3 years (May 2018–April 2021) were included in this study. Results: Diagnoses of different extrapulmonary tubercular lesions were: lymphadenitis (n = 27), cold abscess (n = 18), breast abscess (n = 2), epididymitis (n = 4), oral cavity (n = 3), spine, long bone (n = 2 cases each) and fingertip and TB of the penis (n = 1 case each). Forty-six cases were diagnosed by fine-needle aspiration cytology. CBNAAT diagnosed ten cases where the result of aspiration cytology was inconclusive. Radiology directly diagnosed four cases, whereas it helped another seven cases indirectly to clinch the proper diagnosis of extrapulmonary tubercular lesions. Conclusion: Tuberculous lymphadenitis was the most common extrapulmonary lesion. Females outnumber male cases. Aspiration cytology aided by CBNAAT and radiology proved indispensable to diagnose extrapulmonary tubercular lesions, especially for economically constrained persons.

A rare presentation of multifocal tuberculosis in an immunocompetent patient

Introduction: Multifocal tuberculosis (MT) is an uncommon presentation in immunocompetent patients. It’s associated more with an immune-depression like Human Immunodeficiency Virus infection. We report a case of MT with presternal cold abscess, mediastina and cervical adenopathy, bone, and vertebral location that occurred in an apparently immunocompetent patient. Case presentation: A 19-year old woman with no previous history of tuberculosis (TB) exposure was admitted for chronic chest pain lasting for 13 months. She presented with a history of fever, night sweat and weight loss (09 kg). The first clinical examination noticed a voluminous presternal abscess. The chest X-Ray showed an enlargement of the middle mediastinum associated to pleural effusion opacity, but any active pulmonary lesions. A computed chest tomography revealed the presence of a parietal mass centered on the sternum, with extension in the soft parts, bone lies of the sternal manubrium, lies of the vertebral hemi-bodies of T10 and T11, cervical lymph nodes, phrenic mediastina and sub-pectoral nodes with peritoneal and mesenteric involvement. Magnetic resonance imaging of the spine showed tiered thoracic lumbar and sacral spondylitis with paravertebral and anterior epidural collections responsible for spinal cord compression next D10 without signs of spinal cord pain. The draining of the cold abscess revealed some whitish pus, in which acid-alcohol resistant bacilli were identified. There was no history of diabetes, renal failure, or long-term treatment with corticosteroids or immunosuppressant’s: HIV serology and viral hepatitis were negative. The blood glucose was normal. The patient was treated with anti-tuberculosis regimen based on: Ethambutol, Rifampicin, Isoniazid, and Pyrazinamide for two months, and then rifampicin and isoniazid for seven months. The outcome was good with the disappearance of the abscess and all the radiological signs. Conclusion: Multifocal TB such as the case reported are uncommon and confined mostly to immunocompromised patients especially those with HIV infection. Because of the clinical polymorphic features of multifocal TB, the diagnosis is usually difficult to make, resulting into delay before beginning of the adequate treatment.

Dorso-Lumbar Wall Abscess Associated with Sacroiliitis: Exceptional Localizations of Tuberculosis

Introduction: Tuberculosis of the abdominal wall is a rare localization, the diagnosis of which on imaging remains difficult due to the absence of specific radiological signs, despite advances in imaging. Objective: The aim of this work is to reveal the interest of imaging in the diagnosis of this pathology. Case Report: We report the case of a 42- year-old man, with no history of tuberculosis infection, who presented for 4 months with a painless right dorsolumbar tumefaction, without fever, progressively increasing in volume, with the appearance of low back pain and uncounted weight loss 2 months later. Ultrasound examination of the swelling revealed two parietal collections, measuring respectively 1.2x3.5 cm and 4.8x3cm in long axis, with thickened walls communicating with each other through a pertus; they had a heterogeneous hypoechoic echostructure, containing fine non-vascularized echoes on color Doppler. A complementary CT scan) showed heterogeneously dense collections opposite L4 and L5, merging in depth, associated with a right sacroiliitis consisting of a significant widening of the joint space, erosions and subchondral geodes of the sacral joint side, with bone sequestration.The lesion assessment revealed another cerebral localization in the form of a left parietal tuberculoma. Percutaneous puncture of the parietal collection with culture on Löwenstein-Jensen medium revealed tubercle bacilli. Conclusion: Isolated parietal localization is a rare and unrecognized form of tuberculosis. Imaging can distinguish a tuberculous cold abscess from a wall tumor. Only histological and/or bacteriological examination of biopsies of the mass can confirm the diagnosis.

Hyper‐IgE syndrome presenting with early life craniosynostosis in monozygotic twin sisters

<scp>Hyper‐IgE</scp> syndrome presenting with early life craniosynostosis in monozygotic twin sisters

Multifocal Tuberculosis in a Diabetic: An Atypical Manifestation

Introduction: Multi-focal tuberculosis is an attack of two extra-pulmonary sites with or without pulmonary involvement. It is a rare pathology that is characterized by its large clinical and radiological polymorphism. We report the case of a 27-year-old patient with type 1 diabetes, who had had a stroke for 1 year. She reported the appearance of a sushyphoidal collection for a month. The clinical examination noted a sus-xyphoid collection firm edge and renit in its center of 5cm in diameter painless evoking a cold abscess. Examinations had shown poorly systematized opacity at the level of the right lung base on chest radiography, with the ultrasound of the upper xyphoidal region showing abscess collected supersternal with discontinuous sternal cortices, suggesting bone lysis. The CT scan confirmed the appearance of sternal osteitis with collections of the soft tissues opposite, multiple associated hepatic collections were objectified at the level of the abdominal sections with pulmonary involvement of infectious origin objectified to the thoracic sections. the puncture of the abscess had not found AFB. The diagnosis of multifocal tuberculosis was retained following a positive expert Gen test. Management consisted of anti- bacillary therapy, adjustment of insulin doses. The appearance of multi-focal tuberculosis is often misleading and can mislead the diagnosis. However, the essential thing is to know how to evoke them in order to be able to target the specific examinations and to engage the therapeutic strategy without delay. Our case illustrates an atypical manifestation of multifocal tuberculosis in a diabetic patient with pulmonary, cutaneous, hepatic and bone lesions of tuberculosis origin.

Air-fluid level in the mediastinum.

A 19-year-old man presented to the emergency department with weakness, loss of appetite, and a weight loss of at least 13 kg in 5 months. He also complained of exertional dyspnea, dry cough, day and night sweats, and abdominal plus lower back pain. The physical examination revealed a temperature of 39.3°C but nothing else abnormal. The chest x-ray (Figure 1) revealed a mass that appeared to be located in the posterior mediastinum. A computed tomography (CT) scan (Figure 2) was performed in the emergency department to assess the extent of the disease, which showed pulmonary tuberculosis and spinal osteomyelitis associated with a perispinal collection from T1 to T12 and from L5 to S2, suggesting Pott's disease.1 The diagnosis of disseminated tuberculosis was confirmed by the presence of Mycobacterium tuberculosis in culture.2 A quadri-therapy for tuberculosis was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol, then downgraded to a tri-therapy because of the absence of resistance at the antibiogram.3 Magnetic resonance imaging (Figure 3) performed later during the hospitalization revealed a staged spondylodiscitis associated with collections from the beginning of the extension to the central nervous system. Echocardiography confirmed the presence of associated chronic pericarditis. Finally, the indication for radio-controlled drainage of the posterior mediastinal collection was decided owing to the important risk of fistulization.4 Tuberculosis is caused by slow growing aerobic bacilli, Mycobacterium tuberculosis complex. This disease, affecting mainly the lungs, also takes osteoarticular forms, the most frequent of which is spondylodiscitis. Spinal involvement is always secondary to hematogenous dissemination of bacilli from the primary site.5 Pott's disease results from an infection of the vertebrae (spondylitis) and intervertebral discs (discitis) with M. tuberculosis. The intervertebral disc is a relatively avascular structure and is spared until late stage of the disease. Bone destruction in spinal tuberculosis can be fragmentary, osteolytic, subperiosteal, or localized destruction with sclerosed margins. Cold abscesses are pus collections that lack surrounding inflammatory response and are seen in nearly 70% of patients with spinal tuberculosis. This is a severe form of the disease, located near nerve structures, which may be significantly and permanently affected, and may be life threatening.