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CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 226-229  

A rare case of tubercular collarstud abscess of anterior abdominal wall


Department of General Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission04-Oct-2020
Date of Decision06-Aug-2020
Date of Acceptance02-Dec-2020
Date of Web Publication3-Mar-2021

Correspondence Address:
R Shiva
Department of General Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_355_20

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  Abstract 


Tuberculosis (TB) is considered as a ubiquitous disease, as it can involve any organ or a part of the body. Commonly, it involves the lungs and the abdomen. Muscle involvement is rare. In most cases, it is secondary to tubercular costochondritis or TB of the spine. Autopsy studies have revealed the abdominal wall involvement in <1% of patients who died of TB. A high index of suspicion is necessary to diagnose tubercular lesions in unusual anatomical locations. Antitubercular therapy is the main form of treatment; however, some patients may require surgical intervention. We are hereby presenting a case of tubercular anterior abdominal wall abscess secondary to wet peritonitis in a 40-year-old apparently healthy male with no past history of TB. The objective is to alert the clinicians and radiologists to the possibility of TB when considering such cystic lesions of the anterior abdominal wall.

Keywords: Anterior abdominal wall, antitubercular therapy, tuberculosis


How to cite this article:
Shiva R, Ali I, Eswarawaka M. A rare case of tubercular collarstud abscess of anterior abdominal wall. Med J DY Patil Vidyapeeth 2021;14:226-9

How to cite this URL:
Shiva R, Ali I, Eswarawaka M. A rare case of tubercular collarstud abscess of anterior abdominal wall. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 13];14:226-9. Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/226/310709




  Introduction Top


Tuberculosis (TB) is a rampant disease, especially in endemic countries, including India. Numerous cases of pulmonary, abdominal, and extra-abdominal TB have been reported till date; however, the skeletal muscles are rarely affected by TB[1] because they are not a favorable site for the survival and multiplication of Mycobacterium tuberculosis. Even in patients with involvement of other organs, TB rarely involves skeletal muscles. Petter et al. recorded primary muscular TB with an incidence of 0.015%.[2] We present a case of collarstud tubercular abscess of anterior abdominal wall secondary due to wet peritonitis with no evidence of pulmonary or skeletal TB in an immunocompetent patient. This case report should serve as a reminder that varied manifestations seen in TB are because of the difference in the number and virulence of bacilli, the routes of infection, and the host's immune status.


  Case Report Top


A 40-year-old male presented to our Outpatient Department of General Surgery, Dr. D.Y. Patil Medical College, Hospital, Pimpri, with a painless, gradually increasing swelling over the anterior abdominal wall for the past 4 months. There were no other symptoms, and the patient did not have any other past medical history suggestive of TB. Physical examination revealed a nontender swelling (7 cm × 5 cm) on the anterior abdominal wall in midline, midway between xiphi sternum and the umbilicus. The swelling was soft and cystic in consistency with no overlying skin changes and the swelling became prominent when making the anterior wall muscles taut. Per abdominal examination showed mild tymphany with no evidence of organomegaly or lump. There was no associated lymphadenopathy, and systemic examination was normal [Figure 1].
Figure 1: Clinical photograph showing of anterior abdominal wall cold abscess

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Routine blood and urine examinations were within the normal limits. Chest radiograph and blood chemistry were within the normal limits, and human immunodeficiency virus test was nonreactive.

Ultrasound of the abdomen was suggestive of two abscess cavities, one in the subcutaneous plane containing 30 cc of pus and another immediately subjacent with a volume of 32 cc of pus in the preperitoneal plane, and these collections were connected to each other through a small 2 mm defect. There was no intraperitoneal extension noted. Contrast-enhanced computed tomography (CT) scan of the abdomen showed a dumbbell-shaped abscess cavity in the midline of anterior abdominal wall in the epigastric region with evidence of necrotic mesenteric lymphadenopathy and minimal interbowel free fluid suggestive possibility of TB [Figure 2].
Figure 2: Computed tomography scan of the abdomen showing two cystic collections in the anterior abdominal wall with peripheral enhancement (a) axial view (b) sagittal view – no involvement with the spine

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Aspiration of the abscess showed the aspirated sample to be purulent. Aspiration cytology revealed the presence of both acute and chronic inflammatory cells with few isolated epithelioid cells against an hemorrhagic background. However, there was no evidence of acid-fast bacilli or caseous necrosis on microscopic examination of the aspirate. The pus sample showed low positivity for M. tuberculosis in Cartridge-based nucleic acid amplification test (CBNAAT).

The patient was started on directly observed treatment short course - antitubercular treatment category 1 (DOTS-ATT CAT I) regimen. Since the patient had recurrent collection in spite of repeated aspiration from the abscess cavity, we wanted to find out the primary focus; hence, the patient underwent diagnostic laparoscopy, and the findings were as follows:

  1. There was minimal free fluid, and tubercles were present on the peritoneal wall and mesentery
  2. The whole abdomen looked like a cocoon with multiple flimsy adhesions
  3. There was no intraperitoneal extension of the abscess cavity [Figure 3].
Figure 3: Intraoperative picture during diagnostic laparoscopy showing tubercles and multiple filmsy adhesions present in between peritoneal wall and mesentery

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Based on the diagnostic laparoscopy and CT scan report, we explored the collarstud abscess cavities, and on exploration, it was revealed that there were two abscess cavities communicating with each other through the small opening in linea alba. However, the peritoneal cavity was intact. The abscess cavities had thick wall with the plenty of unhealthy granulation tissue; however, no tubercles was seen. Drainage and scrapping of abscess cavities were done. Skin over the abscess cavity was closed loosely with drains in situ in both the cavities. Postoperative period was uneventful. A final diagnosis of tubercular peritonitis leading to the collarstud abscess in the anterior abdominal wall was made, DOTS-ATT CAT I regimen was continued, and the patient recovered and is doing well on follow-up [Figure 4].
Figure 4: Intraoperative pictures showing two abscess cavities (Dumbbell shaped) in the anterior abdominal wall (a) superficial part (b) deeper part of the collarstud abscess

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  Discussion Top


TB of the anterior abdominal wall is rare, and only a few cases have been documented from developing countries where the disease is endemic.[3],[4],[5] Culotta[6] found only four cases of TB myositis out of 2224 autopsies done on TB patients while Petter et al. recorded only one case with primary muscular TB in over 6000 cases with all types of TB. The possible explanations for the rarity of muscle involvement in TB include high lactic acid content, absence of reticulo-endothelial and lymphatic tissue, highly differentiated state of muscle tissue, and its rich blood supply.[7],[8]

A large TB focus in the muscle mass is usually manifested as swelling and pain. The infection is usually limited to one muscle but rarely several muscles are involved.[9] There may be a frank abscess as seen in our case followed finally by calcification in some cases.[3] The skeletal muscles are involved usually by a direct extension from a neighboring joint or cold abscess but rarely by hematogenous spread. A tubercular abscess arising in the costochondral junction may track downward, either lateral or medial to the linea semilunaris. If it extends lateral to the rectus, they spread downward between internal oblique and the transversus muscles, but if it extends medial to the linea semilunaris it may spread into the sheath of rectus and may extend downward behind the muscle.[10] In our case, the collarstud abscess was located in the midline with no involvement of the rectus muscle. This can possibly be explained by the unique anatomy and arrangement of fibers in the linea alba from xiphisternum to pubis [Figure 5]. The decussation and interweaving of aponeurotic fibers of the linea alba in the midline predispose to congenital apertures in it.[11],[12],[13],[14] These apertures might have served as a route of spread of tubercular (wet) peritonitis through linea alba either by direct extension or lymphatics leading to the formation of cold abscess.
Figure 5: Interdigitation of the aponeuroses of the right and the left external oblique muscles to form linea alba

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The prognosis, however, is good with appropriate anti-TB treatment and surgical intervention if necessary.


  Conclusion Top


We intend through this case report to bring to the attention of clinicians and radiologists to consider the possibility of TB in the differential diagnosis of a cystic lesion even in an unlikely area such as anterior abdominal wall.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Derkash RS, Makley JT. Isolated tuberculosis of the triceps muscle. Case report. J Bone Joint Surg Am 1979;61:948.  Back to cited text no. 1
    
2.
Petter CK. Some thoughts on tuberculosis of fascia and muscle. Lancet 1937;57:156-9.  Back to cited text no. 2
    
3.
Gahlaut DS, Nath K, Sikka KK, Singh KN, Samuel KC. Generalised skeletal muscle tuberculosis. J Indian Med Assoc 1973;61:92-3.  Back to cited text no. 3
    
4.
Garg KM, Joshi M, Joshi N. Tubercular intra muscular abscess: An unusual presentation of tuberculosis. Curr Med Trends 2002;6:1174-6.  Back to cited text no. 4
    
5.
Dixit R, Dixit K, Shah H, Shah K. Tuberculous abscess of rectus abdominis muscle. Indian J Tuberc 2004;51:231-3.  Back to cited text no. 5
    
6.
Culotta A. La tubercolosis muscolare. Rev Pathol Clin Tuberc 1929;3:1-26.  Back to cited text no. 6
    
7.
Plummer WW, Sanes S, Smith WS. Skeletal muscle tuberculosis. J Bone Joint Surg 1934;16:631-2.  Back to cited text no. 7
    
8.
Desai N, Patil S, Thakur BS, Das HS, Manjunath SM, Sawant P. Abdominal wall abscess secondary to subcapsular tubercular liver abscess. Indian J Gastroenterol 2003;22:190-1.  Back to cited text no. 8
[PUBMED]    
9.
Abid M, Ben Amar M, Abdenadher M, Kacem AH, Mzali R, Mohamed IB. Isolated abscess of the thoracic and abdominal wall: An exceptional form of tuberculosis. Rev Mal Respir 2010;27:72-5.  Back to cited text no. 9
    
10.
Bruce SJ, Walmsley R, Ross JA. Manual of Surgical Anatomy. Edinburgh: E & S Livingstone Ltd.; 1967. p. 286-7.  Back to cited text no. 10
    
11.
Agur AM, Dalley AF. Grant's Atlas of Anatomy. Vol. 13., Southasian ed. India:Wolters Kluwer india Pvt Ltd; 2013. p. 104.  Back to cited text no. 11
    
12.
Moschowitz AV. The pathogenesis and treatment of herniae of the linea alba. Surg Gynaecol Obstet 1914;18:504.  Back to cited text no. 12
    
13.
Askar O. A new concept of the aetiology and surgical repair of paraumbilcical and epigastric hernias. Ann R Coll Surg Engl 1978;60:42-8.  Back to cited text no. 13
    
14.
Askar O. Surgical anatomy of the aponeurotic expansions of the anterior abdominal wall. Ann R Col Surg Engl 1977;59:313-21.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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