71
Clinical Brief
Tuberculous Cold Abscess
Avyact Agrawal and Anuj Jain
Department of Pediatrics, N.S.C.B. Medical College, Jabalpur
ABSTRACT
A tubercular cold abscess secondary to adjoining bone involvement is a well-known entity. However, a primary cold abscess
with no bony involvement in children is very rare. We present such a case. [Indian J Pediatr 2007; 74 (8) : 771-773]
Key words : Tubercular; Cold abscess
CASE REPORT
An 11-month-old female infant was presented to us with
complaints of a painless swelling over right glutei region
since last 8 months, which had been gradually
progressive. There were additional complaints of
decreased appetite and poor weight gain since the
swelling first came to notice.
On examination, the child had weight 72% of expected
for age (previous weight record at 6 months of age being
78%), normal developmental milestones, was afebrile,
normal vitals and no abnormality detected on systemic
examination. Child was fully immunized for the routine
vaccines. The only positive finding was presence of a
swelling 2.5×1.5 cm, in the gluteal area near the
trochanteric region, firm in consistency, nontender,
mobile, non fluctuant and with negative
transillumination.
The parents had consulted a physician at 4 months of
age who diagnosed it as an ‘injection abscess’ as there was
history of (DPT) Diphtheria, Fertussis and Tetanus
vaccination at three and a half months of age and
prescribed suspension coamoxiclavunate and syrup
Paracetamol for 5 days to which the swelling had not
responded and rather had increased in size markedly
since then, as per the mother.
We made a provisional diagnosis of an ‘organized
abscess’. Investigations were done. Complete blood
counts revealed hemoglobin 10gm/dl, Total Leucocyte
Counts 9400/cubic millimeters with polymorphs 38%,
Correspondence and Reprint requests : Dr. Anuj Jain, C/o Mr. Rohit
Asolkar, 1036, Shastri Nagar, Near Medical College, Jabalpur (M.P),
Pin - 482003; Ph. No. 09907222753
[Received July 7, 2006; Accepted March 28, 2007]
Indian Journal of Pediatrics, Volume 74—August, 2007
lymphocytes 60% and eosinophils 2%. Erythrocyte
Sedimentation Rate was 40 mm/hour.
Radiographically, plain X-ray right hip joint and upper
thigh revealed evidence of soft tissue swelling on outer
aspect of right hip with an intact femur and hip joint.
Ultrasonography (USG) over the swelling revealed
evidence of hypoechoeic mass lesion, 2.6×0.89 cm in size
in the subcutaneous tissues at right gluteal region
involving the muscle tissue suggestive of intramuscular
abscess infiltrating the subcutaneous tissues (Fig 1).
USG was suggestive of thick fluid filled abscess. Fine
needle aspiration cytology was done and material was
sent for histological examination. H and E staining
revealed presence of macrophages and giant cells. Gram
staining was negative. Modified Zeil Nelson staining was
negative for (AFB) Acid fast bacilli.
In view of USG report and histological findings, a
large bore (15 gauge) needle aspiration was done. White
cheesy thick material was aspirated which was sent for
the Polymerase Chain Reaction (PCR) analysis for
Mycobacterium tuberculosis. A bacterial culture was done
which was negative. Zeil Nelson staining was repeated
which was positive for AFB.
There was no history of identifiable contact with the
tuberculosis. Family survey for tuberculosis with the aid
of chest X-ray was done which showed no evidence of
tuberculosis. Both parents and the child were non reactive
for (ELISA) Egyme Linked Immuno Sorbent Assay for
(HIV) Human Immo Deficiency Syndrome.
Later on PCR came out to be positive for M.
tuberculosis. The chest X-ray of the baby was normal.
Mantoux’s reading was 14 mm after 72 hours of the
administration.
Patient was prescribed anti tubercular therapy (ATT)
for 6 months {2HRZ+4HR} (H-ISONIAZIDE, R-
771

A. Agrawal et al
(A)
Fig. 1. (A) U.S.G. over the swelling revealed evidence of hypoechoeic mass lesion, 2.6×0.89 cm in size in the subcutaneous tissues at right
gluteal region involving the muscle tissue suggestive of intrmuscular abscessinfiltrating the subcutaneous tissues.
(b). X-ray right hip and upper thigh with evidence of softtissue swelling in lateral aspect of thigh without any bony abnormality.
RIFAMPICIN, Z-PYRAZINANIDE). After one month of
starting ATT, gradually the swelling started decreasing in
size. At present the child is in the last month of
continuation phase; the swelling is not appreciable even
on deep palpation and the child has gained weight being
88 %of expected weight at present.
DISCUSSION
Tuberculosis of the soft tissues is not uncommon in the
form of proven entities like tubercular bursitis, tubercular
synovitis, and tubercular spondylitis secondary to
underlying bone involvement. 1, 2 However, selective
tissue involvement without bony abnormality is rare.
Since the intact human skin is a protective barrier to
Mycobacterium tuberculosis spread,3 so the infection to the
musculoskeletal system is presumed to spread
hematogeneously from a primary focus, yet the incidence
of active pulmonary tubercular lesion on chest X-ray is 29
% only.4
There are sporadic reports of primary tubercular
abscess in the gluteal region that have been presumed to
be syringe transmitted either through used needles or
due to coughing by the infected nursing staff over the site
of injection.5 Injection administration can cause bacteria to
enter in the subcutaneous tissues. Tamura et al, in fact
reported an epidemic of 102 children who were given
typhoid vaccine and who later developed indurations at
the injection site followed by axillary lymphadenopathy.
772
72
(B)
One of the three vaccinators was later found to be an
open case of pulmonary tuberculosis.6
In our case, though there was a positive history of DPT
vaccination in the preceding month of when the swelling
was first recognized, it cannot be incriminated as the
cause.
The other close differential diagnosis of such cases can
be a pyogenic injection abscess secondary to vaccination
or any intramuscular injection, which can be the result of
contamination of vaccine or injection equipment. Sterile
abscesses can be seen due to local reactions from
aluminium containing vaccines, especially DPT.7
In addition, there are case reports of retrocecal
appendicitis in children presenting with thigh abscess8
also. Pyomyositis of glutei muscle initially described in
adults has also been reported in pediatric patients.9 If an
injection abscess is AFB positive, the rare diagnostic
possibilities apart from Mycobacterium tuberculosis
infection can be infection due to Mycobacterium fortuitum
and Mycobacterium chelonei. The distinction between a
tuberculous abscess and injection abscesses caused by
Mycobacterium fortuitum and Mycobacterium chelonei can
be done by biochemical tests and heterotrophic plate
counts (HPC). Also, the differentiation can be done by a
therapeutic trial of (ATT) Arti Tubercular Therapy to
which the latter do not respond.10
CONCLUSION
If any swelling at the injection site is not showing signs of
Indian Journal of Pediatrics, Volume 74—August, 2007
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Tuberculous Cold Abscess
inflammation, is gradually increasing in size and is not
responding to antibiotics then the possibility of
subcutaneous tubercular cold abscess should be kept in
mind. Further studies are needed to know the exact
pathogenesis in such cases.
Pediatricians should be highly vigilant about
maintaining asepsis while administrating vaccines or
injections and should also ensure their proper storage,
proper site and proper route of administration.
Acknowledgements
We thanks acknowledge with thanks to Dr. Vikesh Agrawal and
Sanjay Pandey, Department of Surgery, Department of
Radiodiagnosis, N.S.C.B. Medical College, Jabalpur, for their help in
the preparation of this report.
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