Tuberculosis-The Great Mimicker: A Case of Traumatic Drainage of Cold Abscess

Tuberculosis is characterized by cold abscess, which classically lacks the usual signs and symptoms of inflammation. This case report highlights an atypical presentation of tuberculous cold abscess in the form of appearance of massive swelling in the back overnight after a blunt trauma, mimicking post-traumatic hematoma.

A 32-year-old man came to our outpatient department with sudden swelling over the right side of the upper back (25 × 8 × 8 cm) and loin (10 × 4 × 4 cm) after a fall from 1.5 to 2 m height the previous night. The possible differential diagnosis of a traumatic pathology, complicated by a bleeding disorder, resulting in massive hematoma was initially made. However, hematologic investigations were within normal limits. Magnetic resonance imaging suggested an anterior subligamentous abscess at the C7-T1 level tracking through the paraspinal muscles and communicating with the subcutaneous abscess, and at the L3 level, paraspinal abscess tracking to the subcutaneous plane. There was no cord compression or signal changes in the cord. Both the abscesses were pigtailed in antigravity fashion, and material was sent for culture, which proved to be tuberculosis. The patient was treated with antituberculosis treatment for 18 months and improved over the course with complete resolution of symptoms. At 4-year follow-up, the patient is asymptomatic with no evidence of recurrence.

Appearance of massive swelling overnight in patients with cold abscess has not been described in the literature. While evaluating an atypical presentation such as sudden post-traumatic swelling over the thoracolumbar area, the clinician should keep a differential diagnosis of tuberculous abscess and investigate clinicoradiologically to rule out tuberculosis, especially in developing countries.