Cold abscess

Introduction
Cold abscess is a painless, fluctuant, mass, not so warm formed by a
collection of products of liquefaction and the reactive exudation that is
produced in later stage of tuberculosis.

Composition:
Viva-
1. Serum
2. Leucocytes
 Significantly, there are no signs of
inflammation hence called a ‘cold
3. Caseous materials abscess’.
4. Bone debris  Clinical manifestation of
5. Tubercle bascilii
Sites:
1. Commonly at neck and axilla
2. Also at groin, back, side of chest wall etc.

Course:
The abscess, penetrates
The ligaments in articular disease, -----
joint
Bone and periosteum in osseous disease
----- bone
Migrates in various directions following
The facial planes and
Along the vessels and nerves.
A superficial abscess
May get secondarily infected and clinically
behave like phyogenic abscess;
It may burst to form a sinus or an ulcer.
The walls of an abscess, sinus or ulcer are covered with tuberculous
granulations.

C/F
1. Constitutional symptoms
2. Insidious onset Painless swelling
a. Site
b. Shape
c. Soft and smooth mass
d. Cystic in consistency
e. Fluctuation present Fliud
f. Slip sign negative differ from lopoma
g. Transillumination test - ve differ from cyst
D/D
1. Pyogenic abscess -
2. Cyst transillumination
3. Lipoma Slip sign
4. Soft tissue tumor Biopsy (confirmatory)
Investigation:
1. Raised ESR and CRP,
 2. Low haemoglobin
3. Positive Mantoux test
[is not significant in a patient from an endemic area. The
Mantoux test (tuberculin skin test), although in use for
over a hundred years, has now been superseded by
interferon gamma (IFN-_) release assays.]

4. Interferon gamma (IFN-_) release assays –

[This is an in vitro blood test of cellular immune response. Antigens unique
to Mycobacterium tuberculosis are used to stimulate and measure T-cell
release of IFN-_. This helps to earmark patients who have latent or
subclinical tuberculosis and thus benefit from treatment.]
]
5. Sputum for culture and sensitivity
[the result may take several weeks and staining by the Ziehl–
Neelsen method for acidfast bacilli (the result is obtained much
earlier) should also be done.]
6. Specific investigations include aspiration of the pus in a cold
abscess for culture and sensitivity.
7. If the mass is still in the early stages - excision biopsy should
be done

Treatment
Aspiration – Should be aspirated through a nondependent part and
injection Streptomycin
with or without INH instilled locally. [Non dependent – to avoid
sinus formation]
This local treatment may have to repeated 2/3 times

N.B - radiologically, the soft tissue shadow of a cold abscess appears like a
bird’s nest and in the
mediastinum it is heart-shaped or fusiform.
Viva
- If Left untreated, the cold abscess initially deep to the deep fascia
- now bursts through into the space just beneath the superficial fascia.
- This produces a bilocular mass with cross fluctuation. This is called a ‘collar-
stud’ abscess.
- Eventually, this may burst through the skin discharging pus & forming a
tuberculous sinus.
- Sinus has watery discharge with undermined edges

Natural history