What is the treatment for a cold abscess in the chest?

Treatment of Cold Abscess in the Chest Wall

The most effective treatment for a cold abscess in the chest wall is complete surgical resection of the abscess including any suspicious ribs, combined with appropriate antituberculous medication for at least 12 months. 1

Understanding Cold Abscess of the Chest Wall

Cold abscesses of the chest wall are typically tuberculous in origin and represent a rare form of extrapulmonary tuberculosis. They are characterized by:

• Palpable chest wall mass, often painless or with minimal pain 2
• Absence of typical inflammatory signs like redness and heat 3
• Progressive increase in size without trauma or previous effort 3

Diagnostic Approach

Diagnosis of chest wall cold abscess can be challenging and requires:

• Imaging studies (MRI or CT scan) to delineate the extent of the collection 3
• Surgical debridement with histopathological examination showing granulomatous inflammatory reaction with focal necrosis 3
• PCR and culture for Mycobacterium tuberculosis complex 3

Treatment Algorithm

1. Medical Management

• Preoperative antituberculous medication is recommended before surgical intervention 2
• Standard multidrug antituberculous therapy should be initiated once diagnosis is confirmed 3, 4

2. Surgical Management

• Complete surgical resection is mandatory and should include:

  • Complete excision of the abscess 1
  • Resection of any suspicious ribs or affected chest wall portions 2
  • Adequate debridement of all infected tissue 5

• Surgical options (in order of effectiveness):

  • Complete excision including chest wall (recurrence rate 9.2%) 1
  • Complete excision without chest wall resection 1
  • Abscess debridement and drainage (recurrence rate 40%) 1

3. Postoperative Care

• Antituberculous medication must be continued postoperatively for a minimum of 12 months 2, 4
• Regular follow-up to monitor for recurrence 2

Important Considerations

• Needle aspiration alone is often inadequate for diagnosis and treatment 5
• Medical treatment without surgical intervention has limited success in most cases 5
• Recurrence rates are significantly higher when only drainage is performed compared to complete resection (40% vs. 9.2%) 1
• Surgery should be performed in centers with expertise in both medical and surgical management of mycobacterial diseases 6

Specific Antimicrobial Regimens

For confirmed tuberculous cold abscess:

• Standard first-line antituberculous drugs (isoniazid, rifampin, ethambutol, pyrazinamide) 4
• Duration of therapy should be at least 10-12 months 2, 4

For non-tuberculous mycobacterial infections (if identified):

• For M. abscessus: combination of macrolide (clarithromycin or azithromycin) with parenteral medications (amikacin, cefoxitin, or imipenem) 6
• For M. kansasii: daily regimen including rifampin, ethambutol, isoniazid, and pyridoxine 6

Monitoring and Follow-up

• Close clinical monitoring with regular follow-up examinations 2
• Assess for potential complications: bleeding, pus discharge, empyema, pleural effusion, wound dehiscence 2
• Monitor for recurrence, which may require a second operation 1