"More cyst than abscess;" what is it? how to manage?

[tdod]

PGY-1 here with little experience with abscesses.

On my second shift we had a patient come in with an "abscess." It looked like an abscess externally, even was expressing some pus. However, I&D expressed almost exclusively blood. There was little change in size of the mass. The attending said "it was more cyst than abscess." I've never heard/read about this before; everything I've read about relates to abscess vs. cellulitis vs. NSTI. Never heard about cyst.

Here are my questions:
1) How can cysts be differentiated from abscesses?
2) Do "Cysts" require I&D?

---

Members don't see this ad.

 

[RustedFox]

What's NSTI?

 

[LChristmas]

What's NSTI?

Necrotizing soft tissue infection

 

[RustedFox]

Necrotizing soft tissue infection

Thanks.
I figured it was " --- ----- skin infection", but "non-toxic skin infection", etc.

[write your own joke here]

Non smoking tobacco indication.

New school transfer initiation.

 

[Tenk]

Random thoughts:

Did the attending look at it before you cut?

You can bedside ultrasound big hot red things before you cut, or aspirate. Sometimes they are just cellulitis or something else.

Location and demographics matter. One time my attending saw an older man with an abscess looking thing in his left proximal thigh, something seemed off so he got an ultrasound. Was the femoral artery. Imagine cutting that. He had all the residents go in and asked if they would cut into it.

I’ve cut into things that initially didn’t drain pus. Get in there and break up loculations and irrigate when that happens, sometimes stuff comes out, other times it doesn’t. Sometimes they already drained and the patient just isn’t that smart to tell you that.

Overall, this happens and no big deal, don’t think too hard about it, just always think before you cut (ie femoral artery). If something seems like a bad idea, let someone else do it.

 

[Cinclus]

I recently ultrasounded a fluctuant thing surrounded by cellulitis. Looked like a big 'ol fluid pocket. Turned out to be a huge hematoma. No pus, but patient felt much better after I drained it.

 

[Dr Mantis Toboggan]

Sebaceous cysts frequently become infected and look a lot like an abscess. The wall on those is thick, almost like an orange rind. You can I&D them and they’ll shrink back down to normal size. They can become infected again later tho, a dermatologist or surgeon can definitely excise them as an outpatient.

PGY-1 here with little experience with abscesses.

On my second shift we had a patient come in with an "abscess." It looked like an abscess externally, even was expressing some pus. However, I&D expressed almost exclusively blood. There was little change in size of the mass. The attending said "it was more cyst than abscess." I've never heard/read about this before; everything I've read about relates to abscess vs. cellulitis vs. NSTI. Never heard about cyst.

Here are my questions:
1) How can cysts be differentiated from abscesses?
2) Do "Cysts" require I&D?

 

[emergentmd]

I&D. Cyst has stuff in in and draining an infected cyst will make them feel better. You can rarely go wrong doing and I&D be it ab abscess, cyst, hematoma.

 

[Apollyon]

I&D. Cyst has stuff in in and draining an infected cyst will make them feel better. You can rarely go wrong doing and I&D be it ab abscess, cyst, hematoma.

Unless it's a lymph node!

I was working fast track 15 or so years ago, and a pt had what I thought was an abscess. I don't recall the specifics (whether surgery was there in the department or what), but I had surgery look at it. As the attending said, "good thing you didn't cut it. That wouldn't have been an abscess drainage, but, a biopsy!"

 

[RustedFox]

Unless it's a lymph node!

I was working fast track 15 or so years ago, and a pt had what I thought was an abscess. I don't recall the specifics (whether surgery was there in the department or what), but I had surgery look at it. As the attending said, "good thing you didn't cut it. That wouldn't have been an abscess drainage, but, a biopsy!"

Funny; I've seen this happen as well.

 

[turkeyjerky]

I’ve had similar experiences when incising hidradenitis lesions.

 

[Apollyon]

I’ve had similar experiences when incising hidradenitis lesions.

I don't know how many surgeons (at least 5, to be literal) told me to not do those in the ED. The resounding refrain was that docs in the ED did an incomplete job, over and over, and they had to do revisions in the OR, with scar tissue making it a pain. They all said to just refer them to surgery.

Now, I'm old. I don't know what the young whippersnappers are being taught in residency.

 

[emergentmd]

I drain those all the time. If the surgeon can guarantee me they will be seen tomorrow then sure. But otherwise there would be some pissed off pts.

 

[deleted836128]

Random thoughts:

Did the attending look at it before you cut?

You can bedside ultrasound big hot red things before you cut, or aspirate. Sometimes they are just cellulitis or something else.

Location and demographics matter. One time my attending saw an older man with an abscess looking thing in his left proximal thigh, something seemed off so he got an ultrasound. Was the femoral artery. Imagine cutting that. He had all the residents go in and asked if they would cut into it.

I’ve cut into things that initially didn’t drain pus. Get in there and break up loculations and irrigate when that happens, sometimes stuff comes out, other times it doesn’t. Sometimes they already drained and the patient just isn’t that smart to tell you that.

Overall, this happens and no big deal, don’t think too hard about it, just always think before you cut (ie femoral artery). If something seems like a bad idea, let someone else do it.

You literally just gave me palpitations!!! Holy cow!!!

 

[skougess]

Funny; I've seen this happen as well.

The simple solution is to ultrasound it. I ultrasound everything before I cut into it.

 

[BoardingDoc]

The simple solution is to ultrasound it. I ultrasound everything before I cut into it.

Same. It takes literally 3 extra minutes and I frequently find there's no drainable pocket and so it saves me the time and the patient the pain of being stabbed.

 

[turkeyjerky]

I don't know how many surgeons (at least 5, to be literal) told me to not do those in the ED. The resounding refrain was that docs in the ED did an incomplete job, over and over, and they had to do revisions in the OR, with scar tissue making it a pain. They all said too just refer them to surgery.

Now, I'm old. I don't know what the young whippersnappers are being taught in residency.

I never drain them anymore. I think this was when I was a resident, I told the attending that even she might have hidra, this one seemed like an abscess and I was going to drain it. Afterwards he kinda smirked at me when he asked me if I got anything good out of it.

But, yeah, the problem is way to many of these patients have never been adequately counseled on the condition, and just end up in the ER repeatedly where someone drains them. Then they get pissed if you don't do it, because they think it's required.

 

[RustedFox]

I never drain them anymore. I think this was when I was a resident, I told the attending that even she might have hidra, this one seemed like an abscess and I was going to drain it. Afterwards he kinda smirked at me when he asked me if I got anything good out of it.

But, yeah, the problem is way too many of these patients have never been adequately counseled on the condition, and just end up in the ER repeatedly where someone drains them. Then they get pissed if you don't do it, because they think it's required.

I don't disagree; but I'll add that even if the patient was adequately counseled; they don't listen and revert to the default statement of: "the doctor didn't tell me nothin'."

"Still a man hears what he wants to hear and disregards the rest."
- "The Boxer", Simon and Garfunkel.

 

[jw3600]

Not the point but I feel for hidradenitis suppurativa patients. That disease is soul sucking.

 

[Apollyon]

Not the point but I feel for hidradenitis suppurativa patients. That disease is soul sucking.

Yeah, it's the pits!

 

[Zebra Hunter]

I don't know how many surgeons (at least 5, to be literal) told me to not do those in the ED. The resounding refrain was that docs in the ED did an incomplete job, over and over, and they had to do revisions in the OR, with scar tissue making it a pain. They all said to just refer them to surgery.

Now, I'm old. I don't know what the young whippersnappers are being taught in residency.

Patients who have been diagnosed with it, or I suspect it because they are in the ER for an armpit abscess for the third time in a year, I almost never I&D those unless appears to clearly be infected. I advise warm compresses, I’ll typically rx topical clinda, and give either derm or gen surg follow up depending on severity.

 

[bravotwozero]

I don't know how many surgeons (at least 5, to be literal) told me to not do those in the ED. The resounding refrain was that docs in the ED did an incomplete job, over and over, and they had to do revisions in the OR, with scar tissue making it a pain. They all said to just refer them to surgery.

Now, I'm old. I don't know what the young whippersnappers are being taught in residency.

Makes sense to me, given that the definitive treatment is wide surgical excision, something I would not be doing in an ED.

 

[thegenius]

I drain those all the time. If the surgeon can guarantee me they will be seen tomorrow then sure. But otherwise there would be some pissed off pts.

I haven't seen hidra in some time, but if some person came in with numerous small to medium sized abscesses in both axilla...I would probably just put them on clinda and send them to GS. The pt can wait. It's a chronic condition and provided they are not septic (and they never are)...you are just wasting 30-60 mins numbing and I&Ding things that are guaranteed to come back

 

[thegenius]

Yeah, it's the pits!

HAR HAR HAR

 

[thegenius]

Not the point but I feel for hidradenitis suppurativa patients. That disease is soul sucking.

Yea man it f'ing stinks and there pus coming out of your groin and armpits. F'ing terrible.

 

[skougess]

I feel like my decision to drain or not for HS is based on patient pain level. I’m just not gonna send a patient home in bad HS pain when I can literally do something about it (temporarily). Definitive treatment or not be damned.

Same thing for pilonidal cysts.

 

[turkeyjerky]

I feel like my decision to drain or not for HS is based on patient pain level. I’m just not gonna send a patient home in bad HS pain when I can literally do something about it (temporarily). Definitive treatment or not be damned.

Same thing for pilonidal cysts.

I've never heard someone recommend against draining a pilonidal abscess, and I've never heard of someone recommend draining HS lesions.

Oh, and to the OP, just in case you haven't gathered yet, whatever your attending told you about it being more 'cyst than abscess' is completely meaningless...

 

[skougess]

I've never heard someone recommend against draining a pilonidal abscess, and I've never heard of someone recommend draining HS lesions.

Oh, and to the OP, just in case you haven't gathered yet, whatever your attending told you about it being more 'cyst than abscess' is completely meaningless...

It’s a somewhat analogous pathology. Pilonidal cyst simple drainage does not fix the problem. Sure does make them feel better though.

 

[WheezyBaby]

My experience is surgically managed HS outcomes are ass. If they're not systemically ill let surgery see in clinic. If they're systemically ill admit to surgery or medicine with surgery consulting. Can consider plugging in with derm for biologic eval. HS sucks.

 

[d2305]

I saw a NP cut into a ganglion cyst. Of course they had no insurance, and ortho won't see anything which might not pay. It healed eventually.

 

[RoyBasch]

My suspicion based on what I can infer from your description is this was a probably sebaceous cyst that became secondarily infected. There can be a pocket of purulence, so I think I&D is warranted. I would certainly start antibiotics with coverage for SSTI including MRSA (something like bactrim DS and keflex provided no allergies). The one thing I would do differently than with a typical abscess is explain to the patient there is a cyst, and that to definitively manage this, they will need and excision done (typically by a general surgeon). I explained recurrent infection is possible, and even remotely, sometimes these are malignant tumors (although typically benign) and the excised mass will be biopsied as well for definitive diagnosis.

 

[RoyBasch]

Patients who have been diagnosed with it, or I suspect it because they are in the ER for an armpit abscess for the third time in a year, I almost never I&D those unless appears to clearly be infected. I advise warm compresses, I’ll typically rx topical clinda, and give either derm or gen surg follow up depending on severity.

Yep, if its really HS, just ABx and follow up. It can be a quite devastating disease, and the only definitive treatment is wide excision of the prone tissue by a plastic surgeon.

 

[Apollyon]

Yep, if its really HS, just ABx and follow up. It can be a quite devastating disease, and the only definitive treatment is wide excision of the prone tissue by a plastic surgeon.

Plastics? This is directly in the GSx wheelhouse.

 

[MediCane2006]

Plastics? This is directly in the GSx wheelhouse.

It is, but GS often tries to punt these to plastics especially the more extensive disease.

Plastic surgeon here, interestingly I’ve been having some decent results with intralesional steroid injection (when not actively infected) combined with laser hair removal in some of these patients. It is a really miserable disease though.

 

[RoyBasch]

It is, but GS often tries to punt these to plastics especially the more extensive disease.

This has been my experience. Hence, I skip a step and refer directly to plastics.

Of course, the extent matters, if its fairly mild I'll start with GSx. But the ones I've seen tend to have fairly extensive involvement.

 

[doctalaughs]

Targeted excision with plastics may be necessary to reset the scarring, sinus tracts, fistulas etc— but having followed hundreds of these over many years it’s not curative. Bad disease will come back at edges (not to mention other areas).

Aggressive medical management for bad HS. I go right to infliximab infusions + /- dapsone. Antibiotics don’t help except in mild/moderate disease (and clinda + rifampin has the most evidence). Major weight loss of course helps too.

 

[Arcan57]

Proposed decision rule for deciding on I&D:
<3 days of sx: don't
3-14 days of symptoms:
Has it drained in last 24 hours - don't
Maybe drained - U/S
Definitely hasn't drained - I&D

14 or more days of symptoms:
Don't or US

 

[robellis]

Random thoughts:

Did the attending look at it before you cut?

You can bedside ultrasound big hot red things before you cut, or aspirate. Sometimes they are just cellulitis or something else.

Location and demographics matter. One time my attending saw an older man with an abscess looking thing in his left proximal thigh, something seemed off so he got an ultrasound. Was the femoral artery. Imagine cutting that. He had all the residents go in and asked if they would cut into it.

I’ve cut into things that initially didn’t drain pus. Get in there and break up loculations and irrigate when that happens, sometimes stuff comes out, other times it doesn’t. Sometimes they already drained and the patient just isn’t that smart to tell you that.

Overall, this happens and no big deal, don’t think too hard about it, just always think before you cut (ie femoral artery). If something seems like a bad idea, let someone else do it.

His artery was like literally poking outside of his body that you could see it?

 

[Tenk]

His artery was like literally poking outside of his body that you could see it?

It was a pseudoaneurysm. Looked just like an abscess.

Medicine is dumb.

 

[Dral]

OP, this could have been an Epidermoid cyst (Sebaceous cyst is a misnomer). They can rupture and cause a host inflammatory response that is not infection.

In derm, we inject ILK (intralesional kenalog), wait until they cool down, and excise them.

An ultrasound, +/- drainage (of what you can), and referral to surgery or derm is good way to go.

 

[turkeyjerky]

OP, this could have been an Epidermoid cyst (Sebaceous cyst is a misnomer). They can rupture and cause a host inflammatory response that is not infection.

In derm, we inject ILK (intralesional kenalog), wait until they cool down, and excise them.

An ultrasound, +/- drainage (of what you can), and referral to surgery or derm is good way to go.

Do you think intralesional steroids are the way to go for HS lesions? (my usual practice is topical clinda + oral doxy w/ referral)

 

[Dral]

Do you think intralesional steroids are the way to go for HS lesions? (my usual practice is topical clinda + oral doxy w/ referral)

Yep, ILK (probably 10 mg/ml...maybe 20) to any lesions that are particularly bothersome/symptomatic, topical clinda, po Doxy, referral.

 

[HowlPrenderghast]

It was a pseudoaneurysm. Looked just like an abscess.

Medicine is dumb.

Shouldn't the mass pulsate if it was arterial in origin? In any case, how was the pseudoaneursym managed? Just curious.

 

[Tenk]

Shouldn't the mass pulsate if it was arterial in origin? In any case, how was the pseudoaneursym managed? Just curious.

I’m sure if you pressed on it, you would have felt a pulse. Don’t remember it pulsating tho. Just admitted to vascular and moved on. Our EMR in residency was crap so hard to follow patients. Nowadays with interesting cases I just message myself the chart and follow up on it days later.

 

[RustedFox]

I’m sure if you pressed on it, you would have felt a pulse. Don’t remember it pulsating tho. Just admitted to vascular and moved on. Our EMR in residency was crap so hard to follow patients. Nowadays with interesting cases I just message myself the chart and follow up on it days later.

It was worse than Meditech.
That's... that's BAAAD.