Abscess (Abscesses)

Five day old Abscess[1]

An abscess is a localized collection of pus in a cavity formed by disintegration of tissues, characteristically caused by staphylococci or streptococci, but also caused by parasites and foreign materials. There are two types of abscesses, septic and sterile. It is frequently associated with swelling, local pain, redness and other signs of inflammation and general malaise, fever and lymphadenitis.

This disease is promted by the following process: infectious.

Presentation

Abscesses found inside the body start to manifest compression symptoms when they reach considerable size. The signs and symptoms associated with organ abscesses depend on the primary organ that is infected. Cutaneous abscesses are more visible and noticeable during the early phase of the clinical course. The following symptomology are commonly seen among patients suffering from cutaneous abscesses:

  • Small reddish swellings that are sometimes painful
  • Swollen skin around the swelling
  • Progressive increase in size of the swelling
  • Rupture of abscess when size increases

Workup

The diagnosis is easily made with the aid of a careful clinical history taking and a detailed examination of the skin. However, ancillary tests and diagnostic modalities may be needed to ascertain the diagnosis of abscess. The following tests and diagnostic methods may be implored to patients suffering from abscess:

Laboratory tests

Pus aspirates from the abscess may be brought to the laboratory for examination of its contents and the identification of the offending bacteria. Skin swabs may be taken from the abscess sites and placed on a culture media. The bacterial culture may be studied to accurately identify the causative agent. Sensitivity testing determines which antibiotics are most effective against the offending bacteria or agent.

Ultrasound

Abscesses found within the body may require imaging studies like ultrasound to visualize the abscess formation. Liver and lung abscesses are sensitively detected by the sonogram in most cases.

Computed tomography (CT scan)

The CT scan is most useful in diagnosing brain abscess to assess its location, size and the structures that it impinges. Brain abscess must be identified and treated promptly because of its potentially lethal nature [5].

Magnetic resonance imaging (MRI)

This is a more detailed rendering of the internal structures as compared to the CT scan. MRI are arbitrarily used in the imaging of perianal abscesses [5].

Treatment

The treatment modalities used is dependent on the size and location of the abscess formation. The following treatment modalities are implored for the treatment of abscess:

  • Empiric topical antibiotics: Cutaneous abscess are usually treated with empiric antibiotics like bacitracin and mupirocin [6]. 
  • Oral and parenteral antibiotics: Cutaneous abscess with larger diameters and unresponsive to topical antibiotics may require oral doses of cloxacillin or flucloxacillin given in a period of 7 to 10 days [7]. Intravenous or parenteral antibiotics are reserved for more serious forms of abscess like brain abscess, empyema, and hepatic abscess
  • Surgical incision and drainage: This surgical procedure is implored on large abscesses and those that cause severe discomfort and pain. The incision will drain the pus from the cavity to relieve pressure signs and hasten healing of the lesion [8]. Tooth abscess are usually drained to control the toothache
  • Surgical debridement: For large confluent abscesses and complicated fasciitis, there is an immediate need to remove dead tissues to get rid of the source of infection.

Prognosis

Small cutaneous abscesses that resolve with minimal intervention carry a very good prognosis. Boils like carbuncles and furuncles rarely complicate, but infection might reach the blood stream and cause a systemic infection.

Life threatening abscess variants like the necrotizing fasciitis are treated promptly to prevent serious complications [3]. Brain abscess, lung abscess, and liver abscess however should be treated instantly because of their probable serious complications [4].

Etiology

Bacterial infections are commonly implicated as the causative factors in the formation of abscess. Less commonly abscess is caused by viruses and protozoans among susceptible patients. The more common bacterial pathogens associated with cutaneous abscesses include: Staphylococcus aureus, Beta-hemolytic streptococcus, Bacteroides fragilis, Eneterobacter sp, and Pasteurella multocida [1].

Epidemiology

Abscess is fairly common in worldwide population. Because mild cutaneous abscess resolves spontaneously with home remedy treatment, most cases are not brought to medical attention and are not subsequently recorded. For this reason, the exact epidemiologic data is not available. There is no sexual and racial predilection for abscess. Abscesses are more common in countries with warmer climates.

The incidence among children belonging to the lower socioeconomic status is high. This is probably related to the poor health conditions, poor hygiene, dirty environment, malnutrition, and poor access to medicines and medical care.

Sex distribution
Age distribution

Pathophysiology

Pathogenesis of abscess formation depends on the site of the formation. Abscesses from acne are formed after the cutaneous oil glands and sebaceous glands are obstructed. The obstructed gland propagates the growth of the pathogenic organisms within the sebum sac where pus forms, and the swelling starts to bulge out of the skin.

Breaks in the skin may cause abscess of the hair follicles giving rise to folliculitis. Soft tissue organs like the lungs, liver and the brain may also develop abscesses from systemic sources by sepsis [2].

The pus collection found in the middle of the abscess is a collection of dead cells, bacteria, and some cellular debris. Patients who have diminished immune response can easily develop abscess formation because of an incompetent cell mediated immunity.

Prevention

Frequent hand washing and proper bathing should regularly be done to prevent the propagation of pyogenic bacteria in the skin. Persistent bumps and lumps must be promptly brought in for medical attention to prevent the untoward complications of such. Patients with low immune response like those on chronic steroids and anti-cancer regimens must take oral antibiotics when treating simple cutaneous abscess. Smoking must also be controlled for it increases the risk for anal abscess formation [9]. A good glucose control among diabetics may prevent the emergence of cutaneous and internal abscess formation.

Summary

Abscess is a bump or lump that contains a collection of pus. Often, abscess is a result of a bacterial infection. It may occur almost anywhere in the body with soft tissues. It is a clinical condition characterized by the local collection of pus within a confined tissue space. Abscesses are usually caused by an infectious agent that causes localized redness, pain, tenderness, and swelling of the affected tissue. Abscess can be further classified to carbuncles, and furuncles (boils) according to its size and clinical course. These are usually treated with surgical drainage and oral antibiotics. 

Patient Information

Definition

Abscess is a clinical condition characterized by the local collection of pus within a confined tissue space. This may occur on the skin or any other soft tissue organ in the body.

Cause

Abscesses are basically caused by bacterial infections that invade the skin and other organs. A decreased cell mediated immune response among the immunecompromised patients, and long term steroid users predisposes one from developing abscess in any part of the body.

Symptoms

Cutaneous abscesses will present as lumps and bumps on the skin. The lesion may appear initially as a reddish lump or bump with a painful localized swelling. The lesion may later evolve a whitish punctum in the center through pus may drain with the abscess ruptures. Internal organ abscess may present in the later stages of its development when the size is big enough to cause pressure symptoms.

Diagnosis

The accurate diagnosis of abscess is done with a detailed clinical history and physical examination of skin. Ancillary tests like culture and sensitivity may be done to determine the causative agent and the antibiotics through which they are sensitive. Imaging studies like ultrasound, MRI and CT scan are used to identify abscess located within the body.

Treatment and follow-up

Abscesses are initially treated with empiric antibiotics in topical, oral, and parenteral form depending on the severity. Surgical incision and drainage may be needed to relieve the abscess and hasten its recovery. The active removal of tissues that are no longer viable through surgical debridement may be necessary to eliminate the source of the infection and prevent further complications.

Self-assessment

References

  1. Tintinalli JE, Stapczynski JS, Ma OJ, et al. Emergency Medicine: A Comprehensive Study Guide. 7th Ed. New York: McGraw Hill Medical Publishing; 2010:1001-1008.
  2. Salahi R, Dehghani SM, Salahi H. Liver abscess in children: a 10-year single centre experience. Saudi J Gastroenterol. 2011; 17(3):199-202 
  3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. Jul 15 2014; 59(2):e10-52.
  4. Tam MH, Wong GK, Ip M, Kam MK. Management outcome of NPC-related and non-NPC-related brain abscess in Hong Kong. Clin Neurol Neurosurg. 2012; 114(6):560-3 
  5. Sankararaman S, Riel-Romero RM, Gonzalez-Toledo E. Brain abscess from a peritonsillar abscess in an immunocompetent child: a case report and review of the literature. Pediatr Neurol. 2012; 47(6):451-4 
  6. Li X, Qiang JW, He C, Ji XS, Zhang B. Magnetic resonance imaging study of perianal abscess. Zhonghua Wei Chang Wai Ke Za Zhi. 2011; 14(11):868-70 
  7. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. Feb 1 2011; 52(3):e18-55.
  8. Barclay L. IDSA: skin and soft tissue infections guidelines updated. Medscape Medical News. Accessed November 16, 2014.
  9. Holtzman LC, Hitti E, Harrow J. Incision and drainage. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Saunders Elsevier; 2013: chap 37.
  10. Devaraj B, Khabassi S, Cosman BC. Recent smoking is a risk factor for anal abscess and fistula. Dis Colon Rectum. 2011; 54(6):681-5 

  • A comparison of amebic and pyogenic abscess of the liver. - PF Barnes, KM De Cock, TN Reynolds, PW Ralls - Medicine, 1987 - ukpmc.ac.uk
  • Acute pediatric potentially thrombogenic craniocervical infections: a consecutive series of Lemierre and Lemierre-like syndrome cases - A El-Hawrani, M Noga, R Gareau, J Robinson - International Journal of , 2006 - Elsevier
  • Brucellar and tuberculous spondylitis. A comparative study of their clinical features - M Cordero, I Sanchez - Journal of Bone & Joint Surgery, , 1991 - bjj.boneandjoint.org.uk
  • Aortic aneurysm secondary to mediastinal abscess: report of two cases - DE Blickenstaff, CM Nice - CHEST Journal, 1965 - journal.publications.chestnet.org
  • Adjunctive hyperbaric oxygen for treatment of rhinocerebral mucormycosis - BJ Ferguson, TG Mitchell, R Moon - Review of Infectious , 1988 - cid.oxfordjournals.org
  • ABC of diseases of liver, pancreas, and biliary system: Liver abscesses and hydatid disease - JEJ Krige, IJ Beckingham - BMJ: British Medical Journal, 2001 - ncbi.nlm.nih.gov

Media References

  1. Five day old Abscess, CC BY-SA 3.0

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