Psoas abscess - not as rare as we think?

Primary psoas abscess as a complication of postpartum: A case report

Primary psoas abscess is an uncommon yet critical factor contributing to postpartum sepsis. This report is of a case of postpartum primary psoas abscess in a 24-year-old Moroccan woman. After an uncomplicated vaginal delivery, a 24-year-old primiparous Moroccan woman presented to our hospital with a 3-week history of severe left-sided lower abdominal pain that radiated to the anterior aspect of the left thigh. She had been taking ciprofloxacin, metronidazole, and paracetamol for a week without any improvement. On examination, she was febrile and pale. The laboratory analysis revealed the presence of microcytic anemia, an elevated erythrocyte sedimentation rate, and an increased level of C-reactive protein. Computed tomography scans of the abdomen, and pelvis were conducted, revealing a substantial left psoas abscess. Under the guidance of computed tomography, anterior abdominal percutaneous drainage of the abscess was successfully performed. A pan-sensitive Streptococcus agalactiae strain was identified through culture of the specimen. The patient showed a favorable response to treatment with amoxicillin/clavulanate and gentamicin. This case illustrates that primary psoas abscess should be considered in cases of any postpartum infectious presentation.

Conservative Treatment of an Unusual Presentation of Iliopsoas Phlegmon Related to Infected Intrauterine Contraceptive Device

Iliopsoas phlegmon/abscess is uncommon, and individuals often present with nonspecific symptoms. Diagnosis is often delayed and almost always requires advanced imaging techniques such as computed tomography or magnetic resonance imaging. We report a case of a 51-year-old woman who presented with right lower limb swelling and associated rash with imaging demonstrating iliopsoas abscess secondary to an infected intrauterine contraceptive device. This rare case highlights the nonspecific presentation of iliopsoas abscess and the need to consider unusual sources of infection such as an intrauterine contraceptive device in women presenting with iliopsoas phlegmon and abscess.

Campylobacter fetus-induced primary psoas abscess in patient with gouty arthritis: A case report and literature review

RATIONALE

Campylobacter fetus is rare pathogen with high mortality rate in immunosuppressive hosts. This study aimed to summarize clinical and pathological presentation of C fetus induced psoas abscess.

PATIENT CONCERNS

A 66-year-old male patient with long medical history of poorly-controlled gouty arthritis and steroid intake complained of a severe low back pain. Physical examination showed tenderness in his psoas.

DIAGNOSES

The patient underwent puncture biopsy to the lesion in the psoas under ultrasound guidance. The lesion was indicated as abscess by pathological examination, and its pathogen was indicated as C fetus by the next generation sequencing.

INTERVENTIONS

Meropenem 1 g q8.h were administered intravenously for 10 days. Then the antibiotic treatment was switched to amoxicillin/clavulanate potassium 0.375g q.8.h and levofloxacin 0.5g q.d oral administration when discharge.

OUTCOMES

The patient's fever and low back pain improved and infectious parameters declined. He was discharged in good general condition with advice for further monitoring and therapy. In the first month follow-up, the patient did not report recurrence or aggravation of his symptoms.

LESSONS

C fetus should be noticed in immunosuppressive patient with exposure to livestock who present with rare systematic or local invasive infection. We advocated the meropenem for the first-line treatment against C fetus.

Full Endoscopic Treatment for a Fibrosis Complication after Psoas Abscess

BACKGROUND

Psoas abscess is a challenging disease that may sometimes lead to a devastating prognosis. Early diagnosis and treatment are mandatory for better results in their treatments and to avoid complications.

PURPOSE

There is no article regarding a fibrosis treatment of the psoas muscle with a psoas abscess that is treated with full endoscopic debridement (FED).

STUDY DESIGN

a case report and literature review.

RESULT

we successfully treated this case, who suffered from psoas fibrosis with a clinical and MRI diagnosis, with full endoscopic debridement.

CONCLUSIONS

FED is a viable alternative to open debridement for this rare complication of a psoas muscle abscess.

Epidural phlegmon and iliopsoas abscess caused by Salmonella enterica bacteremia: A case report

INTRODUCTION AND IMPORTANCE

Iliopsoas abscesses (IPA) are rare and typically present with a non-specific triad of fever, back pain, and antalgic gait. Staphylococcus aureus is the organism responsible for nearly 90 % of IPA cases. We present a case of primary IPA with progression to osteomyelitis and discitis due to Salmonella enterica bacteremia, an exceedingly rare etiology occurring in an otherwise healthy individual.

CASE PRESENTATION

This patient presented with fever, back pain, and hip pain. Initial imaging and laboratory workup did not reveal any source of infection. He became septic within 72 h of admission, and blood cultures were confirmed as Salmonella enterica. However, the etiology of the infection remained unclear. Computed Tomography (CT) imaging revealed a right-sided psoas abscess measuring 7 mm × 7 mm and an epidural phlegmon. He was discharged home with intravenous ceftriaxone and levofloxacin. However, the patient was readmitted due to L2-L3 osteomyelitis and discitis with an eccentric disc bulge causing compression of the right L3 nerve root and neutropenia.

CLINICAL DISCUSSION

This case in unique in the fact that this occurred in a healthy patient with no significant risk factors or exposure to this bacteria. Additionally, this case highlights the rapid progression of IPA and the spread to adjacent spinal structures with the potential to cause nerve compression with successful medical management.

CONCLUSION

Salmonella enterica is rare cause of iliopsoas abscess. This case emphasizes the importance of including iliopsoas abscesses as a differential diagnosis in patients with a high index of clinical suspicion.

Primary psoas tuberculosis abscess with an iliac bone lytic lesion: a case report

BACKGROUND

Primary psoas tuberculosis is the presence of "Koch's bacillus'' within the iliopsoas muscle caused by hematogenous or lymphatic seeding from a distant site. Muscular tuberculosis has relatively low prevalence in comparison with other cases of extrapulmonary tuberculosis, which explains the difficulties in establishing the diagnosis.

CASE PRESENTATION

In this report, we present a challenging diagnostic case of primary psoas tuberculosis in a 38-year-old middle eastern female from southern Syria. The diagnosis was based on the clinical orientation, the observation of pulmonary lesions on the computed tomography scan, and the necrotic signs in the vicinity of the infected area. Despite the misleading primary false-negative results, the final diagnosis was reached after sufficient repetition of tuberculosis-specific testing. The patient was treated with isoniazid-rifampin-pyrazinamide-ethambutol for 2 months, then isoniazid and rifampin for 7 months, with full recovery in follow-up.

CONCLUSIONS

This case highlights the importance of a clinical-based approach in the treatment of patients with psoas abscesses, especially in areas with high tuberculosis prevalence.

Characteristics and Outcomes of Psoas Abscess: Experience From a Tertiary Care Center in North India

Background

Psoas abscess (PA) is an uncommon disease involving infection of the psoas muscle with abscess formation. The evidence concerning clinical and diagnostic characteristics of PA and its outcomes is limited. The literature is heterogenous, with varying presentations and outcomes in different regions worldwide. We present a retrospective analysis of the clinical, radiological, and laboratory characteristics of PA, its management, and outcomes from a tertiary care center in North India.

Methodology

We reviewed the clinical records of confirmed cases of PA treated in our institute from January 2016 to December 2020 with a minimum follow-up of one year. Further, we performed a descriptive analysis of demographic characteristics, clinical features, laboratory parameters, radiological investigations, the basis of diagnosis confirmation, causative microorganisms, definitive management, treatment outcomes, and complications.

Results

We reviewed 33 cases with a mean age of 29.9 ± 16.8 years. Overall, 48.4% of PAs were right-sided, and 24.2% were bilateral. Abdominal discomfort was the most common presenting symptom. Blood laboratory parameters were mostly within the near-normal range except for the elevated erythrocyte sedimentation rate, C-reactive protein, and neutrophil-to-lymphocyte ratio. Ultrasonography was the most commonly performed radiological investigation and was the basis of diagnosis confirmation. Mycobacterium tuberculosis was the most common causative microorganism. Most patients required percutaneous drainage, and around one-fourth required open drainage. All patients had symptomatic as well as radiological improvement and no major complications.

Conclusions

Tuberculosis is the most prevalent cause of PA in the North Indian population. Most patients respond well to the less invasive treatment with percutaneous therapeutic drainage and antitubercular drugs, with few patients requiring open drainage. However, tissue diagnosis may remain inconclusive in a few patients, and antitubercular treatment may need to be initiated based on the clinicoradiological evaluation. Nevertheless, the rate of complications is low, with nil mortality probably related to the mild-to-moderate disease course of tuberculosis.

A Case of Recurrent Right-Sided Loculated Pleural Effusion With Right Psoas Abscess

Tuberculous psoas abscess is a rare entity and is mostly associated with tuberculosis of the spine in view of the close vicinity. It is mostly secondary to direct extension from adjacent structures. Here we present a case of a young man who presented to us with a persistent swelling in the right side of the back and with a history of taking anti-tubercular drugs for six months. He was finally diagnosed with a recurrent right-sided loculated pleural effusion with a right-sided psoas abscess. Surgical drainage of the psoas abscess was done and he was again started on anti-tubercular therapy (ATT).

Psoas abscess during treatment with intravenous tocilizumab in a patient with rheumatoid arthritis: a case-based review

Interleukin-6 receptor antagonist tocilizumab is a biologic drug used for treating patients with active rheumatoid arthritis (RA) who failed to respond to synthetic or other biologic disease-modifying antirheumatic drugs or where they were contraindicated. Interleukin-6 receptor blockade results in a decrease of disease activity but has some potential adverse effects, the most common being infections. We present a case of a 75-year-old female patient with long-lasting RA, several comorbidities and multiple prior therapies, who developed back pain and general malaise during tocilizumab intravenous treatment. The laboratory findings were typical of toxemia, and the imaging findings revealed large psoas muscle abscess. Surgical and antibiotic treatment was performed with a good outcome. To our knowledge, this has been the first case of a psoas abscess in a patient with RA treated with tocilizumab described in the literature so far. We also present a review of the literature regarding infection, and particularly abscess formation in patients treated with biological disease-modifying antirheumatic drugs, tocilizumab included.

Psoas Abscess Presented as Right Hip Pain in a Young Adult With Crohn's Disease

A 27-year-old man with a past medical history of Crohn's disease presented in the Emergency Department complaining of right hip pain that has been going on for one month. At presentation, the patient was tachycardic. Physical examination revealed a positive psoas sign. Laboratory tests showed elevated white blood cells, C-reactive protein, and erythrocyte sedimentation rate. Computed tomography of the abdomen and pelvis revealed ileo-psoas fistula and psoas abscess. This rare case aims to provide awareness that intra-abdominal pathology should always be suspected in patients with referred hip pain and Crohn's disease. A thorough physical examination including maneuvers for assessment of possible iliopsoas inflammation should be effectively performed at the bedside to determine the likelihood of the condition and proper imaging should follow to confirm the diagnosis.

Psoas Abscess Caused by Candida Glabrata: A Case Report

Psoas abscess caused by Candida is an uncommon condition. We report a case of psoas abscess caused by Candida glabrata, which was completely resolved with drainage and oral voriconazole. Because of the nonspecific clinical presentation, the diagnosis of psoas abscess can be a challenge. Prompt suspicion, with early diagnosis and drainage with an appropriate antifungal agent, seems to improve the clinical outcome.

Atypical Cause of Sepsis from Bilateral Iliopsoas Abscesses Seeded from Self-mutilation: A Case Report

INTRODUCTION

An iliopsoas abscess (IPA) is an abscess located adjacent to the iliopsoas and iliacus muscles. Although rare, their variable clinical presentations often lead to a delay in diagnosis.

CASE REPORT

We present a case of sepsis secondary to multiple IPAs that was missed despite multiple healthcare encounters. The patient had no classical risk factors for an IPA, and the abscesses were found to be seeded via hematogenous spread from self-inflicted cutting.

CONCLUSION

This case illustrates the importance of obtaining a complete history, including psychiatric screen, and performing a thorough examination when evaluating patients with low back pain to rule out overlooked sources of bacteremia.

Primary tuberculous psoas abscess as a postpartum complication: Case report and literature review

BACKGROUND

Primary psoas abscess is an unusual clinical entity rarely encountered in the postpartum period. Only seven cases have been reported to date. Here, we present a woman with a primary psoas abscess caused by Mycobacterium tuberculosis and occurred 2 months following a normal vaginal birth. We highlight the difficulties in the management of this uncommon condition in light of the relevant literature.

CASE DESCRIPTION

A 34-year-old woman who was previously healthy was presented at 2 months' postpartum with important right sciatica and low back pain without fever. Examination of the abdomen revealed tenderness in the right iliac fossa but obstetric/gynecologic and neurologic examinations were normal. The patient had an elevated C-reactive protein level and computed tomography (CT)-scan demonstrated a large psoas abscess on the right side without sacroiliac or spine abnormalities. Initial posterior lumbar percutaneous drainage was useful, but no pathogens were identified. The patient was discharged home with oral antibiotics therapy (amoxicillin/clavulanate and metronidazole). Four weeks later, the follow-up CT-scan showed a re-accumulation of the abscess cavity. Subsequently, the patient underwent a right anterolateral laparotomy with a retroperitoneal approach for abscess drainage. Again, no microorganisms were found. However, diagnosis of tuberculosis was established on histopathologic study. She was successfully treated with antituberculous drugs with a good outcome.

CONCLUSIONS

Most primary psoas abscesses present with a delay in diagnosis because of the rarity of this infectious disease, the lack of specific symptoms and signs, and its similarity to many differential diagnoses. When suspected, CT-scan and/or magnetic resonance imaging help in making an accurate diagnosis and facilitate percutaneous or open surgical drainage of the abscess. Correct and fast identification of the microorganisms in addition to appropriate usage of antibiotic regimen improves the outcome.

Rare Case of Iliopsoas Abscess Secondary to Mucinous Adenocarcinoma of the Colon: A Case Report

Introduction

Iliopsoas abscess (IPA) has varied clinical symptomatology and various clinical disorders may mimic it. Tuberculosis of spine is the most common source of secondary IPA in the developing countries. However, IPA may be rarely caused by colon cancer which is the most common gastrointestinal malignancy. A mixed culture gives an indication of gastrointestinal or genitourinary etiology. We present here, a rare case of an 86-year-old patient with IPA secondary to adenocarcinoma of colon.

Case Report

An 86-year-old female presented with pain in the right thigh in February 2014. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen confirmed the clinical suspicion of right IPA which was drained surgically. Intraoperatively, mucinous material was noted, emerging from a small opening in a rounded structure located lateral to the psoas muscle, which could not be identified. On post-operative day 2, the right flank swelling recurred. Culture reports showed a polymicrobial infection with viridans group Streptococci and Pseudomonas aeruginosa. The abscess was re-explored and biopsy of the opening was taken. Histopathology of the tissue sample revealed metastatic cells of a mucin-secreting adenocarcinoma that had infiltrated the psoas muscle with a secondary pyogenic abscess. On reviewing the CT scan, there was a suspicion that the abscess was communicating with a tumor in the colon. No further active intervention was done for the tumor in view of advanced age and stage of tumor. The patient had significant pain relief and was able to resume walking. The infection resolved with 6 weeks of oral linezolid and ciprofloxacin. The patient died 8 months later secondary to metastasis.

Conclusion

Although the diagnosis of IPA does not pose problems, diagnosing secondary IPA requires a high index of clinical suspicion. A Gram-negative culture must raise the suspicion of gastrointestinal or genitourinary pathology. Colon carcinoma, although extremely rare, can lead to secondary IPA. CT and MRI though extremely useful, may not pick up the pathology and a definitive diagnosis of colon neoplasia perforating into the psoas muscle may be evident only intraoperatively. Atypical presentation may delay the diagnosis of colon cancer and subsequently result in higher morbidity and mortality.

A Devasting Course of an Iliopsoas Muscle Abscess Subsequently Leading to Septic Shock, Septic Hip Arthritis, and Extended Gluteal Soft Tissue Necroses in an Elderly Immunocompromised Patient with Multiple Carcinomas: A Case Report and Brief Review of Literature

BACKGROUND

A devasting course of Iliopsoas Muscle (IPM) abscess remains a challenging therapeutic problem.

METHODS

A 69-year-old polymorbid male had a history of multiple carcinomas and presented with advanced stage of septic shock due to a right IPM abscess which communicated with the right hip joint and subsequently led to septic hip arthritis accompanied with post-infectious right gluteal deep soft tissue necroses. Management of surgical treatment included abscess revision, coverage with the use of Long Head Biceps Femoris Muscle (LHBFM) 180° turnover flap, and creating a Girdlestone resection-arthroplasty.

RESULTS

After a duration of patient's hospitalization of six months that included the necessity of artificial respiration over two months accompanied with in summary 18 required surgical procedures, the patient could be recovered successfully regarding his polymorbidity and his low-demand claims in activities of daily living with his Girdlestone resection-arthroplasty.

CONCLUSION

Recovery of immunocompromised patients with those life-threatening situations can only be achieved by an interdisciplinary management. The LHBFM 180° turnover flap can be useful for filling off post-infectious deep soft tissue cavities communicating with the hip joint. The definitive Girdlestone resection-arthroplasty for treatment of septic hip arthritis is the method of choice for mobilization of elderly polymorbid patients with low demand claims in their activities of daily living.

Cerebrospinal fluid infection after lumbar nerve root steroid injection: a case report

A 45-year-old woman was admitted due to severe headache and neck stiffness. She had visited a local clinic for back pain and received a lumbar nerve root steroid injection 10 days before admission. Computed tomography and magnetic resonance imaging showed psoas abscess, pneumocephalus, and subdural hygroma. She was diagnosed with psoas abscess and meningitis. The abscess and external ventricle were drained, and antibiotics were administered. Unfortunately, the patient died on hospital day 19 due to diffuse leptomeningitis. Lumbar nerve root steroid injections are commonly used to control back pain. Vigilance to "red flag signs" and a rapid diagnosis can prevent lethal outcomes produced by rare and unexpected complications related to infection. Here, we report a case of fatal meningitis after infection of the cerebrospinal fluid following a lumbar nerve root steroid injection.

Primary psoas abscess caused by group A streptococcus in a child: Case report with microbiologic findings

Primary abscess of the iliopsoas muscle in children is uncommon, especially due to Streptococcus pyogenes (group A streptococcus: GAS), which causes a variety of diseases ranging from pharyngitis to invasive life-threatening infection. We present primary iliopsoas abscess in a nine-year-old boy presenting with fever, mild disturbance of consciousness, limp, and pain in the right loin. Magnetic resonance imaging and isolation of GAS from both blood and abscess samples led us to the confirmative diagnosis. The patient recovered after treatment comprising drainage and intravenous antibiotics. The CovRS system is one of the best-characterized systems with two-component signal transduction in the GAS, and mutations in covRS induce overproduction of various virulence factors that play a crucial role in invasive GAS infection. RopB, also known as a GAS regulator, influences the expression of multiple regulatory networks to coregulate virulence factor expression in GAS. In the present case, sequence analysis revealed the isolated GAS as emm type 6 with alterations in covS, whereas the covR and ropB genes were intact. The covS alterations might have influenced the virulence of the strain causing this severe GAS infection.

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.

Psoas muscle abscess simulating acute appendicits: A case report

INTRODUCTION

Psoas abscess is a rare clinical entity with vague symptomatology. We report a psoas abscess that simulated symptoms of acute appendicitis.

PRESENTATION OF CASE

A twenty-five year old male presented pain irradiating to the right iliac fossa and lumbar region associated with thigh flexion. Laboratorial exams revealed leukocytosis with a neutrophil shift to the left. Abdominal Ultrasound showed significant intestinal distension and a small quantity of free fluid at the right iliac fossa. Laparotomy and an appendectomy were performed. During immediate post-operative, the patient evolved with worsening of the pain and the leukocytosis, therefore, we chose to maintain his antalgic posture. An abdominal Computerized Tomography scan with contrast was solicited, revealing an increase of the iliac and psoas muscles of the right side, and multiple bacterial focuses. A retroperitoneal access was performed and 300ml of purulent secretion was drained. Afterwards, we implanted a Penrose Drain. The patient had a good post-op evolution, being discharged 7days after the drainage.

DISCUSSION

The psoas muscle is a flexor of the thigh. Psoas abscess is an underdiagnosed condition, its main treatment is surgery associated with antibiotic therapy. CT scan seems to be the best choice of diagnostic image exam, although some authors prefer the nuclear magnetic resonance.

CONCLUSION

The psoas muscle abscess is uncommon and poorly characterized in its etiology, clinical associations, and its therapeutic approach. On the other hand, acute appendicitis is the most common abdominal emergency, with a 7% death rate, and surgery is its main treatment.

A 15-year-old girl with fever and abdominal pain

We present a case of a previously healthy 15-year-old girl with fever, right lower quadrant pain, and hip pain. Her history was notable for a recent laparoscopic appendectomy that was complicated by the development of intraabdominal abscesses. She reported normal bowel movements and good appetite on a regular diet, although she did endorse a recent 5-kg weight loss. Further investigation and examination revealed a diagnosis of Crohn's disease with recurrent psoas muscle abscess as the etiology of her pain and fevers. Psoas abscess is a rare complication of Crohn's disease, and vague presenting symptoms may complicate its diagnosis. This case demonstrates the importance of maintaining a broad differential diagnosis when treating a child presenting with abdominal pain and fever.

An easily overlooked presentation of malignant psoas abscess: hip pain

Psoas abscess is a rare infectious disease with nonspecific clinical presentation that frequently causes a diagnostic difficulty. Its insidious onset and occult characteristics can cause diagnostic delays. It is classified as primary or secondary. Staphylococcus aureus is the most commonly causative pathogen in primary psoas abscess. Secondary psoas abscess usually occurs as a result of underlying diseases. A high index of clinical suspicion, the past and recent history of the patient, and imaging studies can be helpful in diagnosing the disease. The delay of the treatment is related with high morbidity and mortality rates. In this paper, 54-year-old patient with severe hip pain having an abscess in the psoas muscle due to metastatic cervical carcinoma is presented.

Management of primary iliopsoas abscess in an immunocompetent patient followed by streptococcal toxic shock syndrome: A case report

Objectives:

Clinical diagnosis of iliopsoas abscess can be challenging, as this pathology often presents without obvious focal findings. Iliopsoas abscess should thus be a differential diagnosis for patients presenting with fever of unknown origin.

Patient and methods:

A 62-year-old healthy Japanese man showed primary iliopsoas abscess of Klebsiella pneumoniae complicated by shock after a complete course of treatment for streptococcal toxic shock syndrome. Successful treatment was achieved with culture-driven antibiotic selection and delayed drainage.

Results:

This case demonstrates the importance of identifying the causative microorganisms in iliopsoas abscess to guide therapy. The standard treatments for iliopsoas abscess are antibiotics and drainage of the abscess. Management of this case included successful antibiotic use along with delayed drainage.

Conclusion:

This case report advances the knowledge on the etiology of iliopsoas abscess and sheds light on the need for scientific development of a treatment strategy.

Infectious Spondylodiscitis, Epidural Phlegmon, and Psoas Abscess Complicating Diabetic Foot Infection: A Case Report

Few published case reports have cited vertebral osteomyelitis as a sequela of a diabetic foot infection. The purpose of the present report is to increase awareness of a potentially severe complication of diabetic foot ulceration: vertebral osteomyelitis and associated pathologic features. We present the case of a 63-year-old male with right calcaneal osteomyelitis who developed acute onset lower back pain with concomitant fever and chills. Magnetic resonance imaging revealed L4-L5 vertebral osteomyelitis, a T9-L1 epidural abscess, and a right psoas muscle abscess secondary to hematogenous seeding from the calcaneus. The patient underwent right partial calcanectomy, spinal and right psoas abscess incision and drainage, and direct lumbar interbody fusion of L4-L5 with a right iliac crest allograft. All bone, blood, and abscess cultures were positive for methicillin-resistant Staphylococcus aureus. After the surgery, the patient's pain resolved in his back and hip and he regained full right lower extremity function. The 1-year follow-up examination revealed that the patient had vertebral arthritis but was able to perform his activities of daily living with a walker and cane. It is important to recognize the potential complications of diabetic foot ulcerations and be aware of the identifying symptoms and treatment options for this condition to prevent significant morbidity and mortality.

Metallosis, psoas abscess and infected hip prosthesis in a patient with bilateral metal on metal total hip replacement

Metal on metal hip (MoM) resurfacing / replacement has recently been one of the most discussed topics in orthopaedics. Significant revision rates and complications are associated with MoM. We report a patient presenting with infection of a total hip prosthesis in conjunction with a psoas abscess in which the presentation is complicated by radiological evidence of suspected metallic debris in the lower limb tissues and elevated chromium and cobalt levels, suggestive of metallosis secondary to MoM.

Increasing incidence of iliopsoas abscesses with MRSA as a predominant pathogen

OBJECTIVES

Iliopsoas abscesses (IPAs) are rare infections involving purulence within the muscles of the iliopsoas compartment, seldom due to Methicillin-resistant Staphylococcus aureus (MRSA) historically. This study was designed to evaluate the clinical characteristics and outcomes of patients with IPAs.

METHODS

A retrospective analysis of the demographics, clinical presentation, microbiologic data and treatment modalities among patients with IPAs from 1993 to 2007 at The Johns Hopkins Hospital was performed.

RESULTS

Among 61 patients with IPAs, infection rates increased from 0.5 cases/10,000 admissions (1993-2004) to 6.5 cases/10,000 admissions (2005-2007) (P < 0.001). An adjacent infectious focus was identified in 80% of patients, from skeletal (48%), intra-abdominal (23%), vascular (5%), genitourinary (3%), and cutaneous sources (2%). During 2005-2007, MRSA became a predominant pathogen, accounting for 25% of all cases and 37% of cases with a definitive microbiologic diagnosis (P = 0.006). Patients with IPAs >2 cm were more likely to undergo drainage, with trends toward longer hospitalizations, longer antibiotic courses, and increased odds of securing a definitive microbiologic diagnosis.

CONCLUSIONS

Since 2005, rates of IPA have dramatically increased, with MRSA now the leading cause of infection. Knowledge of common pathogens should guide antimicrobial therapy including empiric coverage for MRSA in institutions with similar populations, especially if culture data are not available.

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.

Iliopsoas abscesses: diagnostic, aetiologic and therapeutic approach in five patients with a literature review

OBJECTIVE

Iliopsoas abscess is a relatively rare disease. Many cases present atypical clinical characteristics. Iliopsoas abscess can be primary or secondary to gastrointestinal and genitourinary infections and in developed countries most of these abscesses are of non-tuberculous aetiology. A high index of clinical suspicion, the past and recent history of the patient and imaging studies can be helpful in diagnosing the disease. Early treatment with drainage, surgery or appropriate antibiotic therapy is necessary before the sepsis becomes lethal. The purpose of the study was to present five cases with iliopsoas abscesses based on the rarity of this clinical entity.

MATERIAL AND METHODS

Five cases with iliopsoas abscess, treated during the past 10 years were analysed retrospectively, with emphasis on the diagnostic and therapeutic approach to the disease.

RESULTS

Three out of five cases were primary abscesses; one was of tuberculous aetiology and one secondary to bowel perforation due to a tumour. Staphylococcus aureus was the main bacterium in primary abscesses. Percutaneous drainage with administration of appropriate antibiotics was the main treatment. The secondary psoas abscess was treated successfully with surgery. Owing to long-standing septic and atypical symptoms before admission, one case had a lethal course, despite the early hospital diagnosis and treatment.

CONCLUSIONS

The aetiology of iliopsoas abscess can vary, disposing to a high index of suspicion. Imaging studies can confirm the diagnosis early, and differentiation between primary and secondary type determines the most appropriate kind of treatment.

Group C streptococcal psoas abscess associated with a homolateral hip joint prosthesis infection: a case report

An abscess in the psoas muscle is rare and frequently misdiagnosed. A delay in the diagnosis can increase its mortality rate. Some clinical signs can help the clinician but they all are not always present, and not at the same time. We describe in this paper a case report of an association between a psoas abscess and a homolateral hip joint prosthesis infection. It was suspected because of no improvement in clinical state despite treatment of the abscess by antibiotics and drainage, and it required finally other complementary therapeutic solutions. The pathogenic microorganism was a group C streptococcus. We discuss all these points and thereafter we suggest some recommendations for the clinician.

Fever, pain, and a limp: a case of a psoas and spinal epidural abscess caused by methicillin-resistant Staphylococcus aureus in a diabetic patient

Psoas and spinal epidural abscesses are rare conditions that are infrequently found occurring simultaneously in the same patient. This case presents an 18-year-old female with diabetes mellitus who presented with fever and leg pain. Blood and urine cultures were positive for methicillin-resistant Staphylococcus aureus. A CT scan of the abdomen showed a large psoas abscess with loculations extending and involving the spinal canal. The abscesses were drained and the patient completed a 6-week course of intravenous antibiotics with remarkable improvement of her clinical condition. The diagnosis of psoas and epidural abscesses is difficult and can be overlooked or delayed as a result of their vague clinical manifestations and their rarity, which leads to a lack of clinical suspicion.

Percutaneous drainage of psoas abscess under real-time computed tomography fluoroscopic guidance

OBJECTIVES

The goal of our study was to determine the usefulness of percutaneous abscess drainage under guidance of computed tomography (CT) fluoroscopy.

MATERIALS AND METHODS

Our subjects were 21 patients (seven women, 14 men; mean age 64 years; age range 30-87 years) who had undergone percutaneous drainage of 26 psoas abscess lesions under CT fluoroscopic guidance between May 2001 and January 2008. Drainage methods involved a needle puncture, insertion of a guidewire, serial dilations, and the exchange of the needle with a drainage tube. The procedures were guided by use of a helical CT scanner that provided real-time fluoroscopic reconstruction.

RESULTS

Percutaneous drainage under real-time CT fluoroscopic guidance was successfully performed in every procedure. Use of real-time CT fluoroscopy allowed rapid assessment of needle, guidewire, and catheter placement. No patient had serious complications related to the drainage procedure. The mean procedure time required to drain one lesion was 35.6 +/- 13.6 min. Mean period after the drainage procedure until complete disappearance of the abscess as confirmed by CT was 12.4 +/- 10.0 days (range 3-46 days).

CONCLUSION

CT fluoroscopy is useful in achieving accurate and safe drainage of abnormal psoas fluid collections.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

Primary psoas abscess due to Streptococcus milleri

Primary Psoas abscess (PPA) is an infrequent clinical entity with obscure pathogenesis and vague clinical presentation. High index of clinical suspicion is required for the diagnosis of psoas abscess. We also emphasises the importance of bacteriological confirmation of microorganism involved, although Staphylococcus aureus remains the commonest pathogen. We report an extremely rare case of PPA caused by Streptococcus milleri. Only one case has been reported in literature so far.

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.