Cold abscess


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  • Cold abscess

    1. 1. COLD ABSCESS Dr. P.Sudheer kumar Orthopaedics postgraduate Narayana medical college & hospital
    2. 2. Introduction  An Abscess is a collection of pus within the body.  It is cold because it is not accompanied by the classical signs of inflammation  Almost always a sequel of tubercular infection anywhere in the body commonly in the lymph nodes & bone.
    3. 3. Pathogenesis  Any osteoarticular tubercular lesion is a result of a hematogenous dissemination from a primarily infected visceral focus  Primary focus may be in Lungs,lymph glands of mediastinum/mesentry/cervical region or kidneys or other viscera.  Phagocytosis of tubercle bacilli by RES
    4. 4. Pathogenesis  The characteristic microscopic lesion is the tuberculous granuloma– a collection of epithelioid and multinucleated giant cells periphery.  Within the tubercle, small patches of caseous necrosis appear. These may coalesce into a larger yellowish mass, or the centre may break down to form an Abscess.
    5. 5. Pathogenesis Polymorpho nuclear cells Langhans giant cells Macrophages & monocytes Central caseation necrosis Epitheliod cells Cold abscess
    6. 6. Histology
    7. 7. Pathology  It is formed by collection of products of liquefaction & the reactive exudation  It penetrates the ligaments in articular disease, bone & periosteum in osseous disease  Migrates in various directions following the path of least resistance along fascial planes,blood vessels and nerves, to distant sites
    8. 8. Composition  Mostly composed of      -serum -leucocytes -caseous material -bone debris -tubercle bacilli
    9. 9. Sites  Commonly at Neck & Axilla  Also at Groin,back,side of chest wall  These are sequel of tubercular infection of spine,ribs & posterior medistinal group of lymph nodes.
    10. 10. Clinical features  Painless Swelling -insidious onset -soft & smooth mass -cystic consistency -fluctuation present -slip sign negative -No transillumination
    11. 11. Clinical features…  Sinus or ulcer  superadded infection with pyogenic organisms  Constitutional symptoms like low grade fever, cough , weight loss,loss of appetite  Symptoms of primary tuberculosis
    12. 12. Clinical features…  Local Pressure effects due to swelling c-spine: exudate collects behind prevertebral fascia & protrude as retropharyngeal abscess causing dysphagia, dysphonea, hoarseness of voice & respiratory obstruction  abscess may track down to enter trachea, esophagus or pleural cavity. It may spread laterally into the sternomastoid muscle & forms an abscess in the neck.
    13. 13. Clinical features…  T-spine: exudate confined locally as paravertebral abscess  it may enter into spinal canal & compress spinal cord leading to Early onset pott’s paraplegia  it can penetrate anterior longitudinal ligament to form mediastinal abscess .  pass downwards through medial arcute ligament to form a lumbar abscess.
    14. 14. Clinical features…  Lumbar spine -abscess can have pus track along the psoas muscle towards the groin & presents as psoas abscess  Flexion deformity of hip can develop due to it.(pseudo hip flexion)  Can gravitate beneath inguinal ligament to appear on the medial aspect of thigh  exudate can follow vessels to form an abscess in scarpa’s triangle or gluteal region
    15. 15. Differential diagnosis  Pyogenic abscess  Lipoma  cyst  Soft tumors
    16. 16. Investigations  Lab studies  Microbiology studies to confirm diagnosis  Radiological diagnosis
    17. 17. Lab studies  Mantoux / Tuberculin skin test  ESR may be markedly elevated (neither specific nor reliable).  ELISA : for antibody to mycobacterial antigen- 6 , sensitivity of 60% – 80%.  PCR
    18. 18. Fnac & Biopsy  Percutaneous , CT scan ̶ guided needle biopsy of bone lesions is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses  Biopsy is confirmative
    19. 19. Microbiology studies to confirm diagnosis  • Ziehl-Neelsen staining: Quick and inexpensive method. • Bone tissue or abscess samples stain for acid-fast bacilli (AFB), & isolate organisms for culture & drug susceptibility. • Culture results - few weeks. • Positive only in 50% of cases.
    20. 20. Radiological diagnosis 1. PLAIN RADIOGRAPH 2.ULTRASOUND 3. CT SCAN 4. MRI SPINE 5.BONE SCAN
    21. 21. Plain Radiograph  Cervical region - b/w vertebral bodies , pharynx and trachea  Upper thoracic - ‘V’ shaped shadow , stripping lung apices laterally and downwards  Below T4 – fusiform shape (bird nest appearence)  Below diaphragm – unilateral / bilateral psoas shadow
    22. 22. Plain Radiograph…
    23. 23. ULTRASOUND Detect cold abscess A HYPO ECHOEIC LESION Internal echoes represent debris within. Guided aspiration
    24. 24. CT IMAGE Patterns of bony destruction. Calcifications in abscess (pathognomic for Tb)
    25. 25. MRI •Assessment of extradural abscesses / subligamentous spread. •Skip lesions •Spinal cord involvement.
    26. 26. Radionucleotide Scan T 99m  Increased uptake in up to 60 per cent patients with active tuberculosis.  Avascular segments and abscesses show a cold spot due to decreased uptake.  Highly sensitive but nonspecific.  Aid to localise the site of active disease and to detect multilevel involvement
    27. 27. TREATMENT  Anti tubercular drugs  Aspiration  Ultrasound guided Pigtail catheter drainage  Surgical management
    28. 28. ANTI TUBERCULAR DRUGS  Same as tuberculosis elsewhere in the body.  The chemotherapy is continued for 18 months.  Drug: Dosage: Side effects:  Rifampicin: 450-600mg Liver toxicity  Isoniazid 300-450mg  Pyrizanamide: 40mgms/kg peripheral neuritis Liver toxicity. hyperuricemia  Ethambutol: 15-25mgms/kg.  Streptomycin(inj) 20mgms/kg Optic neuritis. vestibular damage, nephrotoxicity
    29. 29. Aspiration •Palpable Cold abscess must be drained as early as possible & instil 1gm Streptomycin +/- INH in solution •Technique: Zig-Zag aspiration using Wide bore needle from non-dependent area to prevent sinus formation
    30. 30. Ultrasound guided Pigtail catheter drainage
    31. 31. Surgical  Open drainage may be performed if aspiration failed to clear it.  Drainage using non-dependent incision,later closure of wound without placing a drain  Correcting underlying bony lesion/defect.