Abscesses are an infection as a result of a defensive reaction by our body’s immunological system when a bacteria, fungus or other type of germ enters our body. It is characterized by causing inflammation and accumulation of pus in an area of the skin or subcutaneous tissue, internal organs or between their cavities, in so many words, they can appear anywhere in the body, however, the most dangerous are those that are formed internally and are not visible.
“An abscess is a localized collection of purulent fluid that can have a significant impact on the care and clinical outcome of a patient. It is at times a relatively benign event, potentially treatable with antibiotic medication alone. However, not uncommonly, abscess formation can be a life-altering event if it leads to sepsis, a spectrum of severe systemic illness resulting from hematogenous spread of infection and an important cause of morbidity and mortality. Sepsis is among the 10 leading causes of death in the United States and results in a rapid cascade of potential life-threatening events that can include bacteremia, cardiac decompensation, acute respiratory distress syndrome (ARDS), hemodynamic compromise, and organ failure. Sepsis typically results in prolonged hospitalization or even death. In addition, treatment of sepsis is a major component of health care expenditure.”1
The term abscess comes from the Latin root ‘abscedere’, which means ‘to move’. The prefix ‘abs’, means ’to get away’ or ‘leave a place’. Therefore, the word means something that separates and moves to another place. What is separated is pus, which is concentrated in a specific area.
The first time humans spoke of abscesses was about 2,050 years ago. The one who used the word for the first time was the Roman writer Aulo Cornelio Celso. Before him, Hippocrates had spoken of ‘apostemas’, which are basically the same thing. The word abscess began to be used regularly in medical literature on the sixteenth century.
There are two types of abscesses: external and internal. The first one is formed under the skin, when microbial invasion occurs. This almost always happens when there is an open wound and hygiene is poor.
The second one forms in the internal organs or in the spaces between them because there are problems in the patient’s state of health. It may also be that an organ is not functioning properly. Appendicitis, a liver infection or pneumonia can all lead to the formation of an abscess of that particular organ.
It is also common for internal and some external abscesses to be associated with difficulties in the immune system. Abscesses can be developed by exposing an unhealed wound to a dirty environment or coming into contact with another person with very poor hygiene. Coupled with a weak immune system, an infection is likely and therefore, the development of an abscess. The causes of an abscess appearance are many.
The most frequent types of abscess
Cutaneous and subcutaneous
“Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions.”2
“It is an inflammatory space- occupying lesion of the liver caused by Entamoeba histolytica. The incidence of ALA has been reported to vary between 3% and 9% of all cases of amoebiasis. […] The diagnosis of this condition has undergone major changes after the advent of advances in imaging and molecular biology techniques. This has also enabled a reappraisal of the disease with recognition of the wide variety of clinical presentations and multitude of complications. It has been observed that the classical description of an ALA needs to be modified due to a large number of patients who present with variants. This may be due to a better understanding of the pathogenesis and presentation of the disease or changing patterns of the disease. Long-term follow up of patients has helped in identifying the factors affecting the healing pattern. Separation of patients at high risk is of clinical relevance so that more aggressive treatment can be instituted.”3
“Obstruction of the Bartholin’s duct may result in the retention of secretions with resultant dilatation of the duct and cyst formation. The cyst may become infected and an abscess may develop in the gland. A Bartholin’s duct cyst does not necessarily have to be present before a gland abscess develops. Symptomatic Bartholin gland cysts and abscesses can be associated with significant discomfort and disruption of the sexual function and daily activities of women. Clearly identified causes for Bartholin’s cysts and abscesses are elusive, however the risk profile is similar to those of women at risk for sexually transmitted diseases. Some risk factors include previous history of Bartholin’s gland cyst, multiple sexual partners, sexually transmitted infection, medio-lateral episiotomies, vulva trauma. […] Obstruction of this gland’s duct is common and may follow infection, trauma, and changes in mucus consistency or congenitally narrowed ducts. When the distal ducts are blocked, there is mucus build-up with continued secretion, cystic dilation of the duct leading to cyst formation. Infection of this cyst is likely to result in Bartholin’s gland abscess. Bartholin’s cysts are generally asymptomatic and may be discovered on routine pelvic examination but when they become significantly enlarged, they can cause discomfort while walking and during sexual intercourse. Infection of the cyst leads to abscess formation which is associated with severe pain, dyspareunia, fever and limitation of physical activity. Bartholin’s Cysts or abscesses which are usually unilateral distends the affected labia majora causing vulva asymmetry and a vaginal discharge may be present. When palpable, it is fluctuant and may or may not be tender but abscesses can be extremely tender”4
“Brain abscess (BA) is defined as a focal infection within the brain parenchyma, which starts as a localized area of cerebritis, which is subsequently converted into a collection of pus within a well-vascularized capsule. BA must be differentiated from parameningeal infections, including epidural abscess and subdural empyema. The BA is a challenge for the neurosurgeon because it is needed good clinical, pharmacological, and surgical skills for providing good clinical outcomes and prognosis to BA patients. Considered an infrequent brain infection, BA could be a devastator entity that easily left the patient into dead. The aim of this work is to review the current concepts regarding epidemiology, pathophysiology, etiology, clinical presentation, diagnosis, and management of BA.”5
“Perianal and perirectal abscesses are common anorectal problems. The infection originates most often from an obstructed anal crypt gland, with the resultant pus collecting in the subcutaneous tissue, intersphincteric plane, or beyond (ischiorectal space or supralevator space) where various types of anorectal abscesses form. Once diagnosed, anorectal abscesses should be promptly drained surgically. An undrained anorectal abscess can continue to expand into adjacent spaces as well as progress to generalized systemic infection.
Anorectal abscesses and fistulas can be thought of as two sequential phases of the same anorectal infectious process: an abscess represents the acute phase of infection, while a fistula represents the chronic phase of suppuration and fistulization. Thus, it is not surprising that 30 to 70 percent of anorectal abscesses are associated with a concomitant anorectal fistula and that 30 to 40 percent of patients develop an anorectal fistula after undergoing treatment for an anorectal abscess”6
“Dental caries, dental trauma, and poor dental hygiene are the most frequent causes of a dental abscess. Break down in the protective enamel of teeth allows for oropharyngeal bacteria to enter the tooth cavity (pulp cavity) causing a local infection. As this infection within the pulp cavity grows within the limited space of the tooth, it compresses the inner dentine walls causing severe pain. This infection then tracks down through the root canal and inferiorly into the mandible or superiorly into the maxilla depending on the location of the infected tooth. Another cause that predisposes individuals to a dental abscess is a partially erupted tooth, most commonly a wisdom tooth, where bacteria get trapped between the crown and soft tissues causing inflammation. Other causes include genetic causes such as amelogenesis imperfect that predispose individuals to weakened enamel, more susceptible to wear.”7
“Epidural abscess of the spinal column is a rare but potentially devastating disease. When it is recognized early and treated appropriately, the outcome can be excellent. However, because this disease process and its associated illnesses frequently advance rapidly, the mortality rate is as high as 20%, even in modern series. MRI aids greatly in the diagnostic process and should be obtained, if available, as soon as epidural abscess is suspected. Surgical therapy is preferable in the majority of cases, and as newer surgical techniques and approaches are developed, the indications for medical therapy have become narrower.
Abscesses in the spinal subdural space or in the spinal cord proper are even more unusual but can also lead to complete and irreversible loss of neurologic function if not diagnosed and treated rapidly.
An acute epidural abscess should be suspected in patients with back pain and fever, particularly in those with underlying risk factors.”8
“A lung abscess is a localized area of lung suppuration, leading to necrosis of the lung parenchyma with or without cavity formation. These are now rare in the developed world but still carry a mortality of 10%. This can be increased up to 75%12 in the presence of underlying pneumonia, neoplasm, altered consciousness, anemia (hemoglobin ,10 g dl21), immunocompromise, or infection with Pseudomonas aeruginosa, S. aureus, or Klebsiella pneumoniae. They are most common in alcoholic men over the age of 50 and usually occur in patients with altered consciousness, as most are the result of aspiration. Other risk factors include dental disease, bronchial carcinoma, pneumonia (occurs in 16% of those with S. aureus pneumonia), and septic embolization (e.g. right heart endocarditis secondary to S. aureus in i.v. drug users). Although most commonly secondary, lung abscesses can be primary and also single or multiple, acute or chronic. The presentation is often of an insidious onset with fever, weight loss, and respiratory symptoms such as chest pain and a cough that can be productive of foul smelling sputum or hemoptysis, which can be massive and life threatening.”9
Other abscess locations are: mammary, pulmonary, hepatic, psoas, subphrenic or sub-diaphragmatic and capillary.
As mentioned, there is a response of the immune system to an infection. What the body does is isolate the infection to prevent it from spreading. Once the pathogen causes the infection, white blood cells begin to act by ganging up on the microbial culprit. White blood cells accomplish this by migrating through the walls of blood vessels and finding their target.
There is a specialized white blood cell called a macrophage, these guys are in charge of swallowing unfriendly particles whole. Thus, white blood cells accumulate inside the tissue that is being attacked by microbes damaged. This immunological response causes the pus to form.
Pus is composed of agglutinated white blood cells, some of which are alive while others are dead. It also contains liquids, dead tissue and bacteria or other invasive material. When the pus accumulates, the tissue becomes inflamed. If it doesn’t drain, it causes pain in the affected area. They are not contagious. However, the bacteria that cause them are.
An external abscess is distinguished because it is a firm mass, which almost always causes pain upon contact. Typically, the surrounding appearance of an abscess is a pink or red in color, whereas pus is concentrated in the middle of it. Sometimes, an abscess secretes fluid and may increase in size. A superficial abscess will resemble a pimple, while a deeper tissue abscess looks like a lump of mass. Common locations for abscesses to appear are in the groin, near the coccyx, around the anus, the vaginal area, gums or in the armpits. In some cases, the doctor or specialist will order a sample of the fluid secreted by the abscess to analyze the type of pathogen that is causing the issue, among other things.
To diagnose internal abscesses, specialized exams are usually performed. The most common are: ultrasound, computerized tomography and magnetic resonance.
(1) Charles, H. W. (2012, December). Abscess drainage. In Seminars in interventional radiology (Vol. 29, No. 04, pp. 325-336). Thieme Medical Publishers. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577622/
(2) Schmitz, G., Goodwin, T., Singer, A., Kessler, C. S., Bruner, D., Larrabee, H., … & Bhat, R. (2013). The treatment of cutaneous abscesses: comparison of emergency medicine providers’ practice patterns. Western Journal of Emergency Medicine, 14(1), 23. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582519/
(3) Sharma, M. P., & Ahuja, V. (2003). Amoebic liver abscess. J Indian Acad Clin Med, 4(2), 107-111. Available online at http://medind.nic.in/jac/t03/i2/jact03i2p107.pdf
(4) Anozie, O. B., Esike, C. U. O., Anozie, R. O., Mamah, E., Eze, J. N., & Onoh, R. C. (2016). Incidence, Presentation and Management of Bartholin’s Gland Cysts/Abscesses: A Four-Year Review in Federal Teaching Hospital, Abakaliki, South-East Nigeria. Open Journal of Obstetrics and Gynecology, 6(05), 299. Available online at https://file.scirp.org/pdf/OJOG_2016042617575247.pdf
(5) Bleday, R., & Friedman, L. S. Perianal and perirectal abscess. Available online at https://www.uptodate.com/contents/perianal-and-perirectal-abscess
(6) Miranda, H. A., Castellar-Leones, S. M., Elzain, M. A., & Moscote-Salazar, L. R. (2013). Brain abscess: current management. Journal of neurosciences in rural practice, 4(Suppl 1), S67. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3808066/
(7) Sanders, J. L., & Houck, R. C. (2018). Abscess, Dental. In StatPearls [Internet]. StatPearls Publishing. Available online at https://www.ncbi.nlm.nih.gov/books/NBK493149/
(8) Butler, K. H. (2000). Spinal epidural abscess: Current diagnostic and management protocols. Emerg Med Rep, 21, 95-104. Available online at https://www.reliasmedia.com/articles/54557-spinal-epidural-abscess-current-diagnostic-and-management-protocols
(9) Walters, J., Foley, N., & Molyneux, M. (2011). Pus in the thorax: management of empyema and lung abscess. Continuing Education in Anaesthesia, Critical Care & Pain, 11(6), 229-233. Available online at https://bjaed.org/article/S1743-1816(17)30196-8/pdf