Case of iliopsoas abscess that was markedly recovered after percutaneous and surgical drainage in a patient with poorly controlled type 2 diabetes
Atsushi ObataHideaki KanetoShinji KameiMasashi ShimodaTomohiko KimuraHidenori HirukawaSeizo OkauchiFuminori TatsumiKenji KoharaTomoatsu MuneKohei Kaku
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We experienced a case of iliopsoas abscess which was markedly recovered after percutaneous and surgical drainage in a subject with poorly controlled type 2 diabetes. When iliopsoas abscess is suspected, physicians should survey patients by CT scan or MRI and should consider invasive treatment including surgical drainage. A 77-year-old woman who had been suffering from type 2 diabetes for 12 years, which was poorly controlled (glycated hemoglobin was fluctuating around 9%), complained of left lower quadrant abdominal pain and visited the hospital. Although she was afebrile, laboratory test showed elevated white blood cells (12,000/μL) and C-reactive protein (31.68 mg/dL), and she was hospitalized. On physical examination, small wounds were confirmed on her both elbows, as she fell down and hit her hips several times a week before the onset of abdominal pain. Wounds were 2–3 cm in diameter and partially wet, which had already become dried scabs in most parts. Chest and abdominal X-rays were normal, and there was no significant finding in abdominal ultrasonography. Urinary test was negative for urinary tract infection. As the patient had a history of Stevens Johnson syndrome after contrast agent use, non-enhanced computed tomography (CT) scan was carried out, which showed no specific finding. On the day of admission, cefmetazole (1 g) was given once, but high-grade fever over 40°C and shivering developed, suggesting that the patient had become septic. Therefore, we started tazobactam/piperacillin (4.5 g/every 8 h) and vancomycin (0.5 g/every 12 h). Transthoracic ultracardiogram did not show any sign of infectious endocarditis. In lumber magnetic resonance imaging (MRI) on the fourth day after admission, a high-intensity area in the left iliopsoas muscle at the L4/5 level was observed, which led to the diagnosis of iliopsoas abscess (Figure 1a). Methicillin-sensitive Staphylococcus aureus was detected in blood culture. Therefore, vancomycin was discontinued. On CT on day 7, the left iliopsoas muscle was markedly enlarged (Figure 1b). MRI on day 11 showed that the lesion was multiocular (Figure 1c). As white blood cells were elevated to 25,000/μL and did not decrease even after continuous antibiotic treatment, percutaneous drainage under CT guidance was carried out (Figure 1d). Approximately 8 mL of yellowish pus was aspirated, which was found to be positive for methicillin-sensitive S. aureus. In addition, for the complete recovery from such an abscess, the patient underwent surgical drainage on day 15. After then, her general status was improved, tazobactam/piperacillin was de-escalated to sulbactam/ampicillin (3 g/every 12 h) on day 22 and the antibiotic was changed to oral administration of clavulanic acid/amoxicillin on day 41. Finally, C-reactive protein and white blood cells were decreased to 1.3 mg/dL and 5,100/μL, respectively, and she was discharged without any complications. Iliopsoas abscess is an uncommon disease, which is difficult to diagnose. Risk factors include diabetes and various forms of immunosuppression, such as alcohol addiction, steroid use, malnutrition and HIV infection. The classic presentation includes fever, and back and limb pain1. In the present case, there was a slight delay in the diagnosis, as the most prominent symptom was abdominal pain, which was not typical for iliopsoas abscess, and we could not carry out enhanced CT because of a past history of Steven Johnson syndrome. This patient was a poorly controlled diabetic, and methicillin-sensitive S. aureus might have been hematogenously spread from her elbow wounds. In addition, this patient was taking two antiplatelet agents for old myocardial infarction, which might have induced microbleeding in the iliopsoas muscle when she fell down and hit her hips, and this might have accelerated bacterial growth in the iliopsoas muscle. When an iliopsoas muscle abscess is suspected, CT is generally the investigation of choice with the highest sensitivity. In contrast, MRI provided diagnostic significance in the present case, as we could not carry out enhanced CT. If we could have carried out enhanced CT on the first day of admission, it might have led to earlier diagnosis. Considering the case in the present study, when enhanced CT is not available or contraindicated, MRI could be a very useful alternative for diagnosis. In addition, we believe that it is important to carry out surgical drainage in addition to antibiotic therapy in the case of large, complex or loculated abscesses. Indeed, it was reported that failure rates of percutaneous drainage alone were as high as 60%, and that 44% of patients ultimately required open drainage2. Taken together, when iliopsoas abscess is suspected, physicians should survey patients by CT scan or MRI, and should consider invasive treatment including surgical drainage. The authors declare no conflict of interest.Keywords:
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Acute appendicitis is the most common cause of acute abdomen and on rare occasions can present atypically with a retroperitoneal abscess. In this report, we present a rare case of acute appendicitis combined with iliopsoas muscle abscess. A laparoscopic appendectomy and iliopsoas abscess drainage were performed by a one-step laparoscopic procedure that did not incur any intraoperative or postoperative complications. The results of this case demonstrate that the laparoscopic approach is feasible and effective for the treatment of appendicitis complicated by retroperitoneal abscess. J Curr Surg. 2017;7(1-2):23-25 doi: https://doi.org/10.14740/jcs313w
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Introduction. Iliopsoas abscess is a rare condition, which may be categorized as primary or secondary. Primary iliopsoas abscess is caused by lymphohematogenous spread of infectious agents from a distant site, unlike secondary iliopsoas abscess that is a result of direct spread of a nearby infectious or inflammatory process. The diagnosis and treatment of primary iliopsoas abscess are often prolonged, due to the rarity of the disease and the nonspecific signs and symptoms. Case Report. This study presents a case of a onemonth old infant with a left-sided iliopsoas abscess. The physical examination revealed a swelling with a pronounced vascular pattern in the area of the left groin. Laboratory findings showed leukocytosis and increased inflammatory markers. An abscess within the left hemiabdomen and inguinofemoral region was diagnosed by ultrasonography and computerized tomography. The main therapeutic approach included antibiotic therapy, as well as surgical drainage of the abscess. Staphylococcus aureus was isolated from a 100 ml sample of the drained abscess. The treatment outcome was good. Conclusion. Given the frequency of iliopsoas abscess in infants, which is far less common than other primary diseases, greater attention must be paid to symptoms and signs during clinical examination, along with the appropriate choice of diagnostic procedures. Timely diagnosis, as well as adequate treatment of iliopsoas muscle abscess, is imperative in order to prevent the development of complications, such as systemic inflammation and sepsis.
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Iliopsoas abscess is a relatively uncommon but potentially life-threatening infection of extraperitoneal compartment. Iliopsoas abscess may be classified as primary or secondary. Primary abscess results from hematogenous spread of an infectious process from an occult source in the body. Trauma resulting in intramuscular hematoma formation can predispose to primary iliopsoas abscess formation. Iliopsoas abscess should be considered in patients presenting with lower back or hip pain and fever associated with trauma. Here, we describe two adolescent cases with iliopsoas abscess complicated by septic arthritis following trauma.
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We report a case of giant psoas abscess with aggressive extension outside the muscles of the iliopsoas component. A 57-year-old man was admitted to our hospital, presenting with right flank pain and severe general malaise. He had been diabetic, but no treatment had been performed for diabetes. Leukocytosis, positive CRP and hyperglycemia were noted, but he was nearly afebrile on admission. Computerized tomography revealed a large multilocular mass in the right retroperitoneal space involving the ipsilateral psoas muscle. The diagnosis was not apparent until the 12th hospital day, when moderate grade fever was noted and brownish purulent fluid was obtained by percutaneous puncture of the mass. Staphylococcus aureus was isolated on culture. Antibiotic chemotherapy was started, and ultrasound-guided percutaneous drainage was then performed under the diagnosis of psoas abscess. At that time, the abscess was aggressively extending from the iliopsoas component into the pelvic floor, involving the rectus muscle, the gluteal muscles and formation of subucutaneous lesions. At 46 days after drainage, surgical resection of the abscess with removal of the adjucent tissue was performed because of persistent discharge of pus and multiple residual lesions. The postoperative course was uneventful, and there has been no recurrence. Many cases of psoas abscess have been reported in the Japanese literature. Prompt drainage, either percutaneously or surgically are required. Surgical resection of the abscess, with not only opening the cavity but also removal of the adjacent tissue, may be recommended in some cases, especially those diffuse or multilocular lesions.
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<p><em>Psoas abscess is a rarely found abscess located in the iliopsoas compartment. It characterized by fever, back pain, and limitation of hip movements. Psoas abscess is hard to diagnose due to only 30% of classic symptoms and signs are found. In this study we discussed tuberculous psoas abscess in patient 26 years old male. Anamnesis, physical examination, and supporting medical tests were done to diagnose tuberculous psoas abscess. Therefore we performed abscess incision and drainage, followed by continuous tuberculous therapy.</em></p><p><strong>Keywords: tuberculous psoas abscess</strong></p><p> </p>
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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.
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An 87-year-old female was admitted to the hospital because of a mass with a pain on the left lumbar. On admission, the mass was measuring 15×10cm. The abdominal ultrasound and enhanced computed tomography (CT) showed a large low density area only around this in the left retroperitoneum and under the subcutaneous space. From these results, the patient was diagnosed as having the primary iliopsoas abscess and was operated on. With percutaneous drainage 600ml of non-smelling pus was sprang from the abscess. Any bacteria were not isolated in the pus. Recently, cases of iliopsoas abscess have been increasingly reported with the development of imaging methods. In 54 cases of iliopsoas abscess seen in the Japanese literature in a recent one decade, no case of giant iliopsoas abscess with subcutaneous abscess was included and our case is rare. It is etiologically thought that the onset of the disease in this case might stem from her advanced age, poor nutrition and its resultant proneness to infection. The usefullness of CT in the diagnosis, treatment, and follow-up of iliopsoas abscess is emphasized.
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A psoas (or iliopsoas) abscess is an accumulation of pus in the region of iliopsoas muscle compartment. In regions where Mycobacterium tuberculosis is endemic, this is a frequent cause of psoas abscess. When an inguinal mass in a patient with a psoas abscess is painless, tuberculosis is a more likely cause than a bacterial infection. Here, the author report a rare case of psoas abscess of tubercular origin in a 31-year-old patient who presented with back pain and limping, with features of inflammation. Diagnosis was done based on history, physical examination, ultrasonography, microbiological investigation and Contrast-Enhanced Computed Tomography (CECT) scan of abdomen which revealed a large psoas abscess caused by M. tuberculosis. Patient was diagnosed with a psoas abscess due to Mycobacterium tuberculosis with secondary infection and treated empirically with Directly Observed Treatment Short-Course (DOTS) category I and antibiotics. He presented again with a chest abscess due to Multidrug-Resistant (MDR) tuberculosis.
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Iliopsoas abscess is an uncommon but important and potentially life-threatening infection that is typically difficult to recognize. Even today, most of the literature on psoas abscess includes case reports and small case series with few institutions seeing more than one case of iliopsoas abscess in a year. Large review series have been published by Ricci et al. and more recently by De and Pal. Originally described by Abeille in 1854 as an abscess of the psoas muscle, the etiology of the disease has changed substantially in the Western world since Mycobacterium tuberculosis has decreased in frequency. The incidence of iliopsoas abscess has increased from 3.9 cases per year to more than 12 per year in 1995. At our institution, 1 to 4 cases of iliopsoas abscess are currently seen each year.
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A psoas abscess is an accumulation of pus in the muscular compartment of the iliopsoas. It can originate from a primary or secondary source. Hematogenous or lymphatic seeding from a distant place causes primary iliopsoas abscess. This is frequently linked to a chronic immunocompromised status and is more common in young people. Secondary psoas abscess is caused by infection spreading directly from a nearby structure to the psoas muscle, and it can be caused by trauma or instrumentation in the inguinal region, lumbar spine region, and hip region. Occurrence of psoas abscess is uncommon, and its diagnosis is frequently delayed due to non-specific symptoms. We discuss a patient with chronic kidney disease (CKD) on conservative management who presented to us with complaints of swelling in the right lower back and fever and who was subsequently diagnosed with a right psoas abscess. Microbiology culture of the pus confirmed Escherichia coli (E. coli) as the etiologic agent, which is rare.
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