1. Cold Abscess & Tuberculous spondylitis
Int. 蔣恆斌
Cold abscess, an abscess of slow formation, unattended with the pain and heat characteristic of ordinary abscesses, and lasting for years without exhibiting any tendency towards healing; a chronic abscess.
Cold abscess
        A search for the cold abscess including a careful palpation of the abdomen is an essential part of the clinical examination. The formation of cold abscess is an invariable feature of tuberculosis of the spine. The abscess forms in the paravertebral areas and soon tracks downwards due to gravity and towards the surface following the tracks of nerves and blood vessels. As long as the abscess remains deep to the deep fascia it remains cold to touch without any inflammatory reaction and hence it is called cold abscess. There is no correlation between the size of the destructive lesion and the quantity of pus in the cold abscess. The size is determined by the degree of the allergic exudative reaction that produces the pus.
        In the cervical spine, the cold abscess can point retropharyngeally producing dysphagia or show up in the neck behind the sternomastoid. In the thoracic spine, the cold abscess fills up the posterior mediastinum and tracks along the intercostal nerves to point either in the lateral chest wall or in the anterior chest wall. Abscesses also reach the surface posteriorly under the sacrospinalis muscles. The cold abscess sometimes enters the spinal canal causing pressure on the spinal cord, resulting in paraplegia. Thoraco-lumbar cold abscess can point either in the back or enter the psoas sheath and track down as psoas and iliac abscesses. These abscesses collect as lumps in the iliac fossa and point above the inguinal ligament, ortrack down behind the inguinal ligament and point in the femoral triangle or even lower down.

2. Definition & Correlation – cold abscess
A chronic abscess lack of the characteristics of the pain and heat of ordinary abscesses
Years without tendency towards healing
The formation of cold abscess is an invariable feature of tuberculous spondylitis

3. Tuberculous Spondylitis

4. Incidence <1% of patients with tuberculosis
25-60% of all skeletal tuberculosis

5. Clinical manifestation
Children / adults; M > F
Insidious onset of back pain, stiffness
NO pulmonary lesions in 50%

6. Location
Thoracolumbar area (L1 most common), frequent involvement of multiple contiguous segments
Vertebral body (82%) > posterior elements (18%)

7. Image Findings X-ray : Vertebral collapse & gibbus deformity
+/- intervertebral disc destruction
Calcification
Multiple (non)contiguous vertebra
NECT : Calcifications of chronic paravertebral abscess
CECT : Diffuse or peripherally enhancing epidural and paraspinal soft tissue
T1WI : hypointense marrow; intraosseous, extradural, paraspinal abscess
T2WI : hyperintense marrow, disc, soft tissue infection
T1 C+ :
Marrow, subligamentous, discal, dural enhancement
Diffuse or peripherally enhancing soft tissue

8. X ray X-ray Lower Lumbar -- Collapse
Figure 1. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral
(b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the
end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image
(repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-
weighted (4,300/112) (d) and contrast material–enhanced coronal T1-weighted (360/15) (e) MR images show increased
signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

9. CT CT Vertebral body destruction Paravertebral abscess
Figure 28. Tuberculous spondylitis and paraspinal cold abscess. (a) Unenhanced CT scan obtained above
the aortic arch shows a paravertebral mass that is destroying the vertebral body (arrow) and displacing the
trachea anteriorly. (b) CT scan of the upper abdomen reveals a caudal extension of the paravertebral abscess
(arrow).

10. MRI
T1WI
T4 : hypointense, collapse

11. Hyperintense, collapse T1WI+Gd Enhancement, collapse
(d, e) Sagittal T2-
weighted (4,300/112) (d) and contrast material–enhanced coronal T1-weighted (360/15) (e) MR images show increased
signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

12. Differential Diagnoses
Brucellar spondylitis
DIAGNOSIS – The diagnosis of brucellosis should be considered in an individual with otherwise unexplained chronic fever and nonspecific complaints. Such patients should be questioned for possible sources of exposure to Brucella including contact with animal tissues or ingestion of unpasteurized milk or cheese. The differential diagnosis varies, depending upon the presence or absence of focal features.
Routine laboratory studies are nonspecific. White blood cell counts are usually normal to low (pancytopenia can occur) [12] and minor disturbances in hepatic enzymes are relatively common. While studies such as radiographs, bone scans, computerized tomography, magnetic resonance imaging, and echocardiography may be helpful in isolating or delineating focal disease, they do not provide a definitive diagnosis.
Cultures – Both cultures and serologic tests can be used to establish the diagnosis of brucellosis. Ideally, the diagnosis is made by isolation of the organism from cultures of blood or other sites, especially bone marrow or liver biopsy specimens. However, cultures are not always positive; in one large series, for example, blood cultures were positive in only 80 percent of initial infections [10].
An important problem is that Brucella sp. tend to be slow growing which can lead to erroneous results. Classically, the performance of cultures on biphasic media (Ruiz-Castaneda) or some modification thereof has been recommended. Using these techniques, cultures generally become positive between 7 and 21 days but may take up to 35 days. However, the use of biphasic media is not routine in clinical laboratories, many of which use automated blood culture systems such as BACTEC, routinely hold bottles for 5 to 7 days, and do not perform blind subcultures of "negative" bottles. While some isolates may grow and be detected in the BACTEC system, cultures are unlikely to be positive in the 5 to 7 day period. It is therefore likely that febrile patients with unsuspected brucellosis will have negative cultures with standard blood culture techniques.
Thus, if brucellosis is suspected, the clinician should communicate with the microbiology laboratory to hold cultures for several weeks, to perform blind subcultures, or to use lysis centrifugation cultures or biphasic media [13-16].
In addition to blood, a variety of other specimens may provide positive cultures. These include liver biopsies, aspiration or biopsy of areas of localized disease, especially bone marrow, pleural fluid or tissue, and occasionally cerebrospinal fluid. A shell vial method resulted in the isolation of Brucella from liver abscess pus in several cases in which conventional cultures were negative [17].
Serologic tests – A number of diagnostic serologic tests have been developed for the diagnosis of brucellosis:
• Serum agglutination (standard tube agglutination)
• Complement fixation
• Rose Bengal agglutination
• Antibrucella Coombs
• ELISA (enzyme-linked immunosorbent assay)
TREATMENT
• Regimen A – Doxycycline 100 mg PO twice daily for six weeks plus streptomycin 1 gram IM daily for the first 14 to 21 days.

13. Differential Diagnoses
Brucellar spondylitis
Figure 1. Schematics of the two forms of
brucellar spondylitis. (a) In focal brucellar
spondylitis, disks and soft tissues are normal.
Changes may include one or more of
the following: a, localized area of bone
erosion at the discovertebral junction; b,
reactive bone sclerosis; c, small area of gas
(peripheral vacuum phenomenon) (6) entrapped
between vertebral end plate and
disk, probably representing soft-tissue destruction
(arrow); and d, anterior osteophytes
(parrot’s beak). (b) In diffuse brucellar
spondylitis, sequential changes indude
the following: a, The organisms are
localized in the superior end plate of a vertebral
body (straight arrows), similar to the
focal lesion; b, the infection spreads
throughout the involved vertebra, and by
means of ligamentous (curved arrows) and
vascular communication, it spreads to involve
adjacent vertebrae; and finally c, the
osteomyelitis causes bone softening of the
osseous end plate, with resultant mechanical
instability to the chondral end plate
and disk. The disk is secondarily infected
and may herniate into the vertebral end
plate (Schmorl nodules) (arrow). Granulation
tissue may extend into the epidural
space.

14. Differential Diagnoses
Pyogenic spondylitis
Older patients
Lower lumbar spine
Intervertebral discs typically effected
Posterior elements less involved
Soft tissue calcifications and spinal deformity infrequent

15. Differential Diagnoses
Fungal spondylitis
May be indistinguishable from TS
+/- posterior element involvement
Disc space may be spared
Vertebral deformity less common
Paraspinal involvement not as extensive as TS
Spinal metastasis
Multiple noncontiguous lesions
Disc space preserved
Little soft-tissue involvement
May be difficult to distinguish from isolated tuberculous, fungal, or brucellar spondylitis

16. The patient in NCKUH

17. Clinical Information 68Y / F 20060928 Orthopedics OPD
No complaints of back pain
She was admitted to orthopedics ward for TKA (due to right OA knee)
CXR taken on was for routine preoperative surveillance

18. 郭柳紅 068Y / F
(14:21:19)
Chest shows fibro-calcified lesions over both upper lung fields, TB is considered. Also noted paraspinal lesion with calcification at lower T and lumbar region, compatible with cold abscess.
Scanography of lower extremity reveals:
2.5cm length discrepancy, shorter over right side. Right knee OA with varus deformity.
俞芹英醫師-放診專 116

19. 郭柳紅 068Y / F
(14:21:19)
Chest shows fibro-calcified lesions over both upper lung fields, TB is considered. Also noted paraspinal lesion with calcification at lower T and lumbar region, compatible with cold abscess.
Scanography of lower extremity reveals:
2.5cm length discrepancy, shorter over right side. Right knee OA with varus deformity.
俞芹英醫師-放診專 116

20. No further imaging or management

21. References Imaging of Extrapulmonary Tuberculosis
RadioGraphics 2000; 20:471–488
Tuberculosis from Head to Toe
RadioGraphics 2000; 20:449–470
Brucellar and Tuberculous Spondylitis:Comparative Imaging Features
Radiology 1989; 171:
CT of posterior mediastinal mass
RadloGrapb.ica 1991; 11:
Radiology Review Manual – Tuberculous Spondylitis
Diagnostic Imaging (Spine) Page III:1-10 to 13
UPTODATE – Brucellosis

22. Thanks for your attention!!

23. Clinical Information Past history : 2000 May 20000530 Image
pulmonary TB with irregular treatment years ago
No cough, no fever, no sweating, no BW loss
Image
CXR
TB cold abscess and TB spine is suspected