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A case report of a previously healthy adult patient with a lumbar spinal extradural abscess due to Mycobacterium chelonae is presented. His course of treatment was complicated by recurrent psoas abscesses, as well as multiantibiotic resistance, requiring multiple surgical drainage procedures and antibiotic changes over a 33-month period. Cure was achieved only after aggressive surgical debridement of the abscess.
STUDY DESIGN: Clinical results of posterolateral endoscopic debridement and irrigation followed by percutaneous drainage for pyogenic spondylodiscitis were analyzed. OBJECTIVES: To report clinical results of transforaminal endoscopic surgery for pyogenic spondylodiscitis and to evaluate the effectiveness of this procedure in treatment of pyogenic spinal infections. SUMMARY OF BACKGROUND DATA: Pyogenic spinal infections have been increasing due to the development of medical treatment for patients with comorbid medical problems. Common treatments for spinal infections are administration of antibiotics or surgical debridement with bone grafts. There have been no reports, however, regarding the clinical outcome of posterolateral endoscopic treatment for pyogenic spinal infections. METHODS: Fifteen consecutive patients with pyogenic spondylodiscitis in the thoracic or lumbar spine were enrolled. Preoperative antibiotic treatment had failed in all the patients. The procedures consisted of posterolateral endoscopic debridement and irrigation followed by percutaneous drainage through single portal under the combination of local and intravenous anesthesia. Pain response using visual analog scale (VAS, 0-100 mm), inflammation parameters, and duration of antibiotic therapy were investigated. Radiologic evaluation focused on bony fusion, local kyphosis, disc height reduction, and abscess formation. RESULTS: All patients showed immediate pain reduction after surgery. Averaged VAS for pain was 86 before surgery and 25 at postoperative 1 week. Average of CRP was 4.00 mg/dL before surgery and 1.88 mg/dL at postoperative 1 week. Averaged duration of antibiotics therapy was 3.7 weeks. Spinal fusion was obtained in 13 patients. Two patients with neurologic deficits due to epidural abscess returned to normal. Preoperative psoas abscess in 6 patients disappeared after surgery on MRI. CONCLUSIONS: Posterolateral spinal endoscopic debridement and irrigation brought immediate pain reduction and good clinical results to patients who had comorbid medical problems and had pyogenic spondylodiscitis.
Multiorgan failure (MOF) due to intoxication, trauma or sepsis in the progressive late stages always include acute renal failure (ARF). The prognosis of these patients is poor despite adequate dialysis. This study included 27 consecutive patients (20 men and 7 women, age range 15-77 years) with a rapid progress of MOF including ARF, who were treated by plasma exchange as an attempt to reverse the progress of MOF. Twenty-three of the patients suffered from a septic shock. Oliguria or anuria was present in all, dialysis was performed in 16 of them, and mechanical respiratory aid in 17. Plasma exchange was performed 1-10 times and almost exclusively by centrifuge technique, using albumin and/or liquid stored plasma (in a few cases fresh frozen plasma) as colloidal replacement fluid. Twenty-two patients survived (81%) and 5 patients died. The reasons of death were cerebral haemorrhagia, brain abscess, myocardial sudden death, relapsing sepsis from multiple hepatic abscesses and a not drained psoas abscess. All survivors could leave hospital recovered from renal failure with few other sequelae. The plasma exchange technique is easy to perform despite low blood pressures by using a vein to vein access. Plasma exchange, therefore, may be tried to reverse late stages of multiorgan failure.
The authors discuss the diagnostic and therapeutic aspects of primary pyogenic abscess of the psoas muscle based on a series of 5 cases. Five patients between the ages of 15 and 64 years (mean: 38.2 years) were admitted to the urology department between January 1994 and December 1996 with fever, abdominal pain and low back pain, and psoitis in 1 case. The mean delay to consultation was 42 days. Clinical examination revealed a painful mass in the lumbar region and flank in 5 cases. Leukocytosis was detected in 5 patients. Radiological examination demonstrated loss of the lateral border of the psoas in 4 cases. Ultrasonography showed an enlarged psoas muscle in every case with a hypoechoic mass in 2 cases and a heterogeneous mass in the other 3 cases. Computed tomography, performed in 2 patients, confirmed the ultrasound findings in 1 case and excluded the diagnosis of type IV hydatid cyst of the psoas muscle in the other patient. The abscess was evacuated by percutaneous drain in 1 patient requiring a second percutaneous drainage for reconstitution of the abscess. Surgical drainage was performed immediately in 3 patients and after failure of antibiotic treatment in 1 patient. The hospital stay did not exceed 7 days after surgical drainage, but was 25 days after the first percutaneous drainage and 20 days after the second percutaneous drainage. The authors emphasize the multiple advantages and efficacy of surgical drainage of psoas abscess.
Three cases of abscesses rated as primary of the psoas, after dismissing any likely cause that can be involved in the genesis of secondary abscesses of the psoas, are presented. A review of the literature is made, emphasizing the etiological change in the psoas' abscesses as well as the possible causes involved in the etiopathology of this picture which appears to be caused by distant dissemination from a septic nucleus. This theory is also supported by over 80% cases where Staphylococcus aureus is the causative organism. Reference is made to which clinical data is most relevant and to the value of the traditional diagnostic procedures: simplex x-ray, u.i.v., ultrasound techniques, radionuclides and CAT, the latter being the ideal diagnostic procedure in these processes. Finally, different therapy approaches are presented. Percutaneous draining (supported by ultrasound scanning and CAT) appears to have greater acceptance by most authors, relegating the surgical drainage for selected cases.
The increasing incidence of human immunodeficiency virus (HIV) has resulted in an increase in the number of Mycobacterium tuberculosis (TB) infections worldwide. Musculoskeletal tuberculosis often involves the spine. Due to HIV, patients may present atypically and, as a result, a high clinical suspicion is necessary to avoid the catastrophic consequences of untreated Pott's disease of the spine. A cold abscess as a result of tuberculosis can emerge in a number of anatomical regions, and perhaps most notably as a psoas abscess. We report a less common anatomical location of a cold abscess, presenting as a mass in the inferior lumbar region through the lumbar triangle of Jean-Louis Petit. We consider the route that the pus had followed and highlight the need for vigilance when dealing with an abscess in this region, particularly in communities with a high incidence of HIV infection.
We report a 25-year-old woman who presented with features of peritonitis. At laparotomy, the cause of the pyoperitoneum was found to be a left-sided ilio-psoas abscess. This was drained, but the patient continued to deteriorate with sepsis, and died on the fourth post-operative day.
A 28 year old woman with a history of a dysenteric illness and documented Campylobacter infection presented with amoebic psoas and liver abscesses. A review of the literature of the last 20 years did not yield any reports of an amoebic psoas abscess.
Osteomyelitis with concomitant pyarthrosis or isolated pyarthrosis heads the differential list for a newborn with limb disuse and a flexion deformity of the hip. The diagnosis of psoas abscess, a primary suppurative myositis, should additionally be entertained. Stronger consideration should be given to this clinical entity after pyarthrosis of the hip has been excluded by an arthrocentesis performed under fluoroscopy. Radiologic imaging may facilitate the diagnosis. A blood culture may yield the organism responsible for the skeletal muscle abscess, even in nontoxic patients.
BACKGROUND: Abscess of the psoas muscle (AP) is an infrequent disease of difficult diagnosis, developing spontaneously (primary AP) or by extension of a subjacent infection (secondary AP). In recent years changes have been observed in its etiology, advances in its diagnosis and modifications in the treatment schedules. METHODS: The cases of AP diagnosed from 1983-1996 were retrospectively studied. RESULTS: The cases included 11 AP, 5 (45%) primary and 6 (55%) secondary, of which the source of origin were: spondylitis in four, sacroiliac arthritis in one and intestinal in another. The clinical presentation was characterized by its prolonged course (evolution of symptoms greater than 30 days in 64% of the cases), with the most frequent symptoms being flank/abdominal pain (82%) and hip/inguinal pain (45%), with fever being presented in only 36%. The diagnostic profitability of echography and computerized tomography (CT) were 57% (4/7) and 91% (10/11), respectively. One case was diagnosed with magnetic resonance. The causal microorganisms were: Mycobacterium tuberculosis (36% of the cases), Staphylococcus aureus (18%), polymicrobian flora (18%) and Salmonella enteritidis, Streptococcus intermedius and Escherichia coli in 9% each. Eight cases (73%) underwent percutaneous (5 cases) and surgical (3 cases) drainage, with the evolution being favorable in 10 (91%) and death in one despite adequate medicosurgical treatment. CONCLUSIONS: The clinical presentation of AP is often unspecific, thereby delaying its diagnosis, and thus, CT is the procedure of choice. The tuberculous etiology continues to be frequent in our environment. Ultrasonographic or CT guided percutaneous drainage is a valid therapeutic alternative versus surgery.
Two cases of tuberculous abscess of the psoas muscle are reported which did not improve with antituberculosis chemotherapy. They were treated by sonographically guided percutaneous drainage through a pigtail catheter, with a successful result.
One week after a fall from his buggy, a 2-year-old boy was seen at the first-aid department because he refused to walk. A bone scan and MRI revealed spondylodiscitis at the left side of the discus Liv-Lv and a psoas abscess.
We report a patient presenting with a left psoas abscess causing necrotizing fasciitis of the upper thigh. The patient underwent exploration of the left thigh through a medial approach, confirming necrotizing fasciitis of the adductor compartment and the femoral triangle. The infective process also involved the left psoas. This was explored retroperitoneally through a left pararectal laparotomy incision. Further exploration revealed a carcinomatous ulcer of the sigmoid colon. Despite active resuscitation, antibiotic therapy, and further debridement, the patient died three days after admission.
There is an increasing population of immunocompromised patients with HIV, IV drug abuse, organ transplantation, and long-term steroid treatment developing spinal infections. Delayed diagnosis because of blunted host immune response and lack of outward signs and symptoms places the treating physician at a disadvantage in the treatment of this type of disease, which presents at a later stage of development. Immunocompromised patients are infected by a different group of pathogens than their healthier cohorts (e.g., Pseudomonas, gram-negative bacteria and fungal infections) because their host defenses are diminished. Osteomyelitis with or with out pyomyositis and epidural abscess may occur. The overriding symptom is back pain. Radiculopathy, myelopathy, and sensory loss may accompany local pain and tenderness. Plain film radiography, CT scan, MR image, and bone scan is invaluable in the diagnosis of these infections. The cornerstone of treatment is identification of the responsible pathogen, appropriate medical therapy, immobilization of the affected segment of the spine, and physical therapy to combat physical deconditioning. Psoas abscesses may require surgical debridement if they cannot be adequately drained by CT-guided percutaneous catheterization. Epidural abscesses with neurologic compromise require surgical drainage. Impingement of the spinal cord or cauda equina by collapsed osteomyelitic vertebral bodies requires surgical debridement by anterior vertebrectomy, with an autologous tricortical iliac crest strut and immobilization of the spine using external bracing or posterior instrumentation as dictated by the disease.
A 5-year-old male patient presented with flank pain, limping, weight loss, and cachexia. Magnetic resonance imaging revealed destructive vertebral changes, an epidural mass, psoas abscesses, and lack of involvement of the disc spaces. Blastomyces dermatitidis was isolated from a needle aspiration specimen. Sparing of the disc spaces, an unusual finding, suggested that the spread of infection was by way of paravertebral structures and surrounding potential spaces. Management was simplified by using gadolinium contrast-enhanced magnetic resonance imaging, which indicated that the epidural mass was mainly solid, thereby obviating abscess drainage.
PURPOSE: To determine whether computed tomographically (CT) guided percutaneous catheter drainage of spondylodiskitic abscesses is an appropriate and effective alternative to surgery. MATERIALS AND METHODS: CT-guided percutaneous catheter drainage was performed in 21 patients (16 men, five women; age range, 24-81 years) with 33 spondylodiskitic abscesses. Nine intradiskal, 12 paravertebral, and 12 psoas abscesses were drained with 5.6-14.0-F catheters. In 29 cases, the catheter was inserted by using the Seldinger technique in four cases, a trocar technique was used. All patients underwent follow-up CT or magnetic resonance imaging examinations for 6 months. RESULTS: Successful placement of the drainage catheter was achieved in each patient without procedural complications. The duration of drainage was 4-56 days (average duration, 26.8 days). Three of 33 catheters were changed because of insufficient drainage; one of the 33 catheters had to be reinserted because of dislocation. Two patients underwent surgery for stabilization of the spine with the drainage catheter in place. In 16 of the 21 patients, specific organisms were isolated; thus, definitive medical therapy was possible. Complete evacuation of all abscesses was achieved initially, with no evidence of recurrence during the follow-up. CONCLUSION: CT-guided percutaneous catheter drainage is an efficient and safe procedure in the management of spondylodiskitic abscesses.
BACKGROUND: Retroperitoneal abscess is a rare complication of normal labor and delivery, and no apparent etiology is evident. CASES: We report on two patient who presented with back and leg pain soon after normal deliveries. While the condition was initially clinically misdiagnosed, ultrasonography and computed tomography demonstrated retroperitoneal collections and aided in guided percutaneous drainage. After a protracted course of antibiotic treatment and daily irrigation, the collections resolved. CONCLUSION: Ultrasonography and computed tomography were invaluable in the diagnosis and guided drainage of rare psoas abscesses complicating delivery.
STUDY DESIGN: Single case report. OBJECTIVES: To present an unusual cause of fever in a patient with spinal cord injury (SCI). SETTING: University Hospital, Belgium. METHODS: A 52-year-old man with a complete T9 paraplegia was admitted to hospital with a 7 day history of fever above 39 degrees C without pain and without gastrointestinal, urinary, or respiratory complaints. The patient had had a flap coverage for a sacral pressure ulcer 6 months prior to admission. RESULTS: Bone scintigraphy demonstrated markedly increased activity in the left sacroiliac joint. Computed tomography (CT) revealed an infection of the left sacroiliac joint with a large abscess involving the iliopsoas muscle. The responsible organism, Pseudomonas aeruginosa, was isolated from abscess liquid obtained by CT-guided aspiration. We postulated that P. aeruginosa had colonized the eschar and, due to the proximity, infected the sacroiliac joint and the adjacent iliopsoas muscle. Prompt intravenous antibiotic therapy ensured clinical improvement and radiological regression. CONCLUSION: Pyogenic sacroiliitis is a relatively rare condition that may be difficult to diagnose in patients with normal sensation, and even more so in SCI patients. As far as we know, psoas abscess associated with pyogenic sacroiliitis has never been described in SCI patients. This infectious pathology must be kept in mind in SCI patients with fever of unknown origin and with a history of sacral eschar.