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We present the case of a patient with precedents of endometrial carcinoma treated by surgery and radiotherapy, which presented a psoas abscess by Streptococcus agalactiae as cause of fever of unknown origin, which answered favorably to the antibiotherapy and surgical drainage.
In 3 patients, 2 women aged 16 and 64 years and 1 man aged 64 years, with pain in the left hip region and fever, the diagnosis psoas abscess was made. After antibiotic treatment and drainage they recovered well. The primary from of psoas abscess is presumably caused by haematogenous spread of bacteria, mostly Staphylococcus aureus. The secondary form is caused by spread of infection from surrounding tissue, mostly gastrointestinal micro-organisms with Crohn's disease and diverticulitis. Painful passive extension and endorotation as well as a painful flexion stress-test of the hip joint can indicate a psoas abscess. Echography and blood cultures should be performed if a psoas abscess is suspected. If echography is inconclusive, CT-scan can establish the diagnosis. The psoas abscess should be treated by percutaneous or surgical drainage combined with antibiotic therapy. The underlying cause of a secondary psoas abscess should be treated separately.
A 28-year-old man was referred to our hospital with a complaint of painful induration of right epididymis accompanied with right back pain and persistent low-grade fever. He was finally diagnosed with tuberculosis by sputum culture. Abdominal computed tomography (CT) revealed right psoas abscess and vertebral caries. He underwent a percutaneous drainage of the abscess followed by multidrug (streptomycin, pyrazinamide, refanpicin, isoniazide) combination therapy. Immediately after the drainage, symptoms began to improve with these therapies. However, four months later, abdominal CT showed a worsening of the abscess. Recently there is a stagnation in the decline of incidence of tuberculosis. It is still necessary to examine young people carefully bearing urogenital tuberculosis in mind. The pathogenesis and management of this rare condition are discussed.
Psoas muscle abscess due to Klebsiella pneumoniae infection is rare. We report a 55-year-old diabetic man who presented with progressive back pain of 1 month's duration. The patient had undergone surgical drainage for a deep neck infection with K. pneumoniae 43 days previously. On the present admission, physical examination revealed tenderness over the anterior upper aspect of both thighs, and computed tomography showed pneumoretroperitoneum dissecting the bilateral iliopsoas muscles. Parenteral administration of antibiotics was started immediately. Due to the patient's poor health status, we opted for repeated computed tomographic and sonographic-guided percutaneous drainage rather than surgical drainage. Blood and pus cultures revealed only K. pneumoniae. The patient recovered without significant sequelae. This report stresses the risk of metastatic infections caused by K. pneumoniae, especially in diabetic patients. Our experience suggests that repeated percutaneous drainage is feasible in cases of severe iliopsoas abscess, especially when risks associated with surgery are high.
Two adolescents with psoas muscle abscesses secondary to Crohn's disease are presented. Musculoskeletal signs of hip flexion and scoliosis led to early clinical suspicion. Computed tomography and ultrasonography demonstrated the extent of involvement and allowed specific preoperative diagnosis.
A 22 year old man from Ethiopia suffered from progressive left inguinal pain and weight loss for ten months. The pain aggravated with leg movement, in particular with flexion of the left hip. ESR and CRP were slightly elevated, and a PPD was strongly positive. Abdominal ultrasound was normal but CT-scan revealed a left sided psoas abscess. Pott's disease was suspected and tuberculostatic therapy with INH, PZA, ETH, RIF was initiated immediately. A MRI of the spine excluded spondylodiscitis. Primary Tb psoas abscess was diagnosed. Treatment response after 5 weeks was clinically insufficient and CT-scan showed enlargement of the abscess. Treatment adherence was verified by drug prescriptions and INH urinary stix testing. M. tuberculosis, suspected microscopically in the puncture fluid, grew in culture and was fully drug sensitive. After 12 weeks, surgical abscess debridement had to be performed due to disease progression. The patient's health state improved considerably the first two postoperative months, inflammatory markers normalized, although a small residual abscess was still visible on CT. Subsequently, three months after surgery, pain reemerged, CT showed abscess progression. The patient had to be reoperated. Tb psoas abscess was a frequently described complication of Tb spondylodiscitis (Pott's disease) the first half of the last century and became rare thereafter in the Western hemisphere. However, the last two decades, due to migration policies and a worldwide increase of Tb epidemic because of socioeconomic destabilization and spread of the HIV-pandemic, Tb reemerged in Western countries. Therefore, physicians should be aware of atypical manifestations of tuberculosis. Primary Tb psoas abscess is extremely rare. Only four cases are described in the literature. In analogy to Pott's disease, therapy consists of tuberculostatic treatment, supported by surgical debridement.
Psoas abscess with aortoiliac infection is rare. Patients are often symptomatic for a long time before the correct diagnosis is made. The authors report 4 cases in which the presenting symptom was an antalgic flexion of the left thigh. In 2 patients the cause was an aortic graft infection with enteric fistula; in the other 2, infection developed after transfemoral endovascular procedures. Open surgical treatment was performed in 3 cases and percutaneous drainage in 1. One surgical patient with a late diagnosis eventually died of sepsis; the other 3 are alive and well at mean follow-up of 14 months.
A 9-year-old girl with meningomyelocele, an ileal conduit and a living related kidney transplant presented with a progressive gait disturbance. Radiographic evaluation included a computerized tomography scan that disclosed a large right psoas muscle abscess. The abscess cavity was drained percutaneously and culture of its contents yielded Pasteurella multocida. This case illustrates an unusual presentation of a psoas muscle abscess caused by an uncommon organism that was diagnosed and treated by nonoperative methods.
Tuberculous epididymitis is a rare entity associated with minor complications. We present two cases of tuberculous epididymitis associated with serious complications (bilateral psoas abscesses and Addison's disease with psoas abscess). A review of the literature disclosed six additional cases associated with serious complications (Addison's disease, inappropriate antidiuretic hormone secretion, central nervous system involvement) which are discussed and compared to these cases. We conclude that tuberculous epididymitis represents a grave sequela of genital tract involvement and may be associated with serious and even fatal complications.
Nontuberculous psoas abscess is an unusual disease of childhood. The symptoms closely mimic those of other disorders and delay of treatment is commonplace. Eight children (age range 1.5-12 yr) have been treated for psoas abscess. Each presented with a history of fever (38-40 degrees C) and pain. The pain was localized to the hip (3-right, 4-left) and aggravated by ambulation in 7 cases. In 6 children, there was associated lower abdominal tenderness and flexion of the involved hip at rest with resistance to extension. Only 1 child was correctly suspected of having a psoas abscess. Delay in appropriate therapy averaged 5 days (range 1-20 days). Five children underwent joint aspiration and an additional 3 underwent abdominal exploration prior to diagnosis. Surgical drainage was subsequently performed in each case. A retroperitoneal approach, either flank or inguinal, was employed. Staphylococcus aureus was isolated from all cultures. Primary psoas abscess is seldom included in the differential diagnosis of septic lower abdominal and/or lower extremity pain. It should, however, be considered, particularly in the child with classic findings of psoas irritation.
BACKGROUND: Abscess of the psoas muscle (PA) is an infrequent disease of difficult diagnosis. During the last decade, the number of cases has increased because of the raising use of radiology tecniques: ecography, computerized tomography and magnetic resonance nuclear. METHODS: The presentation and management of psoas abscess was studied retrospectively in 23 patients from 1992 2000. RESULTS: Sixteen of 23 abscesses were regarded as secundary: spondylodiscitis and pyelonefritis were most frequent pathologic processes. Homolateral pain in the flank area and hip were the usual manifestations. The duration of symptoms prior to the diagnosis was superior than 7 days. Staphylococcus aureus was the most common pathogen, followed by Escherichia coli and Mycobacterium tuberculosis. All abscesses were diagnosed by computerized tomography images. Seven patients underwent percutaneous drainage, while nine received surgical debridement. Four of the patients with psoas abscess died and only three relapsed. CONCLUSIONS: Not specific symptoms and signs and subacute presentation difficult diagnosis of AP. High range antibiotics and drainage (percutaneous or surgical) should be considered as the election treatment.
STUDY DESIGN: Case report of a 64-year-old man with psoas abscesses, epidural abscess and spondylitis after acupuncture. OBJECTIVE: To report a case of paraplegia caused by spinal infection after acupuncture. SETTING: Seoul, Korea. CASE REPORT: A 64-year-old man came to an emergency room because of severe back pain. At 3 days prior to visit, the patient received acupuncture therapy to the low back with a needle about 10 cm in length because of back pain. Pain was aggravated gradually for 3 days. Escherichia coli sepsis developed with altered mentality during admission. At hospital day 9, he regained his consciousness and was found to have paraplegia. Abdominal computerized tomography (CT) and lumbar spine magnetic resonance imaging (MRI) revealed abscesses of bilateral psoas muscles and spondylitis with epidural abscess. After conservative management with intravenous administration of antibiotics, infection was controlled but the patient remained paraplegic (ASIA scale C L1 level) without neurological recovery. CONCLUSION: Paraplegia might result from complications of an acupuncture therapy.
Psoas abscess is an uncommon condition and, contrary to traditional teaching, tends to be of non-tuberculous aetiology in developed countries. Diagnosis can be delayed since presenting features are non-specific and in many instances misleading, necessitating a high degree of clinical suspicion and early resort to cross-sectional imaging using CT or MRI. We present a case of iliopsoas abscess secondary to perforated diverticulitis to illustrate the difficulty encountered in early diagnosis and to show that successful management of secondary psoas abscess necessitates surgical resection of the underlying condition in most cases.
A 34-year-old man with human immunodeficiency virus infection and disseminated Mycobacterium avium and Mycobacterium intracellulare infection developed a right psoas muscle abscess due to Mycobacterium tuberculosis. The abscess occurred 18 months after completion of a 12-month course of chemoprophylaxis with isoniazid that was given because of a positive reaction with purified protein derivative of tuberculin. The adjacent vertebrae did not appear to be involved. The abscess was drained with a percutaneously inserted catheter, and he received standard antituberculous chemotherapy. Three weeks into therapy, a second drainage with a catheter was required. The isolation of two mycobacteria in this patient and the apparent failure of chemoprophylaxis with isoniazid are noted.
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