Psoas abscess in pregnancy: a review of the literature and suggestion of minimally invasive treatment options

AIM

Less than a dozen cases of psoas abscesses in pregnancy have been described in the literature. We reviewed the literature when treating a patient with a psoas abscess after ipsilateral double J-ureteral stent placement (in the following: "double J-stent") due to infected hydronephrosis.

METHODS

In January 2022, this review was searched using the Pubmed/MEDLINE database and the mesh terms "Psoas Abscess" AND "Pregnancy". Studies were included in any language and of all years, describing a psoas abscess during pregnancy. When patients did not have a psoas abscess, the abscess occurred after pregnancy, or when there was no full text available, the article was excluded.

MAIN RESULTS

Ten case reports about patients with psoas abscesses during pregnancy were included. The classical symptomatic triad of psoas muscle abscess included lower back pain, limping and persistent fever with daily spikes. However, in most cases, not all three symptoms can be found. Especially, fever is absent in more than half of the patients. Psoas abscesses are described between 13 and 39 weeks of gestation. Primary psoas abscesses with haematogenous spread are more common during pregnancy than secondary with spread per continuitatem. In the literature, the main reasons for psoas abscess are spinal tuberculosis, drug abuse or underlying diseases such as Crohn's disease. It is not uncommon for the definite cause to be unclear. Regarding the patient's symptoms, pyelonephritis is often considered a possible aetiology. In general, the main treatment options include antibiotic treatment and abscess drainage. There is no higher caesarean section rate, and no negative outcome for the foetus has been described.

CASE PRESENTATION

In our patient, a 38-year-old obese Caucasian woman, who had received a left double J-stent for infected hydronephrosis at 15 weeks of gestation, we successfully treated a psoas abscess of 20 × 10 cm with a sonographically assisted abscess drainage and antibiotics. The further course of pregnancy and the elective repeat caesarean section at 38 + 0 weeks of gestation were without any problems. Double J-stent placement and laser stone lithotripsy during puerperium were performed because of recurrent urolithiasis.

CONCLUSIONS

Although rare, psoas abscesses can occur during pregnancy, and it has often been treated surgically in the past. A psoas abscess as a complication after infected hydronephrosis and intervention during pregnancy has never been reported in the literature. Even for obese patients, minimally invasive therapy may be a treatment option that has rarely been reported in the literature.

Endovascular Therapy of Aortic Rupture Secondary to a Psoas Abscess

Secondary infection of the aorta is a sporadic and life-threatening disease. It is usually caused by infection and abscess in an adjacent structure. The most common mechanism for secondary aortic infection is a psoas abscess eroding the aortic wall, which rarely results in non-aneurysmal aortic rupture. Primary treatment is surgical aortic reconstruction, but the risk of emergency surgical treatment is high. Endovascular aortic stent-graft implantation can be lifesaving in this setting by stopping the bleeding. However, the crucial question of durability and late infections remains unanswered and warrants long-term antibiotic treatment and follow-up. In this report, we present a case of primary psoas abscess, which resulted in non-aneurysmal aortic rupture and its endovascular treatment.

[A Case Report of Psoas Abscess Formation Caused by Mucinous Cystadenocarcinoma]

We report a rare case of psoas abscess formation caused by mucinous cystadenocarcinoma. A 65-year-old women was admitted to our hospital for treatment for iliopsoas abscess. She presented with standing difficulty and her laboratory data showed an increased level of leukocytes. CT scan demonstrated an abscess formation in iliopsoas muscle. Colonoscopy showed an ulcer on her cecum. Although percutaneous drainage was performed on the first day, the abscess relapsed repeatedly. Ileocolectomy was performed on post admission day 29. Abscess drainage continued after the operation, the patient was discharged on postoperative day 34. Pathological examination revealed mucinous cystadenocarcinoma on the cecal tumor. Total 8 cycles of FOLFOX6 was performed as adjuvant chemotherapy. The patient has been survived for 20 months with no recurrence.

A rare case of iliopsoas abscess caused by a retained shrapnel from a blast injury

Iliopsoas abscesses (IPA) are uncommon, with an associated mortality rate of up to 20%. We describe the case of a 55-year-old man war veteran who presented with an unusual cause of IPA secondary to retained foreign body (FB). His initial trauma 30 years before was a result of a blast injury with shrapnel penetration suffered after inadvertently driving over a landmine as an ambulance driver in a conflict region. A CT scan was performed, revealing a 13 mmx8 mm radio-opaque FB within the right psoas at the level of the fifth lumbar vertebra with a surrounding collection. Subsequent open surgical exploration removed two gravel fragments. Given the knowledge of a traumatic blast injury with retained FB and repeated episodes of sepsis, surgical exploration is warranted. To our knowledge, this is the first case of recurrent IPA secondary to a retained FB from a historical trauma.

Percutaneous Retroperitoneoscopic Drainage of Complex Extraperitoneal Abscesses Using Flexible Endoscopy: Description of Technique and Perioperative Care

The treatment of primary psoas abscesses usually is performed by a combination of prolongued antiobiotic therapy and drainage with interventional radiology techniques. However, although this combination is usually adequate for the treatment of solitary extraperitoneal collections, the presence of multi-loculated complex abscesses requires usually multiple procedures and feruently mandates open surgery. Herein, we describe an alternative tehnique of percutaneous retroperitoneoscopic drainage of multiple extensive primary psoas abscesses using flexible endoscopy, which can enable treatment these cases as one-stop proedure in a minimally invasive manner.

Transverse process osteotomy for surgical drainage of primary iliopsoas abscess and secondary cases combined with spondylodiscitis

Iliopsoas abscess refers to collection of fluid in iliopsoas muscle compartment. It is well-known condition in medical history as a complication of tuberculous spine infection. Most of the cases now are due to pyogenic infection. Patient usually presents late due to delayed diagnosis. We aim to present a less invasive technique for surgical drainage of iliopsoas abscess.

PATIENTS AND METHODS

It is a prospective study done between 2015 and 2018. The study included 28 patients with confirmed diagnosis of iliopsoas abscess. Laboratory investigations included CBC, ESR, and C-reactive protein that were done for all patients. MRI with contrast enhancement was gold standard for diagnosis. Ten patients underwent surgical psoas abscess drainage by transverse process osteotomy via Wiltse approach without any other spine intervention. Eighteen patients had posterior spine fixation and interbody fusion together with transverse process osteotomy and abscess drainage as treatment for spondylodiscitis. The patients were followed up for clinical improvement, and functional assessment was done by Oswestry disability index. ESR and CRP were used for laboratory follow-up of infection subsidence. Follow-up of abscess size and resolution was done by pelvic-abdominal ultrasonography.

RESULTS

The mean maximum width of the abscesses in MRI axial views was 38.8 mm. Patients were divided into two groups. Group (1) included ten patients who underwent drainage only while group (2) included 18 patients who underwent spine fusion for treatment of spondylodiscitis. The amount of pus drained intra-operatively was of average 234 cc in group 1 and 191.6 in group 2. The drain was removed in average 58.6 hours post-operatively in group 1 with mean of 168.4 cc of drained fluid and in average of 74.3 hours for group 2 with mean of 350.5 cc of drained fluid. The ODI and inflammatory markers improved in all patients. The follow-up period was of average 26.7 months. The organism was isolated from 19 patients (5 patients were tuberculous and 14 patients were different pyogenic pathogens). No fluid recollection was observed in pelvic-abdominal ultrasound during follow-up in our series.

CONCLUSION

Transverse process osteotomy is a safe and effective approach for drainage of psoas abscess. It can be done alone or combined with posterior spine fusion for treatment of spondylodiscitis.

Laparoscopic drainage as a minimally invasive treatment for a psoas abscess: A single-center case series and literature review

A psoas abscess is a rare but potentially devastating condition that is associated with risks of neurological deficits, septic shock, and even death. The current first-line treatment is percutaneous catheter drainage (PCD) under imaging guidance, combined with broad-spectrum antibiotics. Surgical drainage should be considered if PCD fails or is impossible.Although many studies on PCD and open surgical drainage have appeared, the outcomes of laparoscopic drainage have rarely been reported. Thus, we laparoscopically drained the psoas abscesses of 6 patients; drainage was complete and we encountered no recurrence or complication. All patients were evaluated by plain radiography, contrast-enhanced computed tomography, and laboratory tests; all were followed-up for 1 year. Laparoscopic drainage is a good treatment option when PCD fails, affording all the advantages of open surgery (complete drainage, resection of infected tissue, and contermporaneous treatment of concomitant lesions). Also, laparoscopic drainage is minimally invasive, requires a smaller incision, and allows rapid recovery.

[A Case of Laparoscopic Resection of Sigmoid Colon Cancer Complicated by an Iliopsoas Abscess Preceded by Abscess Drainage]

For colon cancer complicated by iliopsoas abscess, it is unclear whether surgery should be performed prior to abscess drainage. We were able to perform laparoscopic sigmoid resection safely after first draining the abscess. We believed it would be beneficial to avoid surgery in the presence of abscess and inflammation, and the minimally invasive operation was performed after improvements of the patient's general status and inflammation.

Fever with intradialytic pelvic pain: a case of iliopsoas abscess complicated with Methicillin-sensitive Staphylococcus Aureus bacteraemia in an end stage renal failure patient

Staphylococcus Aureus is a Gram-positive cocci bacteria which had been found to be the causative organism in over 88% of patients with primary iliopsoas abscess. We report the case of a 53-year-old diabetic woman with end-stage renal failure diagnosed with left iliopsoas abscess with a catheter-related infection. Computed tomogram (CT) of abdomen and pelvis revealed hypodense lesions of left psoas, iliacus and quadratus lumborum suggestive of psoas abscesses. In addition, osteomyelitis changes at left sacroiliac and hip joint were seen. At surgery, she was found to have abscess at the posterior psoas muscle where she underwent open surgery drainage and percutaneous drain was inserted. A high index of suspicion of iliopsoas abscess should be maintained among haemodialysis patients presenting with intradialytic pelvic and hip pain and treated with optimal antibiotics therapy with appropriate surgical intervention.

[Case-control studies of two kinds of method for the treatment of lumbar tuberculosis with psoas abscess]

OBJECTIVE

To compare two kinds of method for treating lumbar tuberculosis with psoas abscess, to provide reference for clinical reasonable select of therapy treatment.

METHODS

From January 2010 to January 2013,42 patients with lumbar tuberculosis combined with psoas abscess with obvious surgical indications were enrolled, including 24 males and 18 females with an average age of (38.5 ± 10.2) years old ranging from 21 to 63 years old. All patients were followed up for 18 to 24 months with an average of 20.9 months. Twenty-two patients underwent posterior vertebral body lesions cleared, bone graft fusion and internal fixation and percutaneous puncture catheter drainage for treatment of psoas major abscess as group A, and twenty patients underwent one-stage extraperitoneal approach to remove abscess, posterior vertebral body lesions cleared, bone graft fusion and internal fixation as group B. The operative time, loss of blood, length of hospital stay, clinical cure rate and other clinical results for the two groups were analyzed and compared.

RESULTS

The loss of blood was (452.3 ± 137.6) ml in group A and (603.5 ± 99.6) ml in group B, there was significant statistical difference (P < 0.05). The time of operation was (193.6 ± 91.2) min in group A and (230.5 ± 56.6) min in group B, there was significant statistical difference (P < 0.05). The time of operation and the loss of blood in group A were obviously less than which in group B. In group A 20 cases were cured and 2 cases relapsed, 19 cases were cured and 1 case relapsed in group B, there was no significant statistical differences between two groups regarding cure rate with chi-square test (χ² = 0.000, P = 1.000). All patients in two groups obtained good clinical curative effect. There were no significant statistical difference between two groups regarding for length of hospital stay with t-test (P > 0.05).

CONCLUSION

Lumbar spinal tuberculosis with psoas abscess is not absolute indications for anterior open operation. Compared with the combined anterior and posterior surgical procedure, the percutaneous puncture catheter drainage combined with posterior debridement, interbody fusion and internal fixation can achieve the same clinical effect but less trauma for the patients.

[Septic Sacroiliitis Complicated by a Pseudoaneurysm of the Internal Iliac Artery. A Case Report]

The case of a 67-year-old woman with a combination of pelvic pyomyositis and left-sided sacroiliitis is reported. After a failed two-week antibiotic therapy, CT-guided percutaneous drainage of psoas muscle abscesses was performed and methicillin-resistant Staphylococcus aureus (MRSA) was isolated. Subsequently, a regression of symptoms was observed. At 6.5 weeks after the onset of symptoms, progression of sacroiliac joint (SI) destruction was again observed and an open revision of the SI joint was indicated (posterior approach, drainage and lavage). This again was followed by symptom regression. At 9.5 weeks after the patient was admitted, her condition markedly deteriorated and a large gluteal abscess was detected on CT examination. The second revision surgery was complicated by massive bleeding and, due to a septic pseudoaneurysm, internal iliac artery ligation was necessary. A significant subsidence of inflammatory changes and no pseudoaneurysm were shown on the follow-up CT scan. The intravenous antibiotic therapy with clindamycin was continued. At follow-up, repeated microbiological cultures from both tissue samples and drained secretions were all negative and CT scanning detected neither any fluid around the SI joint nor a pseudoaneurysm.

Bacteremia with an iliopsoas abscess and osteomyelitis of the femoral head caused by Enterococcus avium in a patient with end-stage kidney disease

A 70-year-old man on hemodialysis for end-stage kidney disease due to polycystic kidney disease presented with hip pain on extension and a high C-reactive protein level. Further examinations revealed an iliopsoas abscess and femoral head osteomyelitis caused by Enterococcus avium (E. avium) detected in blood and pus cultures. Complete resolution of the infection with ampicillin-resistant E. avium required six months of vancomycin therapy and two surgical drainage procedures. There have been no previous case reports in which both blood and abscess cultures confirmed E. avium infection. Careful attention should be paid to the detection of non-specific symptoms in patients on hemodialysis, with blood cultures being essential in such cases.

Limitations of using imaging diagnosis for psoas abscess in its early stage

Objective Patients diagnosed with psoas abscess have a high mortality rate. The major cause of its poor prognosis is delayed treatment. Therefore, making a correct diagnosis rapidly is important. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered to be the gold standards as imaging modalities that have a high sensitivity for detecting psoas abscess. There have been few reports regarding the limitations of these methods, but psoas abscess in its early stage may go undetected by CT and MRI. Methods Detection of psoas abscess by CT and MRI was investigated in the present study through a retrospective review of 15 patients in whom psoas abscess was diagnosed during a course of ten years at our hospital. Results In all patients, psoas abscess was diagnosed by at least a plain CT, enhanced CT, and/or plain MRI. The interval between the onset of symptoms and diagnosis was 20.9±17.9 days (mean ± standard deviation). In three patients, repeat imaging identified a psoas abscess, whereas initial imaging failed to detect it. The overall sensitivity of plain CT, enhanced CT, and plain MRI for psoas abscess was 78%, 86%, and 88%, respectively. From six days after the onset of symptoms, the sensitivity of each modality was 100%, while the sensitivity from day one to five days was only 33%, 50%, and 50%, respectively. Conclusion Although CT and MRI are considered to be gold standard modalities for diagnosing psoas abscess, both methods can fail to notice this condition in its early stage.

Appendicitis with psoas abscess successfully treated by laparoscopic surgery

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

[Psoas abscess as a differential diagnosis in emergency department]

BACKGROUND

A psoas (or iliopsoas) abscess is a rare clinical entity with a wide etiological range. It is defined as a collection of pus that begins and extends through the iliopsoas muscle and can reach up to the inguinal region.

METHODS

We performed a retrospective descriptive study by reviewing medical records from the General Surgery department of Reina Sofía's General University Hospital. Information was collected from patients diagnosed with psoas abscess who were admitted to the General Surgery department from 2006 to 2011.

RESULTS

Five cases were reported for 6 years: four males (80%) and one female (20%). Average age was 51.6 years (range: 35--75). All were admitted to the hospital through the Emergency Department. Lumbar pain, fever and rash were clinical features in three patients. Two patients initiated with septic shock. Each patient had computed tomography performed, which confirmed the diagnosis. Causes of the abscess were as follows: one perforated colon neoplasm, two left hip osteomyelitis, one Crohn's disease and one primary abscess. Surgery was the treatment in three cases and placement of pigtail drainage was the treatment in two patients. Two patients were admitted to the Intensive Care Unit and ultimately died.

CONCLUSION

In our case series report, it is seen that treatment delay developed to septic shock and death. We should consider this entity in emergency practice in order to carry out timely treatment.

Laparoscopic drainage of a recurrent psoas abscess

BACKGROUND

Many Authors suggest that psoas abscess should initially undergo an antibiotic therapy, with or without percutaneous drainage. In their opinion, surgical drainage should be done in case of failure or complicated recurrences. Herein we report a laparoscopic drainage of a recurrent and multilocular psoas abscess.

METHODS

A 43-year-old woman presented to our department with a 4-week history of fever, anorexia, difficulty in walking, and pain in her right flank, lower back and hip. She had a 20-year history of recurrent lower back pain and fever treated with cyclic antibiotic therapy. Abdominal CT scan showed a complex multilocular right psoas abscess and a 17 mm hypodense area in the sixth liver segment. A drainage of the abscess through a laparoscopic access with intraoperative laparoscopic ultrasound of the liver was decided.

RESULTS

The patient was discharged on the 3 th postoperative day. Her white blood cell count was normal and she was symptom free. At 1-, 6-, 12- and 24-months-follow-up, neither fever nor lower back pain were reported.

CONCLUSIONS

According to our experience, laparoscopic drainage of iliopsoas abscess is safe and effective. However, further studies comparing laparoscopic drainage with open drainage and percutaneous drainage are required in order to define the specific indications of laparoscopic drainage.

[Psoas abscess associated with hip arthroplasty infection]

INTRODUCTION

Psoas abscess associated with hip arthroplasty infection is a rare entity. The aim of this report was to review our experience.

MATERIAL AND METHODS

Patients with computerized tomography (CT) diagnosis of psoas abscess associated with a hip arthroplasty infection from 2004 to 2009 were retrospectively reviewed. Demographics, microbiological data, CT results and outcome of each patient were recorded.

RESULTS

Seven patients out of 214 evaluated by CT due to hip infection suspected were identified. Three women and 4 men, with a mean age of 69 years (range 46-89). Mean abscess diameter was of 62 x 47 mm. In all cases, a direct communication between abscess and prosthesis was observed. The most commonly isolated microorganisms were grampositive cocci. All patients were treated with two-stage revision surgery. After a mean follow-up of 65 months (28-113), six patients were in remission.

CONCLUSIONS

The use of CT in the study of suspected infection of a hip arthroplasty identified a psoas abscess in 7 cases out of 214 evaluated. Patients treated with two-stage revision surgery and large debridement was associated with a good clinical outcome.

Right-sided colonic tuberculosis: a rare cause of ilio-psoas abscess

Ilio-psoas abscess due to right colon origin is rare and normally occurs secondary to Crohn's disease, diverticulitis or cancer. We report a case of a caecal tuberculosis (TB) presented initially with an appendicular mass and systemic symptoms of fever and fatigue and 3 weeks after, with right-sided anterior thigh pain and found to have an ilio-psoas abscess. Colonoscopy and histology confirmed the diagnosis of caecal-TB. She had a CT drainage of the abscess and was discharged with anti-TB treatment and her drain in situ. Repeat pelvic MRI 10 days after treatment showed the abscess resolving and her systemic symptoms improving.

A rare diagnostic challenge in acute appendicitis: a case report

Although rare, acute appendicitis presenting as a remote abscess with cellulitis in the gluteal region, retroperitoneal region, groin, or thigh does occur and may present a diagnostic challenge. We report a case of a 78-year-old woman presenting with an extensive gas-forming abscess in the right gluteal region secondary to perforated appendicitis without significant gastrointestinal symptoms. Computed tomography (CT) demonstrated a retroperitoneal abscess extending along the sacropelvic surface of the ilium to the subcutaneous tissue. Subsequently, laparotomy revealed retrocecal appendicitis perforated at the base of the cecum, and contained in the retroperitoneum without any signs of peritonitis. This case not only represents an unusual manifestation of acute appendicitis, but also alerts us to the importance of anatomical considerations when interpreting disease extent with imaging. In the differential diagnosis of gluteal or upper thigh abscesses, the rare possibility of perforated acute appendicitis should be considered.

Psoas abscess with associated septic arthritis of the hip in infants

We describe psoas abscess with concomitant septic hip arthritis in 2 infants, 3 and 7 months old. The common clinical features were a palpable mass in the inguinal region, irritable hip, and delayed treatment. The diagnosis of septic hip was delayed in one child, and they both had residual hip deformity at follow-up. It is possible that initial delay in diagnoses resulted in the concurrent pathologic condition because of spread of infection. These 2 cases demonstrate the first known reports of concurrent psoas abscess and septic hip arthritis in infancy. Magnetic resonance imaging is a valuable method to identify these concurrent pathologic conditions. A proposed etiologic mechanism is also discussed in the article.

Psoas abscess from ureteric stone perforation

This case illustrates a rare complication of an impacted ureteric stone which eroded through the wall of the ureter leading to formation of a psoas abscess. Ureteric stent placement and percutaneous drainage of the abscess were insufficient to resolve the problem. Renal scan revealed poor function and the left kidney was removed. It showed evidence of acute supporative pyelonephritis with nephrolithiasis.