Recurrent Abscesses of the Neck

Report of a Case | A woman in her 80s was referred for surgical treatment of a cervical abscess. Similar abscesses erupted in the cervical region over the course of 2 years (Figure 1A). A needle aspiration biopsy was performed on a node at the left side of the neck, which measured 2 cm. The histopathologic report described a minor nonspecific inflammatory reaction, not suggestive of infection. Findings of the Mycobacterium tuberculosis PCR were negative. A culture was not performed. Two months later, the whole nodule was excised, including the adjacent inflamed skin. The resulting defect, with a diameter of 7 cm, was closed with a rotarytransposition flap. During this intervention, the thoracic nerve was injured resulting in an elevation palsy of the left arm. The histopathologic report of the excised tissue again showed a nonspecific inflammatory reaction; no microbiological analysis was conducted. At presentation, the patient had puckered scars scattered over the neck in addition to an unusual “cold abscess” (Figure 1B). The clinical appearance was suggestive of scrofuloderma. Results of the Mendel-Mantoux test were positive (diameter, 20 mm), as were those from the interferon-γ release assay. However, PCR findings from the skin biopsy specimen and abscess material were negative for M tuberculosis. Histologically, no acid-fast bacilli could be detected by ZiehlNeelsen staining. Cervical sonography and magnetic resonance tomography revealed multiple abscesses in the lateral muscle loge. Chest radiography excluded pulmonary tuberculosis. Laboratory work showed an elevated level of C-reactive protein (115 mg/L; normal, <5 mg/L) but no other pathological findings. (To convert C-reactive protein to nanomoles per liter, multiply by 9.524.) After 19 days, M tuberculosis was cultivated from the skin specimen (Figure 2). The strain was sensitive to isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin. Classic quadruple treatment with isoniazid, 300 mg/d; pyrazinamide, 1500 mg/d; ethambutol, 1200 mg/d; and rifampicin, 600 mg/d, was initiated. After 2 months, the regimen was reduced to isoniazid and rifampicin. After 4 months of the reduced regimen, all skin lesions had healed completely, leaving scars, and sonography revealed no remaining abscesses. Treatment was well tolerated, and at 24-month follow-up, no new nodules had evolved.