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Subcutaneous Abscess

A subcutaneous abscess is a pocket of pus formed in the superficial skin as a result of normal skin bacteria infiltrating broken or damaged skin. This type of skin infection develops anywhere on the body, but has a preference for intertriginous areas. A subcutaneous abscess is painful and appears as a swollen, erythematous, and fluctuant mass. The diagnosis is typically clinical unless the abscess is complex, something which would warrant a more extensive workup.


Presentation

A subcutaneous abscess is a pus-filled cavity located in the superficial skin layers caused by penetration of the skin by bacteria following a cut or other dermal disruption [1]. The implicated pathogens are normal skin flora bacteria [2] [3] such as Staphylococcus aureus (most common), group A Streptococcus, and anaerobes [2] [3] [4]. A subcutaneous abscess is circumscribed by tissue containing inflammatory cells and the purulent collection is composed of bacteria, immune cells, and material from the surrounding necrotic subcutaneous tissue [1]. Abscesses and other skin and soft tissue infections (SSTIs) are a common cause of visits to the emergency department and the doctor's office [5].

A subcutaneous abscess presents as a painful edematous mass with induration [4]. They typically form on regions in the body predisposed to friction, also known as intertriginous areas, although they can appear anywhere [6]. This may manifest as a furuncle, which emerges from a hair follicle, or carbuncles which are clusters of infected follicles [6]. Subcutaneous abscesses can rupture spontaneously in which the overlying skin on the abscess thins out and possibly becomes yellow or white, reflecting the pus collection.

Risk factors for abscesses and SSTIs, in general, include advanced age, trauma, diabetes mellitus, malignancy, immunocompromised state, obesity, and so forth [7] [8] [9]. Additionally, individuals such as athletes playing in close-contact sport and military individuals living in close proximity are predisposed to outbreaks [10] [11].

Physical exam

A superficial abscess is characterized by tenderness, warmth, erythema, and fluctuance. Note that generalized symptoms such as fever and chills do not occur with these simple abscesses [12].

Splenomegaly
  • An echocardiography showed no pathological alterations and the abdominal ultrasound revealed homogeneous hepatomegaly and splenomegaly. An ocular fundoscopy was normal.[mycology.imedpub.com]
Fever
  • Note that generalized symptoms such as fever and chills do not occur with these simple abscesses.[symptoma.com]
  • If there is bacteremia patient may present with systemic signs of sepsis such as fever, rigors, and raised inflammatory markers.[radiopaedia.org]
  • […] include: a smooth swelling under your skin that can feel hard or firm pain and tenderness in the affected area warmth and redness in the affected area a visible build-up of white or yellow pus under the skin in the affected area a high temperature (fever[nhs.uk]
  • A previously healthy 18-year-old man was admitted to the hospital with a 3-month history of coughing, expectoration of reddish sputum, weight loss, and fever; a small region of swelling had developed on his anterior chest wall in the preceding week.[nejm.org]
  • Symptoms may include: Fever or chills, in some cases Local swelling around the infected spot Hardened skin tissue Skin lesion that may be an open or closed sore, or a raised area Redness, tenderness, and warmth in the area Fluid or pus drainage Your health[medlineplus.gov]
Chills
  • Note that generalized symptoms such as fever and chills do not occur with these simple abscesses.[symptoma.com]
  • […] include: a smooth swelling under your skin that can feel hard or firm pain and tenderness in the affected area warmth and redness in the affected area a visible build-up of white or yellow pus under the skin in the affected area a high temperature (fever) chills[nhs.uk]
  • Symptoms may include: Fever or chills, in some cases Local swelling around the infected spot Hardened skin tissue Skin lesion that may be an open or closed sore, or a raised area Redness, tenderness, and warmth in the area Fluid or pus drainage Your health[medlineplus.gov]
  • Signs and symptoms include the presence of a swollen, tender, and erythematous nodular lesion in the skin associated with fever and chills.[fpnotebook.com]
  • The wall of the abscess is made up of dermis infiltrated with inflammatory cells surrounded by a fibrinous capsule. [1] Fevers, chills, and other constitutional symptoms are usually absent unless the infection has spread to deep tissues or into the bloodstream[emedicine.medscape.com]
Asymptomatic
  • Prior to the abdominal trauma, the patient was almost asymptomatic, but with periods of itching and local soreness.[doi.org]
  • The patient was treated with hydrochloroquine and salazopyrine, remaining asymptomatic in the follow-up of one year [ 6 ]. In these two case reports, both were caused by Streptococcus .[clinmedjournals.org]
Rigor
  • If there is bacteremia patient may present with systemic signs of sepsis such as fever, rigors, and raised inflammatory markers.[radiopaedia.org]
Coxa Valga
  • In addition, sequestrectomy and two late operations, for coxa valga and hip subluxation, were deemed to be necessary. Radiographs showed femoral overgrowth of up to 1 cm in two symptomless patients three to seven years after the first discharge.[ncbi.nlm.nih.gov]
Increased Sweating
  • General symptoms of an internal abscess can include: discomfort in the area of the abscess fever increased sweating feeling sick vomiting chills pain or swelling in your tummy (abdomen) loss of appetite and weight loss extreme tiredness (fatigue) diarrhoea[nhs.uk]
Meningism
  • Clinical manifestations included meningitis, a left ankle subcutaneous abscess, and bilateral hand cellulitis. Discussion and review of literature are presented for the previously unreported association of this common childhood pathogen.[ncbi.nlm.nih.gov]
  • Nocardia asteroides pneumonia, subcutaneous abscess and meningitis without brain abscesses developed in a patient with advanced non-Hodgkin's lymphoma, who had received corticosteroid therapy and cancer chemotherapy for a long time.[ncbi.nlm.nih.gov]
  • Corti M, Solari R, De Carolis L, Cangelosi D, Arechavala A, et al. (2013) Candida parapsilosis meningitis in a patient with AIDS. Report of a case and review of the literature. Rev Iberoam Micol30: 122-124.[mycology.imedpub.com]

Workup

The diagnosis of a subcutaneous abscess is clinical, which is based on patient history and focuses on risk factors and visual inspection of the abscess. Laboratory tests, such as complete blood count (CBC) and blood cultures, are reserved for severe and deep infections [4]. Moreover, blood cultures do not influence the management of simple abscesses, especially in healthy individuals [13] [14]. Imaging is not required for subcutaneous abscesses or other simple SSTIs [4].

Note that the workup for complicated SSTIs is extensive and includes needle aspiration of fluid and possibly tissue biopsy [15]. Blood cultures are indicated in patients with systemic involvement, deep tissue infections, and immunocompromised individuals[16] [17]. Furthermore, complicated cases may warrant imaging such as computed tomography (CT) scanning, which is the recommended study [18]. Ultrasonography, magnetic resonance imaging (MRI), and other modalities may be used for further evaluation if needed.

Lymphocytopenia
  • At the time of nocardial pneumonia, profound lymphocytopenia and hypogammaglobulinemia was seen. The severely immunosuppressed condition most likely accounted for the uncommon infection, nocardiosis.[ncbi.nlm.nih.gov]
Nocardia Asteroides
  • Nocardia asteroides pneumonia, subcutaneous abscess and meningitis without brain abscesses developed in a patient with advanced non-Hodgkin's lymphoma, who had received corticosteroid therapy and cancer chemotherapy for a long time.[ncbi.nlm.nih.gov]

Treatment

  • S. aureus causes significant morbidity and mortality in patients who receive acupuncture treatment.[ncbi.nlm.nih.gov]
  • We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.[ncbi.nlm.nih.gov]
  • Scrotal subcutaneous abscess should be prevented from progressing to Fournier's gangrene with early and appropriate treatment.[ncbi.nlm.nih.gov]
  • The organism isolated from the sputum, subcutaneous abscess and cerebrospinal fluid was strongly resistant to cotrimoxazole, which is the recommended standard treatment, but it was susceptible to imipenem (IPM) and erythromycin (EM) in an in vitro antimicrobial[ncbi.nlm.nih.gov]
  • We report a successful treatment of a subcutaneous abscess in a 24-year-old woman caused by hyaluronic acid injection in nasal dorsum augmentation using negative pressure drainage via nasal mucosal approach.[ncbi.nlm.nih.gov]

Prognosis

  • […] tuberculosis is generally associated with an underlying disorder, immunosuppressive therapy, or local injury, but a recent review on tuberculous myositis in Taiwan showed that 71.4% of patients with tubercular myositis had no underlying disease. 2 The prognosis[academic.oup.com]

Etiology

  • Identification and first report of Inonotus (Phellinus) tropicalis as an etiologic agent in a patient with chronic granulomatous disease. J Clin Microbiol. 2005;43:982–7. CrossRef PubMedCentral PubMed Google Scholar 18.[link.springer.com]
  • In these cases the main etiological agents involved are Staphilococcus sp and Streptococcus sp. Post-streptococcal reactive arthritis has been mainly related to cases of tonsillitis [ 3 , 4 ].[clinmedjournals.org]
  • Etiology Numerous organisms can cause abscesses, but the most common is Organisms may enter the tissue by Direct implantation (eg, penetrating trauma with a contaminated object) Spread from an established, contiguous infection Dissemination via lymphatic[msdmanuals.com]

Epidemiology

  • We studied the epidemiological and clinical characteristics of Nocardia infections reported in Japan from 2000 to 2008 and identified 92 cases using the medical article search engine Ichushi-Web (Japan Medical Abstract Society).[ncbi.nlm.nih.gov]
  • Galván B, Mariscal F (2006) Epidemiology of candidemia in ICU. Rev Iberoam Micol 23: 12-15.[mycology.imedpub.com]
  • Molecular epidemiology of Corynebacterium diphtheriae from northwestern Russia and surrounding countries studied by using ribotyping and pulsed-field gel electrophoresis.. J Clin Microbiol 33 :, 1080– – 1083. [PubMed] [Google Scholar] Dias A.[jmm.microbiologyresearch.org]
  • Epidemiology and outcome of invasive fungal diseases in patients with chronic granulomatous disease: a multicenter study in France. Pediatr Infect Dis J. 2011;30:57–62. CrossRef PubMed Google Scholar 6. Shigemura T, Agematsu K, Yamazaki T, et al.[link.springer.com]
  • Definition/epidemiology An abscess is a localized collection of pus resulting from the disintegration of tissue in the dermis and deeper skin tissues.[ahcmedia.com]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology of this disease is not clear, it is believed to occur by immunological cross-reactivity between the infecting organism and the synovial membrane component, causing inflammation of the synovial membrane without infection to the joint[clinmedjournals.org]

Prevention

  • Scrotal subcutaneous abscess should be prevented from progressing to Fournier's gangrene with early and appropriate treatment.[ncbi.nlm.nih.gov]
  • Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis .[academic.oup.com]
  • In National Epidemiological Surveillance of Vaccine-Preventable Diseases, pp. 201– – 216. Tokyo:: NIID;. [Google Scholar] Katsukawa C., Komiya T., Yamagishi H., Ishii A., Nishino S., Nagahama S., Iwaki M., Yamamoto A., Takahashi M.. ( 2012 ; ).[jmm.microbiologyresearch.org]
  • […] reoccurrence. o For example, for repeated incision and drainage of an abscessed paronychia, the medical record should document any additional measures taken to prevent reoccurrence and/or the reason for not performing more definitive treatment (e.g.,[automatedworldhealth.com]
  • Recommendations for prevention are also provided: Antibiotic efficacy in the abscess is limited owing to the acidic and relatively protected environment; therefore, the first-line therapy for a cutaneous abscess is surgical. [1] Incision and drainage[emedicine.medscape.com]

References

Article

  1. Townsend CM, Beauchamp RD, Mattox KL, Evers BM. Surgical Infections and Choice of Antibiotics. In: Sabiston Textbook of Surgery: the biological basis of modern surgical practice. 18th ed. Philadelphia,PA: Saunders Elsevier; 2007: 299-327.
  2. Brook I. Microbiology of polymicrobial abscesses and implications for therapy. J Antimicrob Chemother. 2002; 50(6):805-810.
  3. Dryden MS. Complicated skin and soft tissue infection. J Antimicrob Chemother. 2010;65(Suppl 3):iii35-44.
  4. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and Soft Tissue Infections. Am Fam Physician. 2015;92(6):474-483.
  5. Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(14):1585–1591.
  6. Stulberg DL, Penrod MA, Blatny RA. Common Bacterial Skin Infections. Am Fam Physician. 2002;66(1):119-125.
  7. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: a review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008;19(2):173–184.
  8. Gabillot-Carré M, Roujeau JC. Acute bacterial skin infections and cellulitis. Curr Opin Infect Dis. 2007;20(2):118–123.
  9. Salgado CD, Farr BM, Calfee DP. Community-acquiredmethicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis. 2003;36(2):131–139.
  10. May L, Porter C, Tribble D. Self-reported incidence of skin and soft tissue infections among deployed US military. Travel Med Infect Dis. 2011;9(4):213–220.
  11. Decker CF. Skin and soft tissue infections in the athlete. Dis Mon. 2010;56(7):414–421.
  12. Long SS, Pickering LK, Prober CG. Subcutaneous Tissue Infections and Abscesses. In: Principles and Practice of Pediatric Infectious Diseases Revised Reprint. 3rd ed. New York: Elsevier; 2008:457-464.
  13. Payne CJ, Walker TW, Karcher AM, et al. Are routine microbiological investigations indicated in the management of non-perianal cutaneous abscesses? Surgeon. 2008;6(4):204–206.
  14. Mills AM, Chen EH. Are blood cultures necessary in adults with cellulitis? Ann Emerg Med. 2005;45(5):548–549.
  15. Breen JO. Skin and soft tissue infections in immunocompetent patients. Am Fam Physician. 2010;81(7):893-899.
  16. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections. Clin Infect Dis. 2014;59(2):e10–e52.
  17. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases. Clin Infect Dis. 2013;57(4):e22–e121.
  18. Tayal VS, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006;13(4): 384-388.

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Last updated: 2019-07-11 21:05