Psoas abscess: difficulties encountered

Evaluating Imaging Techniques for Diagnosing and Drainage Guidance of Psoas Muscle Abscess: A Systematic Review

Background: Psoas muscle abscess (PMA) is an uncommon yet severe condition characterized by diagnostic and therapeutic challenges due to its varied etiology and nonspecific symptoms. This study aimed to evaluate the effectiveness and accuracy of various imaging techniques used in the image-guided percutaneous drainage (PD) of PMA. Methods: A systematic review was conducted following the PRISMA guidelines. We searched PubMed, Google Scholar, and Science Direct for studies published in English from 1998 onwards that reported on the use of PD in treating PMA, detailing outcomes and complications. Imaging modalities guiding PD were also examined. Results: We identified 1570 articles, selecting 39 for full review. Of these, 23 met the inclusion criteria; 19 were excluded due to unspecified PMA, absence of imaging guidance for PD, or inconclusive results. Eleven studies utilized computed tomography (CT) for PD, with six also using magnetic resonance imaging (MRI). Ten studies implemented ultrasound (US)-guided PD; variations in diagnostic imaging included combinations of US, CT, and MRI. A mixed approach using both CT and US was reported in two articles. Most studies using CT-guided PD showed complete success, while outcomes varied among those using US-guided PD. No studies employed MRI-guided PD. Conclusions: This review supports a multimodal approach for psoas abscess management, using MRI for diagnosis and CT for drainage guidance. We advocate for Cone Beam CT (CBCT)-MRI fusion techniques with navigation systems to enhance treatment precision and outcomes, particularly in complex cases with challenging abscess characteristics.

Ultrasound-Guided Percutaneous Drainage of Iliopsoas Abscess With Septicemia in an Adolescent: A Case Report and Literature Review

Introduction

Iliopsoas abscess with septicemia in the pediatric population is rare. Early diagnosis and effective management of this emergent disorder remain challenging for clinicians.

Case Presentation

A 14-year-old girl presented with right lateral and posterior hip pain and fever for 7 days before admission. Blood culture was positive for Staphylococcus aureus. Enhanced magnetic resonance imaging revealed abscesses located in the right iliopsoas muscle and on the surface deep to the fascia of the right sacroiliac joint that were 6.8 cm × 6.2 cm × 5.7 cm and 3.7 cm × 3.5 cm × 2.1 cm, respectively. A diagnosis of right iliopsoas abscesses with septicemia was made. The patient received intravenous antibiotics, underwent ultrasound-guided percutaneous catheter drainage, and recovered uneventfully. Medical literature regarding this issue published in the English language during the last two decades was reviewed.

Discussion

Primary synchronous psoas and iliacus muscle abscesses are rare and emergent disorders in the pediatric age group. The diagnosis is generally delayed owing to the deep anatomic location and nonspecific signs and symptoms. A comprehensive medical history, meticulous physical examination, and judicious use of imaging studies could establish a timely and accurate diagnosis. Surgeons should be aware of the occurrence of multiple abscesses. Prompt and adequate antibiotic therapy accompanied by a mini-invasive approach, such as ultrasound-guided, laparoscopic, or video-retroperitoneoscopic drainage of the infectious focus, if indicated and feasible, is important to achieve a good outcome in the management of iliopsoas abscess.

Minimally invasive outpatient management of iliopsoas muscle abscess in complicated spondylodiscitis

BACKGROUND

Iliopsoas muscle abscess (IPA) and spondylodiscitis are two clinical conditions often related to atypical presentation and challenging management. They are both frequently related to underlying conditions, such as immunosuppression, and in many cases they are combined. IPA can be primary due to the hematogenous spread of a microorganism to the muscle or secondary from a direct expansion of an inflammatory process, including spondylodiscitis. Computed tomography-guided percutaneous drainage has been established in the current management of this condition.

AIM

To present a retrospective analysis of a series of 8 immunocompromised patients suffering from spondylodiscitis complicated with IPA and treated with percutaneous computed tomography-guided drainage and drain insertion in an outpatient setting.

METHODS

Patient demographics, clinical presentation, underlying conditions, isolated microorganisms, antibiotic regimes used, abscess size, days until the withdrawal of the catheter, and final treatment outcomes were recorded and analyzed.

RESULTS

All patients presented with night back pain and local stiffness with no fever. The laboratory tests revealed elevated inflammatory markers. Radiological findings of spondylodiscitis with unilateral or bilateral IPA were present in all cases. Staphylococcus aureus was isolated in 3 patients and Mycobacterium tuberculosis in 2 patients. Negative cultures were found in the remaining 3 patients. The treatment protocol included percutaneous computed tomography-guided abscess drainage and drain insertion along with a course of targeted or empiric antibiotic therapy. All procedures were done in an outpatient setting with no need for patient hospitalization.

CONCLUSION

The minimally invasive outpatient management of IPA is a safe and effective approach with a high success rate and low morbidity.

Chronic active non-lethal human-type tuberculosis in a high royal Bavarian officer of Napoleonic times-a mummy study

In paleopathology, morphological and molecular evidence for infection by mycobacteria of the M. tuberculosis complex (MTC) is frequently associated with early death. In the present report, we describe a multidisciplinary study of a well-preserved mummy from Napoleonic times with a long-standing tuberculous infection by M. tuberculosis senso stricto who died at the age of 88 years of focal and non-MTB related bronchopneumonia. The well-preserved natural mummy of the Royal Bavarian General, Count Heinrich LII Reuss-Köstritz (1763–1851 CE), was extensively investigated by macro- and histomorphology, whole body CT scans and organ radiography, various molecular tissue analyses, including stable isotope analysis and molecular genetic tests. We identified signs for a long-standing, but terminally inactive pulmonary tuberculosis, tuberculous destruction of the second lumbar vertebral body, and a large tuberculous abscess in the right (retroperitoneal) psoas region (a cold abscess). This cold abscess harboured an active tuberculous infection as evidenced by histological and molecular tests. Radiological and histological analysis further revealed extensive arteriosclerosis with (non-obliterating) coronary and significant carotid arteriosclerosis, healthy bone tissue without evidence of age-related osteopenia, evidence for diffuse idiopathic skeletal hyperostosis and mild osteoarthrosis of few joints. This suggests excellent living conditions correlating well with his diet indicated by stable isotope results and literary evidence. Despite the clear evidence of a tuberculous cold abscess with bacterioscopic and molecular proof for a persisting MTC infection of a human-type M. tuberculosis strain, we can exclude the chronic MTC infection as cause of death. The detection of MTC in historic individuals should therefore be interpreted with great caution and include further data, such as their nutritional status.

Percutaneous drainage of retroperitoneal abscesses: variables for success, failure, and recurrence

PURPOSE

We aimed to evaluate the success and failure rates and minor and major complications of percutaneous drainage of retroperitoneal abscesses.

METHODS

Between 1990 and 2010, percutaneously drained 170 retroperitoneal abscesses in 150 patients (83 males, 67 females, median age 44.2 years, age range, 1-86 years) were included retrospectively. Percutaneous drainage of retroperitoneal abscesses was performed under the guidance of ultrasonography and fluoroscopy or computed tomography. Six abscesses were drained via single needle aspiration whereas 164 abscesses were drained via catheters of 6-14 F calibre using the Seldinger technique.

RESULTS

When all retroperitoneal abscesses are considered, success rates were found as follows: 75.3% cure (128/170), 7.7% temporization (13/170), 4.1% palliation (7/170). Failure rate was 12.9% (22/170). Recurrence rate was 10.6% (18/170), and 13 of the recurred abscesses were treated via second session percutaneous drainage. Mortality rate was 2.7% (4/150).

CONCLUSION

Percutaneous drainage is the first treatment option for retroperitoneal abscesses due to procedural reliability, elimination of need for general anesthesia, better tolerability, and lower morbidity and mortality rates compared with the surgical methods. High cure, temporization, or palliation rates can be obtained via imaging-guided percutaneous drainage for all retroperitoneal abscesses with a safe access route.

[Acute abdomen - a practical approach]

CLINICAL PROBLEM

Acute abdomen describes a critical clinical condition which includes a heterogeneous group of clinical presentations. Several diseases require immediate surgical treatment. Therefore, fast radiological assessment is demanded.

STANDARD RADIOLOGICAL METHODS

Stable patients presenting at the emergency department with acute abdominal pain require an abdominal x‑ray, an ultrasound examination and/or a computed tomography (CT) scan, depending on the location and character of their pain. These standard radiological methods provide a quick differentiation between simple and complicated pathologies. Unstable patients should undergo immediate CT and, if positive, be sent directly to surgery.

METHODICAL INNOVATIONS AND ASSESSMENT

The ongoing technical developments in the field of computed tomography allow a quick and detailed characterization of pathologic conditions of the abdominal organs. A structured approach, based on the analysis of typical radiological signs and patterns, combined with the evaluation of extra-abdominal findings helps to assign the observed imaging findings to specific diseases.

RECOMMENDATION

A systematic 4‑point approach for structured analysis of specific and nonspecific imaging features and common pitfalls aids to choose the correct radiological method and help to narrow the broad spectrum of potential differential diagnoses.

Infections of the Spine

Pyogenic infections of the bony spinal column and the intervertebral discs are on a steady rise in an aging western population. Despite advanced medical imaging, this clinical entity of devastating consequences if missed, still presents a diagnostic conundrum and is plagued by an unacceptably long diagnostic delay. The aim of this article is to raise awareness of the heterogeneity of spinal infections paralleling the complex structure of the spinal column and neighboring soft tissues. Emphasis is placed on the clinical presentation and management of septic facet joints and psoas muscle abscesses associated with lumbar spondylodiscitis.

Surgical management of psoas abscess in the Human Immunodeficiency Virus era

OBJECTIVES

Thai aims of this study were to provide an epidemiological and microbiological analysis of psoas abscess in the human immunodeficiency virus (HIV)-infected population, and to describe the optimal investigative and management approach of this condition.

METHODS

A retrospective chart analysis of 20 patients with a diagnosis of psoas abscess admitted to a regional academic hospital from January 2012 to December 2014 was performed.

RESULTS

Twenty patients with psoas abscess were identified, of which 14 were HIV positive (70%) and five HIV negative (25%). One patient remained untested (5%). The mean CD4 count was 402 cells/mL (range 150-796 cells/mL, median 367 cells/mL). Acid fast bacilli were positive in psoas abscess aspirates in 13 cases (65%). Staphylococcus aureus and Escherichia coli were identified in 15% of cases. The radioisotope bone scan showed increased vertebral uptake in 10 patients (62.5%), with the lumbar spine (L1-L4) being most commonly involved (31%). There was a statistically significant increase in radioisotope uptake in the lumbar vertebrae in tuberculous psoas abscess than in pyogenic psoas abscess (p=0.003). Ultrasound-guided percutaneous drainage was used in 16 patients (80%) with a success rate of 87.5%; only two cases required repeat drainage (12.5%). Open drainage was used in four patients (30%) with a 100% success rate. There were no mortalities at 30-day follow-up.

CONCLUSION

Tuberculous psoas abscess from underlying vertebral osteomyelitis is more common than pyogenic psoas abscess. Ultrasound has high diagnostic accuracy and guides percutaneous drainage with excellent success rates. Ultrasound-guided percutaneous drainage should be regarded as the first-line therapeutic modality.

Percutaneous drainage of psoas and iliopsoas muscle abscesses with a one-step technique under real-time computed tomography fluoroscopic guidance

PURPOSE

To evaluate the utility and safety of drainage catheter installation for psoas/iliopsoas muscle abscesses using a one-step technique under the guidance of real-time computed tomography (CT) fluoroscopy.

MATERIALS AND METHODS

Ten psoas or iliopsoas muscle abscesses in 7 patients that were treated with percutaneous drainage were included in this study. All drainage procedures were carried out using a one-step technique under real-time CT fluoroscopic guidance.

RESULTS

The drainage catheter insertion was performed successfully with the one-step technique in all lesions. Improvements in the patients' symptoms and blood test results were seen after the drainage procedure in all cases. In addition, postoperative CT scans demonstrated that the abscesses had reduced in size or disappeared in all but one patient, who was transferred to another institution while the drainage catheter was still in place. No major complications were seen in any case.

CONCLUSION

The one-step procedure is simple to perform. The percutaneous drainage of psoas or iliopsoas muscle abscesses with the one-step technique under real-time CT fluoroscopic guidance is accurate and safe. Moreover, compared with the two-step technique the one-step procedure results in a shorter drainage procedure and exposes the patient and operator to lower amounts of radiation. J. Med. Invest. 63: 323-327, August, 2016.

'How to deal with this, that and the other?' An orthopaedic surgeon's unexpected encounter with a trio of problems in an elderly man

This is the first clinical report of a psoas abscess encountered during a routine hemiarthroplasty surgery for a femoral neck fracture in a man with a recent urinary tract infection. There were no prior symptoms to suggest a psoas abscess, which was present on the same side as the hip fracture, apart from a history of recurrent urinary tract infection. The surgery had to be altered intraoperatively to that of an excision arthroplasty of the displaced non-viable femoral head along with insertion of an antibiotic-impregnated cement spacer into the hip joint. Relevant microbiological studies confirmed a methicillin-sensitive Staphylococcus aureus psoas abscess with bacteraemia in addition to Staphylococcus bacteriuria, so 6 weeks of intravenous antibiotics were started. A planned second-stage hemiarthroplasty was undertaken and the patient recovered fully without complications. Primary infection of the urinary tract by S. aureus is rare. This case serves to remind clinicians that caution must be exercised in patients with recurrent infections, especially when such infections affect organs or areas close to the intended surgery site. This warrants thorough evaluation for an occult source of infection. A psoas abscess is an unusual cause of hip pain and accurate diagnosis relies on a high index of suspicion. The antibiotic-impregnated articulating cement spacer is a useful surgical adjunct after excision arthroplasty, it not only elutes a high concentration of antibiotics in the infected field, but also facilitates second-stage arthroplasty surgery by preventing muscle and soft tissue contractures from developing.

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.

A case report of a septic hip secondary to a psoas abscess

Psoas abscess was first described by Mynter in 1881. Though rare, its prevalence is increasing with advances in radiology and an increasing ability to accurately diagnose the condition. The symptoms of a psoas abscess can be insidious and nonspecific, and patients often present with a limp, fever, weight loss, and flank or abdominal pain.A psoas abscess can be classified as either primary or secondary depending on the presence or absence of an underlying disease. Primary psoas abscess has become more prevalent in the developed world, especially in immuno-compromised patients.We present the case of a 48 year old man who presented with fever, left hip pain and difficulty weight-bearing. He had a past medical history of chronic renal failure secondary to hypertension. Following laboratory, radiological and microbiological analyses the patient was diagnosed as having a Staphylococcus Aureus hip sepsis secondary to a psoas abscess.Psoas abscess should be included as a differential diagnosis in all patients presenting with hip pain and constitutional symptoms. The case is discussed with reference to the literature.

A case of a recurrent iliopsoas abscess masking a complicated appendicitis successfully treated by a laparoscopic approach

Iliopsoas abscesses can be caused by a secondary adjacent infectious source in the bowel. Complicated retroperitoneal abscesses involving the iliopsoas muscle and the lateral abdominal wall can develop as a serious complication of a perforated acute appendicitis. A 73-year-old man with a history of recurrent iliopsoas abscess was referred to our clinic. He had earlier been treated for recurrent right iliopsoas abscess by a percutaneous catheter and operative drainage and antibiotics in another hospital 3 times for 6 years at 2 or 3 year intervals. At the fourth episode, the abscess was proven to be caused by perforated appendicitis on laparoscopic exploration. The main drainage procedure of the abscess, as well as the appendectomy, was performed through a laparoscopic approach.

A case of primary psoas abscess presenting as buttock abscess

Buttock abscess is a rare clinical manifestation from unusual extrapelvic extension of psoas abscess. A 48-year-old woman presented with painful swelling of the buttock with a sense of local heat. Magnetic resonance imaging revealed a large subfascial abscess over the glutei muscles and was traced into the intraabdominal cavity over the iliac wing to the psoas muscle. Both the psoas abscess and the buttock abscess were evacuated via separate approaches. Empirical antibiotic therapy was delivered for 3 weeks. After 6 months, no evidence of recurrence was found. Psoas abscess could be included in the differential diagnosis of buttock abscess.

A female presenting with prolonged fever, weakness, and pain in the bilateral pelvic region: a case report

Introduction

Psoas abscess, a collection of pus in the iliopsoas compartment that has traditionally been classified as primary and secondary according to its origin.

Case presentation

48-year-old Turkish female presented to the department with fever, weakness and pain in the bilateral pelvic region. In contrast abdominal magnetic resonance, a collection compatible with the hyperintense abscess was observed in the right and left ilipsoas muscles. It was decided to simultaneously drain both abscesses of the case who had been using oral and intravenous broad-spectrum antibiotics for two months. No factors were detected in the microbiological reviews made on the abscess fluid of the operated case. The case was also examined in terms of tuberculosis and Crohn's disease and no findings were encountered to rise suspicions of such diseases.

Conclusion

An abscess of the psoas muscle was a rare entity. However, with the increased use of computed tomography scans to evaluate patients with unknown foci of sepsis, psoas abscesses now are diagnosed and reported more frequently. What should be done after diagnosis are, if possible, defining the infection factor, selecting the appropriate antibiotics and draining the abscess openly or percutaneously.

Psoas abscess in patients with an infected aortic aneurysm

BACKGROUND

Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. Infected aortic aneurysms could be complicated by psoas abscess.

METHODS

A retrospective chart review was conducted to examine the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with an infected aortic aneurysm.

RESULTS

Between 1996 and 2007, 40 patients (32 men) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). In 38 patients a blood or tissue culture had a positive result. The most common responsible pathogen was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One patient underwent endovascular repair but died. In-situ graft replacement was done in 32 patients. Persistent or recurrent infection occurred in seven (22%) of 32 operated on patients. The mortality rate was 86%, and the overall aneurysm-related mortality rate of in situ graft replacement was 22% (7/32). In eight (20%) of the 40 patients, aortic infection was complicated by psoas abscess. Infection complicated by psoas abscess was present in seven of 32 operated patients. It was associated with higher incidence of emergency operation, hospital mortality, prosthetic graft infection, and aneurysm-related mortality than infection without abscess.

CONCLUSION

Psoas abscess was common in patients with infected infrarenal aortic aneurysm. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.

Paraplegia caused by spinal infection after acupuncture

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.

Iliopsoas abscesses

Iliopsoas abscess is a relatively uncommon condition that can present with vague clinical features. Its insidious onset and occult characteristics can cause diagnostic delays, resulting in high mortality and morbidity. The epidemiology, aetiology, clinical features, and management of iliopsoas abscess are discussed.

Psoas abscess: the spine as a primary source of infection

STUDY DESIGN

Case report, literature review, discussion.

OBJECTIVES

To emphasize the role of the spine as primary source of infection for psoas abscess.

SUMMARY OF BACKGROUND DATA

Spine-associated psoas abscesses increase with more frequent invasive procedures of the spine and recurring tuberculosis in industrialized countries. Diagnosis is often delayed by misinterpretation as arthritis, joint infection, or urologic or abdominal disorders.

METHODS

We present six cases of psoas abscesses associated with spinal infections that were treated in our hospital from January to December 2001. Diagnostic and treatment concepts are discussed.

RESULTS

Our data emphasize the importance of the spine as primary source of infection and suggest an increase in the incidence of secondary psoas abscess. Treatment includes open surgical drainage and antibiotic therapy. In patients with high operative risk and uniloculated abscess, a CT-guided percutaneous abscess drainage can be sufficient. It is essential to combine abscess drainage with causative treatment of the primary infectious focus. Related to the spine, this includes treatment of spondylodiscitis or implant infection after spinal surgery. Usually, several operations are necessary to eradicate bone and soft-tissue infection and restore spinal stability. Continuous antibiotic therapy over a period of 2-3 weeks after normalization of infectious parameters is recommended.

CONCLUSION

The spine as primary source of infection for secondary psoas abscess should always be included in differential diagnosis. Because the prognosis of psoas abscess can be improved by early diagnosis and prompt onset of therapy, it needs to be considered in patients with infection and back or hip pain or history of spinal surgery.

Percutaneous drainage of abdominal abcess

The mortality in undrained abdominal abscesses is high with a mortality rate ranging between 45 and 100%. The outcome in abdominal abscesses, however, has improved due to advances in image guided percutaneous interventional techniques. The main indications for the catheter drainage include treatment or palliation of sepsis associated with an infected fluid collection, and alleviation of the symptoms that may be caused by fluid collections by virtue of their size, like pancreatic pseudocele or lymphocele. The single liver abscesses may be drained with ultrasound guidance only, whereas the multiple abscesses usually require computed tomography (CT) guidance and placement of multiple catheters. The pancreatic abscesses are generally drained routinely and urgently. Non-infected pancreatic pseudocysts may be simply observed unless they are symptomatic or cause problems such as pain or obstruction of the biliary or the gastrointestinal tract. Percutaneous routes that have been described to drain pelvic abscesses include transrectal or transvaginal approach with sonographic guidance, a transgluteal, paracoccygeal-infragluteal, or perineal approach through the greater sciatic foramen with CT guidance. Both the renal and the perirenal abscesses are amenable to percutaneous drainage. Percutaneous drainage provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses as well.

[Treatment of primary pyogenic abscess of the psoas: retrospective study of 18 cases]

The primitive abcess of psoas muscle is a rare affection which involves mainly the young. The authors report 18 cases of primitive pyogenic abcess of psoas collected during a period of six years in the urology service of UHC Ibn Rochd Casablanca. The purpose of this review is to discuss the different therapeutic attitudes. The study concerned 11 men and seven women, their mean age was 35 years. The mean delay of evolution was 45 days. The physical exam found a psoitisis (five cases) and a flunk swelling (14 cases). The ultrasound exam showed the collection which was hypoechogenic in seven cases and heterogenous in 11 cases. The CT scan showed an heterogenouse hypodense collection without enhansment in seven cases. The use of antibiotherapy alone (four cases) and percutaneous drainage (four cases) permitted the recovery just respectively in one and two cases. Fifteen patients (83%) were operated through a postero-lateral lumbotomy route without costal resection. The bacteriological exam of the pus found a Staphylococcis aureus (ten cases) and Escherichia coli (two cases). The evolution was favorable in 14 cases; one patient was dead at fifth day post operatively by heart infarction. For the authors, the surgical drainage remains the treatment of choice.

Psoas muscle abscess caused by Mycobacterium tuberculosis and Staphylococcus aureus: case report and review

Tuberculosis psoas muscle abscess is currently an uncommon clinical entity in industrialized countries. It was considered the predominant cause of these abscesses in the early part of the 20th century as a result of complicated Potts disease. We describe the case of a psoas abscess caused by the combination of Mycobacterium tuberculosis and Staphylococcus aureus. In this patient, the abscess was not associated with Potts disease but with osteomyelitis of the iliac crest, in which the evaluation with magnetic resonance imaging was very specific in determining the extent and regional spread.

Psoas abscess complicating Crohn's disease: report of a case

We describe herein the case of a psoas abscess complicating Crohn's disease, and present a review of the literature on this unusual disease entity. A 22-year-old Japanese man with a 5-year history of Crohn's ileocolitis presented with right lower abdominal and hip pain, and a diagnosis of right psoas abscess was subsequently made by abdominal computed tomography (CT). Following the administration of antibiotics and CT-guided percutaneous drainage of the abscess, the patient's symptoms temporarily improved; however, 2 weeks later, the abscess cavity was found to have extended around the periarticular tissue of the right hip joint. To prevent the development of septic arthritis of the hip joint, surgical drainage of the abscess cavity and ileocecal resection were immediately performed, after which the patient's condition greatly improved. The resected specimen showed Crohn's ileocolitis with an external fistula in the terminal ileum which was considered to have caused the psoas abscess. Since psoas abscess in Crohn's disease can result in serious complications such as septic arthritis of the hip joint if left untreated, aggressive treatment should be initiated without delay.

Crohn's disease of the small bowel

Crohn's disease of the small bowel frequently requires surgical intervention. While dealing with the disease complications that require intervention, treatment should be based on a long-term strategic plan that recognizes the likelihood of recurrent disease, repeat surgeries, and the possibility of a future ostomy. Resection forms the basis for surgical treatments, but strictureplasty, abscess drainage, intestinal and diversion bypasses also are used, selectively.

Diagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning

OBJECTIVES

To examine retrospectively the clinical presentations, microbiologic characteristics, and treatment outcomes of psoas abscess in patients with diabetes mellitus (DM) and to assess the usefulness of computed tomography and gallium-67 scanning in its early diagnosis.

METHODS

During a 9-year period, psoas abscesses in patients with DM were collected at a medical center. The clinical history and associated etiologic factors, microbiologic results, clinical outcomes, and hospitalization days were recorded. The use of imaging in the diagnosis of psoas abscess and other concomitant infectious lesions was also studied.

RESULTS

Fifteen patients with DM and psoas abscess (13 women and 2 men; mean age 58.7 +/- 9.0 years) were found. The most frequent symptom was fever (12 of 15). Of the six different microorganisms that grew in the blood and/or abscess cultures, Staphylococcus aureus was the most frequent (7 of 15). The most commonly associated pathologic finding was vertebral osteomyelitis (5 of 15). Computed tomography and/or magnetic resonance imaging confirmed the diagnosis of psoas abscesses in all 15 patients. The gallium-67 scan especially aided in the diagnosis of the patients who had initially been diagnosed as having fever of unknown origin (4 of 5) and in the diagnosis of concomitant lesions (9 of 12). Debridement or surgical drainage of the abscess was done in 12 patients. All the patients received adequate antibiotic treatment. However, the mortality rate was 20%. The average hospitalization stay was 42.7 +/- 20.7 days.

CONCLUSIONS

Psoas abscess in patients with DM is a disease with both diagnostic and therapeutic challenges. We found the infecting microorganisms to be variable and the mortality rate high.

Primary psoas abscess due to Fusobacterium nucleatum

A case of primary pyogenic psoas abscess due to Fusobacterium nucleatum is described. Clinicians must maintain a high index of clinical suspicion for the diagnosis of psoas abscess. Although Staphylococcus aureus accounts for most cases of primary psoas abscess, this report emphasizes the importance of bacteriological confirmation of the microorganism involved.

Retroperitoneal abscess presenting with a buttock swelling and anaemia

Images

An elderly man with an irritable hip

Images

Primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage

We report a case of primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage. A 56-year-old man presented at our hospital with lumbago, right-sided back pain, fever (temperature 38.5 degrees C) and chills. On physical examination, we found dark red skin, swelling, and tenderness localized at the right side at the back of his waist. Laboratory examination showed leukocytosis (white blood cell count 9700/mm3) with a leftward shift and elevated C-reactive protein (5.2 mg/dl). Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging revealed a hypodense lesion in the right iliopsoas muscle extending to the subcutaneous tissue. About 50 ml of thick yellow pus was obtained by ultrasonographically guided aspiration drainage. A drain catheter was inserted in the abscess cavity. Laboratory findings improved and clinical symptoms abated rapidly after drainage. On the twenty-first day after drainage, US and CT showed that the abscess was no longer present. The patient was discharged after 32 days of hospitalization. As possible primary diseases causing iliopsoas abscess, such as digestive tract disease, tuberculosis, and osteomyelitis, were not found, we diagnosed the disease as primary iliopsoas abscess. Although surgical drainage has been performed in most reported cases of iliopsoas abscess, this case report shows that ultrasonographically guided percutaneous drainage is also effective for treating primary iliopsoas abscess if it is diagnosed early enough.

Ilio-psoas abscesses: percutaneous drainage under image guidance

Over a 5-year period, 56 psoas abscesses occurring in 51 patients were managed by image-guided percutaneous drainage, either by needle aspiration (n = 10) or by catheter drainage (n = 46) in conjunction with medical therapy. Twenty-seven patients had tuberculous abscesses (bilateral in five) while 24 patients had pyogenic abscesses. Percutaneous treatment was successful in 16 of the 24 patients (66.7%) with pyogenic abscesses. The reasons for failure were co-existent bowel lesions, phlegmonous involvement of muscle without liquefaction, multiloculated abscess cavity and thick tenacious pus not amenable to percutaneous drainage. Surgery was required in seven patients, either for failed percutaneous drainage or for the management of co-existent disease. Percutaneous drainage was initially successful in all 27 patients of tuberculous psoas abscesses. However, eight patients presented with recurrence requiring repeat intervention. The average duration of catheter drainage was longer in patients with tuberculous abscess (11 days) than in patients with pyogenic abscess (6 days). Percutaneous drainage under image guidance provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses.

Psoas abscess with sepsis mimicking traumatic hemorrhagic shock after a fall

Abscess of the psoas muscle is infrequently encountered. An infectious emergency of this type usually presents in a nonspecific manner and thus poses a significant diagnostic challenge to the emergency physician. Diagnosis and specific treatment are often delayed, which can lead to increased mortality. This case report presents a patient with altered mental status and hypotension after a fall, who was initially managed as a trauma victim. Emergency department evaluation initially focused on a traumatic etiology of the above abnormalities. Subsequent assessment determined that the patient's condition was due to an underlying psoas abscess with sepsis. Appropriate anatomy, clinical presentation, and management are discussed in hopes of increasing physician awareness of this uncommon infectious condition.

Psoas abscess: making an early diagnosis in the ED

The variable and nonspecific presentations of psoas abscess, as well as its infrequent incidence in the emergency department (ED), can result in delayed diagnosis or misdiagnosis. Previous reports have not discussed the diagnostic difficulties of psoas abscess from the viewpoint of emergency physicians (EPs), especially in light of the widespread use of ED ultrasonography. This report describes a 1-year experience between November 1993 and October 1994, during which 10 ED patients were diagnosed to have psoas abscess; in 7 cases, diagnoses were established in the ED. Patients' mean age was 64.6 years (range, 46 to 76). Pain was the most frequently encountered symptom (80%), with 5 patients (50%) complaining of flank pain. The triad of fever, flank pain, and limitation of hip movement, which is specific for psoas abscess, was present only in 3 patients (30%). The mean duration of symptoms was 10.6 days (range, 1 to 30 days). The mean time spent to establish the diagnosis was 1.7 days (range, 0 to 7 days). The diagnosis of psoas abscess was established by ultrasound in 6 patients, by computed tomography (CT) in 3 patients, and by surgery in 1 patient. Four patients who presented with either sepsis and nonspecific abdominal/flank pain or sepsis and thigh swelling were diagnosed to have psoas abscess by ultrasound performed by EPs. Only 3 patients were admitted to the ED with an initial diagnosis of psoas abscess. The remaining 7 had the following initial ED diagnoses: 2, fever of unknown origin; 2, septic shock; 1, shock; 1, sepsis; and 1, peritonitis. All but one had manifestations of sepsis. Two patients died of septic shock; these two patients had failed to be drained well. This report also includes a discussion of the role of EPs and ultrasonography in the diagnosis of psoas abscess. With their alertness and their expertise in ultrasonographic techniques, EPs can make an immediate diagnosis and arrange an early drainage procedure. For patients with sepsis of unknown origin, prolonged fever of unknown origin, and some specific manifestations suggestive of psoas abscess, the screening ultrasound should scan not only abdominal solid organs but also peritoneal cavity and retroperitoneal space. In addition, a flow chart is presented for facilitating the diagnosis of psoas abscess in the ED.

Case report: abscess of the adductor muscles of the thigh--an unusual complication of Crohn's disease

The occurrence of a Crohn's abscess involving the hamstring muscle group has not been reported previously. We report this diagnosis in a patient with ileocolonic Crohn's disease who had presented earlier with a presacral abscess.

Percutaneous catheter drainage of tuberculous and nontuberculous psoas abscesses

OBJECTIVE

To assess the utility of percutaneous catheter drainage in the management of tuberculous and nontuberculous psoas abscesses associated without any bony involvement or with minimal bony lesions that could not cause vertebral instability.

MATERIALS AND METHOD

Eleven patients with psoas, iliopsoas and pelvic abscesses were drained under computed tomography and ultrasonography guidance.

RESULTS

There were 15 (10 tuberculous, 5 pyogenic) abscesses in 11 patients. Six of the tuberculous abscesses and one of the pyogenic abscess were associated with vertebral involvement. Vertebral lesions were located in one or two vertebrae without causing any serious disturbance in the vertebral stabilization. In one case, the abscess was bilateral. Nine cases were drained under computed tomography guidance, while two cases were drained under both computed tomography and ultrasonography guidance. One session drainage was sufficient for abscess resolution in uniloculated cases. In the two of four multiloculated cases, catheter drainage was performed twice. Relapse of the abscess was found in only one patient. The mean abscess volume was 520 ml and mean drainage duration was 12 days. None of the cases required surgery.

CONCLUSION

Percutaneous drainage, chemotherapy and additional external brace application with the cases associated with bony lesion may be used for treatment of tuberculous and nontuberculous unilocule and multiloculated abscesses.

Psoas abscess complicating Crohn's disease: report of two cases

We report herein the cases of two patients with Crohn's disease complicated by a psoas abscess. The first patient was a 29-year-old man who underwent definitive surgery after acute inflammation had been controlled by nutritional therapy. In the second patient, a 37-year-old man, the abscess required drainage under local anesthesia prior to surgery. Both patients have been free from recurrence of any abdominal symptoms for about 2 years since undergoing surgery. Although psoas abscess is still regarded as a rare complication, with the increasing prevalence of Crohn's disease in Japan it has become one of the most important complications requiring surgical intervention.

Haemophilus parainfluenzae: an unusual case of psoas abscess

A case of Haemophilus parainfluenzae psoas abscess in a previously healthy 36-year-old man is reported here. The absence of any bowel pathology indicates that abscess formation occurred secondary to haematogenous spread of the organism.

Tuberculous psoas abscess

Although its historical significance is well established, Mycobacterium tuberculosis today is considered an extremely rare cause of psoas abscess. Nontuberculous bacterial infection, most commonly secondary to an intraabdominal process but at times appearing without an identifiable source, is responsible for the vast majority of psoas abscesses. The recent resurgence of tuberculosis may portend another change in the etiologic trend of psoas abscess. It is essential that the emergency physician not only recognize the potentially subtle presentation of psoas abscess, but also include tuberculosis in the differential diagnosis of infectious causes of this entity. A case of tuberculous psoas abscess in an HIV-negative man is presented. A review of the anatomy, pathophysiology, clinical presentation, epidemiology, and treatment follows, highlighting the similarities and differences between tuberculous and nontuberculous psoas infection.