Disseminated Tuberculosis Presenting as Multiple Cold Abscesses in an Immunocompetent Adult: A Narrative Review

Abstract

Cold abscesses, collections of caseous material with little heat, redness or pain, are among the most recognisable soft-tissue signs of tuberculosis, and several of them appearing together in an adult with no obvious immune defect raises a harder question than any single swelling does. This narrative review asks how multifocal cold abscesses should be understood in such a person, what the published literature says about how the organism spreads, why the host sometimes fails to contain it, and how the diagnosis is established and treated. It draws on work on mycobacterial biology, granuloma immunology, extrapulmonary and miliary disease, host susceptibility, diagnostics and chemotherapy, and it reports no patient data of its own. Dissemination is best viewed as a failure of containment rather than a feature of a particular strain, and "immunocompetent" is a label that hides subtler defects: unrecognised diabetes, undernutrition, alcohol, smoking, and rare inherited abnormalities of interferon-gamma signalling. Diagnosis rests on obtaining tissue or pus for smear, culture and histology, because immune-based blood tests cannot separate active from latent infection. Treatment follows standard multidrug regimens, but abscesses may enlarge or new ones appear during effective therapy, a paradoxical reaction that is easily mistaken for failure. The review concludes that the evidence for adults without HIV is mostly descriptive and indirect, and it sets out what better reporting would contain.