Tuberculous subcutaneous abscess: an analysis of seven cases

A chest wall mass after breast carcinoma surgery: a simple diagnosis?

Tuberculosis affects pulmonary and extra‐pulmonary sites with a multitude of differing presentations. The involvement of thoracic wall is a rare entity. We report the case of a patient who had a tumefaction on the right chest wall 6 months after a right breast mastectomy. After an initial radiological suspicion of malignancy, we detected intraoperatively an abscess in which histologic examination revealed granulomas with multinucleated giant cells.

[Chest wall tuberculosis: report of 3 cases]

Despite the dramatic decline in the incidence of tuberculosis during the last decades, the disease remains a significant public health problem especially in developing countries. Chest wall tuberculosis is a very rare location. Clinically, it can present as a pyogenic abscess or soft tumor, making diagnosis difficult, particularly in the absence of warning signs. Optimal therapeutic management is controversial. Medical treatment alone in often insufficient and must be associated with a surgical excision or debridement.

A tuberculous abscess of the chest wall in a renal allograft recipient

Tuberculous abscess of the chest wall is a rare localization of tuberculosis. We herein report a case of tuberculosis of the chest wall on a renal allograft recipient and provide discussion on optimal therapeutic management.

[Tubercular abscess of the chest wall in the child]

La localisation pariétale thoracique chez l'enfant est une forme très rare de tuberculose. Son diagnostic est souvent difficile nécessitant le recours à la biopsie chirurgicale. Nous rapportons le cas d'une jeune fille de 14 ans, présentant depuis un mois et demi une tuméfaction de la paroi thoracique antérieure. La tomodensitométrie thoracique a objectivé un processus lésionnel pariétal para-sternal droit à limites imprécises responsable d'une érosion du sternum. L'examen anatomo-pathologique des biopsies de la coque d'abcès a confirmé le diagnostic de tuberculose caséo-folliculaire. Le traitement anti-bacillaire a permis une évolution favorable.

En bloc resection of a large tuberculous abscess using the stain plombage procedure

En bloc resection is highly recommended for treating tuberculous abscess of the chest wall because of possible recurrence due to microscopic residual lesions; however, complete resection is often difficult. We present a case with a large dumbbell-shaped tuberculous abscess that developed inside and outside the thorax. En bloc resection was successfully achieved using intraoperative closed drainage, ablution, and stain solution plombage procedures, which enabled easy identification of the abscess configuration. When the abscess wall was torn, only minimal solution leakage occurred; therefore, contamination of the surgical field was avoided. We report the procedures we devised and discuss treatments for this obstinate disease.

Surgical treatment of a tuberculous abscess of the chest wall

Background

Tuberculous abscess of the chest wall is a very rare disease. Few articles have reported on it and those that have enrolled few patients. To determine the characteristics of this disease and to suggest an optimal treatment strategy, we reviewed patients treated by surgical management.

Materials and Methods

Between October 1981 and December 2009, 68 patients treated by surgical management for a tuberculous abscess of the chest wall were reviewed retrospectively.

Results

Of 33 men and 35 women, 31 patients had a current or previous history of tuberculosis. The main complaints were chest pain, a palpable mass, pus discharge, and coughing. A preoperative bacteriologic diagnosis was performed in 12 patients. Abscess excision was performed in 54 cases, abscess cavity excision and partial rib resection in 13, and abscess excision and partial sternum and clavicle excision in 1 case. Postoperative wound infection was noted in 16 patients and a secondary operation was performed in 1 patient. Recurrence occurred in 5 patients (7.35%). Reoperation with abscess excision and partial rib resection was performed in all of the 5 cases.

Conclusion

Complete excision of the abscess and primary closure of the wound with obliteration of space would decrease postoperative complications. Anti-tuberculosis medication may reduce the chance of recurrence.

Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall

The tubercular abscess of the chest wall remains one of the differential diagnoses of a chest wall tumour, and the management strategy is controversial. We reviewed the medical records of 22 patients treated at our institution. Two patients were managed by antitubercular medications alone; eight patients were managed by medication and open drainage. Five patients underwent open drainage with subsequent radical surgery at a constant interval of time, and the mean duration between open drainage and radical surgery was 9.8 weeks (range, 3-12). Seven patients underwent radical surgery without prior open drainage. Five patients required rib resections, and curettage of infected pleural peel was necessary in 5 patients. Antitubercular drugs were administered basically for more than 6 months regardless of surgical management, including for more than 1 month prior to radical surgery. Postoperative empyema was seen in 1 patient after radical surgery. The mean follow-up duration was 32.8 months (range, 3-100), and there was no recurrence. Complete resection of the tubercular abscess with sufficient antitubercular therapy resulted in a satisfactory outcome. Antitubercular therapy with or without open drainage can be a viable choice.

Tuberculosis of the chest wall without pulmonary involvement

Skeletal tuberculosis is usually seen in association with primary pulmonary form. Pulmonary tuberculosis of the chest wall is a rare entity. We herein report a case of tuberculosis of the chest wall without pulmonary involvement that presented with big ulcer in the anterior chest wall and responded completely to the antituberculosis therapy without any surgical intervention.

Incision infection with Mycobacterium tuberculosis after total hip arthroplasty without any primary tuberculosis focus

We describe a case of a tuberculous abscess unassociated with other clinical features of tuberculosis in a 46-year-old woman with a history of 4 hip surgeries plus total hip arthroplasty (THA) due to developmental hip dislocation. Four months after THA, she developed a collection at the incision site for which specimens produced positive culture findings for Mycobacterium tuberculosis. We could not detect any primary focus of tuberculosis anywhere in the patient's body. We performed soft-tissue debridement and drainage completely above the fascia lata to remove pus. The infection recurred twice despite chemotherapy and the earlier treatment. At a 6-year follow-up examination, there was no sign of either tuberculosis or prosthetic loosening. To our knowledge, this is the first report of localized tuberculous abscess within a THA incision.

Surgical management of chest wall tuberculosis

OBJECTIVE

Tuberculosis remains one of the most fatal diseases in the world. Extrapulmonary tuberculosis increases in parallel fashion with the rise of incidence of pulmonary tuberculosis. Tuberculosis of the chest wall is rare.

METHODS

Our study retrospectively evaluated 10 patients with tuberculosis of the chest wall who were treated with surgery in addition to antituberculous chemotherapy in the last 8 years. Seven of the lesions were located on the anterior chest wall, and three of the lesions were on the lateral chest wall.

RESULTS

Surgical therapy consisted of evacuation of the cold abscess material from the cavities and wide débridement of the soft tissue planes in all patients. Partial rib resections were performed in six patients owing to costal or chondral involvement.

CONCLUSIONS

Chest wall tuberculosis must be considered in the differential diagnosis of chest wall lesions, especially in endemic areas.

Complete resection is mandatory for tubercular cold abscess of the chest wall

BACKGROUND

Cold abscess of the chest wall is a rare disease and few literature reports detail any treatment experience with a limited patient number. Hence, an optimal treatment plan remains controversial.

METHODS

We retrospectively analyzed patients with cold abscess of the chest wall, focusing on their clinical features, surgical results, and the long-term outcome. Eighty patients were enrolled between May 1981 and April 2005. There were 35 male and 45 female patients, who underwent surgical treatment for cold abscess of the chest wall. The mean age of the patients was 31.4 +/- 12.5 (14 to 73) years. Forty patients (50.0%) had previous history of pulmonary tuberculosis. A growing chest wall mass was present in every patient. Surgical treatments performed were as follows: abscess debridement and drainage in 15 (18.8%), complete excision of the abscess without chest wall resection in 9 (11.2%), and complete excision of the abscess including chest wall in 56 patients (70.0%).

RESULTS

There were no cases of operative mortality. Operative morbidity developed in four patients; two wound infections, one pneumonia, and one prolonged chest tube drainage. Postoperative antituberculous medication was given to all patients. Twelve patients (15.0%) recurred and required a second operation. The recurrence rate was higher in patients where only drainage of the abscess was performed compared with those in whom complete resection was performed (40.0% vs 9.2%, p = 0.008).

CONCLUSIONS

Cold abscess of the chest wall can be surgically managed successfully with low operative risk. Complete resection of the abscess, including a portion of the involved chest wall, is mandatory to avoid recurrence.

Tuberculose cutanée de l'enfant au Maroc : étude de 30 cas

In Morocco, tuberculosis is still endemic. Cutaneous tuberculosis is ranged the fifth after the pleuro-pulmonary, lymphe node, urogenital and digestive tuberculosis. It mainly affects young people. Few studies of cutaneous tuberculosis are available in this age group. The aim of our study is to emphasize its epidemiological features.

PATIENTS AND METHODS

It is a retrospective study including all cases of childhood cutaneous tuberculosis observed between January 1981 and December 2004. The diagnosis was based on the confrontation of clinical, immunological, bacteriological and histological data.

RESULTS

Thirty cases were collected. The mean age was 11 years. The clinical features are as follows: gumma 46.6%, scrofuloderma 36.6%, lupus vulgaris 13.3% and skin tuberculosis chancre 3.3%. The Mantoux test was positive in 67%, tuberculoid granuloma was observed in 78% and the search of Mycobacterium tuberculosis was positive in 13%.

DISCUSSION

Gumma and scrofuloderma were the most frequent forms as in other Moroccan series. These results attest the endemicity of this affection in our country. The diagnosis relies on the discovery of Mycobacterium tuberculosis; as this situation is rare for the cutaneous location, the diagnosis relies then on the association of clinical and paraclinical criteria.

Tuberculose multi-focale (palpébrale et pleurale) chez une immunocompétente

INTRODUCTION

Tuberculosis of the eyelid and its development in the setting of multifocal tuberculosis is exceptionally rare.

CASE REPORT

The authors report a new observation of multifocal tuberculosis in a non-immunosuppressed woman of 28 years with histologically confirmed pleural and palpebral involvement. A paradoxical reaction was seen following the initiation of anti-tuberculous treatment with appearance of new manifestations (thoracic cold abscesses).

CONCLUSION

The authors draw attention to this rare localisation and to the paradoxical reactions during treatment, emphasising the need for early diagnosis to avoid local and remote complications.

Current Surgical Therapy for Patients with Tuberculous Abscess of the Chest Wall

BACKGROUND

Although anti-tuberculosis medication is essential for the treatment of tuberculous abscess of the chest wall, surgical treatment also plays an important role. We report our surgical experience for patients with tuberculous abscess of the chest wall.

METHODS

The series was comprised of 16 patients with tuberculous abscess of the chest wall, and they were treated from May 1996 to June 2003 at St. Vincent's Hospital, Suwon, Korea. The data were retrospectively reviewed.

RESULTS

Tuberculous abscesses were managed by combined anti-tuberculosis medication and surgery of either abscess excision with rib resection (11 abscesses) or abscess excision alone (7 abscesses). The overall rate of rib involvement for abscess was 44.4 % (8 abscesses in 7 patients), and the rate of rib involvement was not much different according to the extent of the chest wall involvement. The incidence of performing a second surgical procedure was higher in the following groups: (1) the group with pathologic evidence of bone involvement (3 of 7 patients vs 1 of 9 patients), (2) the group that was not given preoperative anti-tuberculosis medication (4 of 7 patients vs none of 9 patients).

CONCLUSIONS

In managing tuberculous abscess of the chest wall, extensive abscess excision with rib resection is considered to be important. Preoperative anti-tuberculosis medication may play an important role in reducing the postoperative complication, including abscess recurrence.

Subcutaneous granuloma of the cheek an unusual case report and review of literature

With the increase in prevalence of extra pulmonary tuberculosis, it has become imperative for clinicians to review their knowledge of unusual presentations of mycobacterial infections. Tuberculous involvement of the subcutaneous tissue and skeletal muscle is rare. Apart from tuberculous lymphadenitis, diagnosis of extrapulmonary tuberculosis may be difficult. We present here a case of tuberculous granuloma of the cheek - an unusual presentation in ENT practice.

Metastatic tuberculous abscesses in an immunocompetent patient

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.

Lupus vulgaris--report of a case with facial involvement

Cutaneous tuberculosis of the orofacial region is a rare condition and when it occurs, can cause confusion regarding the true nature of the lesion. This is compounded by the fact that neither mantoux test nor histopathology is confirmatory. In this report we discuss a case of lupus vulgaris with emphasis on the diagnostic approach to be followed by dental practitioners who come across a similar case.

Surgical Treatment of Tuberculous Abscess in the Chest Wall

BACKGROUND

We reviewed surgical cases of tuberculous abscess in the chest wall and analyzed the indications and methods of surgery, results, perioperative complications, and postoperative treatment.

METHODS

We retrospectively reviewed the records of 13 patients who underwent surgical treatment of tuberculous abscess in the chest wall between January 1994 and December 2003 at National Hospital Organization Tokyo Hospital.

RESULTS

There was a past history of tuberculosis in 3 patients, concomitant active pulmonary tuberculosis in 5, concomitant active tuberculosis in the neck lymph node in 1, and no antecedent tuberculosis in 4. The locations of the tuberculous abscesses were right chest wall in 8 patients, left chest wall in 3, and anterior chest wall in 2. All of the patients underwent surgical treatment. In all patients, postoperative antituberculous treatments were administered. The combination regimens consisted of isoniazid (400 mg/d), rifampicin (450 mg/d), ethambutol (750 mg/d), pyrazinamide (1,500 mg/d), or some combination of these, and the duration ranged more than 6 months. Postoperative complications were not seen, and there was no recurrence.

CONCLUSIONS

We recommend a complete resection of the abscess with rib resection, and postoperative treatment by tuberculous chemotherapy regimen. We consider that these treatments reduce postoperative recurrence.

Extrapulmonary tuberculosis in high prevalence of tuberculosis and low prevalence of HIV

The authors' data show a higher rate of pleural and meningeal involvement among extrapulmonary TB cases than expected by previous works. Special attention should be given to tuberculous meningitis cases among all extrapulmonary TB cases because of its high mortality rate. The most common extrapulmonary involvement is pleural. Pleural involvement is most common among the young male military service personnel. These data underscore the importance of determining pleural involvement among extrapulmonary TB cases and emphasize the need to consider clinic and epidemiologic differences in the diagnosis and evaluation of extrapulmonary TB. Finally, it seems unlikely that HIV infection currently has a role in the cause of extrapulmonary TB in the authors' region.

Tuberculous cellulitis in a child demonstrated by magnetic resonance imaging

The increasing prevalence of extrapulmonary tuberculosis means that it is important for clinicians to review their knowledge of unusual presentations of mycobacterial infections. Involvement of subcutaneous tissue and skeletal muscle is rare in tuberculosis. Occasionally, infection of soft tissue may be the sole manifestation of tuberculosis. Apart from cases of tuberculous lymphadenitis, the diagnosis of extrapulmonary tuberculosis may be difficult. Modern imaging techniques, such as magnetic resonance imaging, may be helpful in making a differential diagnosis. We present here a case of tuberculous cellulitis in an immunocompetent child and discuss the contribution of MRI in diagnosis.

Presumed periorbital lupus vulgaris with ocular extension

OBJECTIVE

To report an unusual case of lupus vulgaris that spread to the left anterior ocular surface.

DESIGN

Case report.

PARTICIPANT

An 18-year-old woman presented with an 8-month history of an infiltrative skin lesion affecting the left lower eyelid and cheek area, left globe, right lacrimal sac area, together with a cystic lesion in the foot area. TESTING/INTERVENTION: The authors describe the clinical findings, radiologic study, and histopathologic study of the conjunctiva, skin, liver, and ankle lesion. The patient was treated with antituberculous medications for 3 months.

MAIN OUTCOME MEASURES

Healing of the skin, conjunctival, and bone lesions.

RESULTS

The lesion of the face healed, leaving scar tissue. The left eye showed symblepharon with loss of its anterior surface features. The right eye showed no symblepharon, the bones of the foot healed with no deformity, and the liver function test results normalized after 3 months of antituberculous medications.

CONCLUSION

Lupus vulgaris can be associated with multiple system involvement. Its clinical presentation and behavior depend on the patient's immunity and duration of the disease. Early diagnosis and appropriate management may cure the disease with no life-threatening sequelae.

Cold abscess of the chest wall: a surgical entity?

BACKGROUND

Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently.

METHODS

During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study.

RESULTS

Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli.

CONCLUSIONS

Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity.