Nigerian Journal of SurgeryJan-Jun 2012 | Volume 18 | Issue 1
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There are only limited case reports of isolated tubercular
involvement of the parietes even though tuberculosis is a rampant
in developing countries and with the rapid spread of acquired
immune deiciency syndrome (AIDS) it has made inroads into the
developed nations as well. The common organs of involvement
are the lungs, kidneys, bones, and gastrointestinal tract. The varied
manifestations seen in tuberculosis are because of the difference
in the number and virulence of bacilli, the routes of infection and
the host’s immune status.
A 62-year-old male presented to outpatient department of
surgery with a painless, gradually increasing swelling over anterior
abdominal wall for the last three years. There were no other
symptoms and the patient did not have any other past medical
history suggestive of tuberculosis. Physical examination revealed
a nontender swelling (7 cm × 5 cm) on the anterior abdominal
wall to left of midline which extended from left hypochondrium
above to the umbilicus below [Figure 1]. The swelling was soft
and cystic in consistency and failed to disappear while making the
anterior wall muscles taut. Rest of the abdominal examination was
normal. There was no associated lymphadenopathy and systemic
examination was normal. Routine blood and urine examinations
were normal. Chest radiograph and blood chemistry including
human immunodeiciency virus (HIV) test did not reveal any
abnormality. Ultrasonography and computerized tomography (CT)
Scan examination revealed two cystic masses one 3.7 × 5.2 cm and
another 7.4 × 5.4 cm abdominal parietal wall mass (predominantly
cystic) of mixed echogenicity, one in right hypochondrium and
another in left hypochondrium extending to umbilical region
with peripheral enhancement [Figure 2]. contrast enhanced
computerized tomography (CECT) abdomen and pelvis was
normal. The differential diagnosis multiple hydatid cyst of anterior
abdominal wall was excluded once indirect hemagglutition test was
reported to be negative. Fine needle aspiration cytology revealed
caseating granuloma with central necrosis, lymphocytes and giant
cells, consistent with tuberculosis. The patient was diagnosed to
have multiple tubercular cold abscess of anterior abdominal wall.
Patient responded favorably to antitubercular drugs and anti gravity
Only isolated cases of tuberculosis of skeletal muscle have been
reported in the medical literature). Culotta found only four cases
in his 2224 autopsies. The incidence of primary muscular
tuberculosis was reported as 0.015% by Petter. Skeletal muscle
involvement occurs in two forms: Most commonly the tubercular
abscess spreads into the muscle through extension from the
neighboring structures like lymph nodes, bone, joint or tendon,
Cold Abscess of the Anterior Abdominal Wall:
An Unusual Primary Presentation
Mohinder Kumar Malhotra
Department of General Surgery, SGT Medical College, Hospital and Research Institute, Gurgaon, India
Tuberculosis is considered as ubiquitous disease as it involves any
organ, but primary involvement of abdominal muscles is very
rare. In most cases, the muscle involvement is secondary and is
caused by either hematogenous route or direct inoculation from a
tuberculous abdominal lymph node or extension from underlying
tubercular synovitis and osteomyelitis. Autopsy studies have
shown abdominal wall involvement in less than 1% of patients
who died of tuberculosis. Antitubercular therapy is main form
of management. Surgical intervention is always secondary in the
form of either sonography or computerized tomography-guided
aspiration or open drainage which is usually reserved for patients
in whom medical treatment has failed. A case is hereby reported
about primary tubercular anterior abdominal wall abscess
without any evidence of pulmonary, skeletal or gastrointestinal
tuberculosis in an apparently healthy individual with any past
history of contact or previous antituberculosis therapy.
KeywoRds: Anterior abdominal wall, antitubercular
therapy, primary tuberculosis
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Nigerian Journal of SurgeryJan-Jun 2012 | Volume 18 | Issue 1
Malhotra: Primary cold abscess of the anterior abdominal wall
etc. A tubercular abscess arising from a costochondral junction
may track down, either lateral or medial to the linea semilunaris.
If it extends lateral to the rectus, it spreads down between the
internal oblique and transverse abdominis muscles, but if it
extends medial to the linea semilunaris, it may spread into the
rectus sheath and may extend downward behind the rectus muscle.
In the second type, the spread is hematogenous. This case is of
interest because he seems to have a primary tubercular anterior
abdominal muscular lesion without any history of contact or
previous anti tubercular therapy. The possible explanation for
the rarity of muscle involvement in tuberculosis may be high
lactic acid content, lack of reticulo-endothelial tissue in muscle,
lack of lymphatic tissue, the abundant blood supply and the
highly differentiated state of muscle tissue.[5,6] Ultrasonography
of the entity usually shows a parietal-wall mass (predominantly
cystic) of mixed echogenicity, with irregular walls and a liqueied,
necrotic center. Sometimes, an evidence of posterior acoustic
enhancement with focal areas of calciication within the lesion
may also be demonstrated sonographically. Computed scan
of the abdomen usually shows a well-deined abscess in the
abdominal wall. Ultrasonography or CT-guided aspiration
followed by cytological examination usually reveals tuberculous
granulomas with areas of caseous necrosis. Ziehl-Neelsen (Z-N)
staining or culture of the aspirate may also help in conirming
the diagnosis. [5,7] Management of this entity is mainly in the form
of anti-tubercular therapy. Surgical intervention in the form of
either sonography or CT-guided aspiration or open drainage is
usually reserved for patients in whom medical treatment fails.
Present case cautions the clinicians and radiologists about the
possibility of tuberculosis in considering the differential diagnosis
of any lesion even in any unlikely anatomical area, especially in
those areas where tuberculosis is endemic or where the disease
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Figure 1: Clinical presentation of anterior abdominal wall cold abscess
Figure 2: CT scan of the abdomen showed two cystic collections in
the anterior abdominal wall with peripheral enhancement
How to cite this article: Malhotra MK. Cold abscess of the anterior
abdominal wall: An unusual primary presentation. Niger J Surg
Source of Support: Nil. Conlict of Interest: None declared.