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
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Abstract:
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.Keywords:
Iliopsoas
Gluteal muscles
This case highlights the importance of early diagnosis of iliopsoas abscess in patients with communication difficulties and appropriate treatment to prevent further complications.
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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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To review the characteristics of patient presentation, microbiology, and treatment of primary iliopsoas abscess.A case series of patients with iliopsoas abscess diagnosed on computed tomographic scans from 1987 to 1994.Tertiary care inner-city university hospital.Eleven patients with secondary iliopsoas abscess, defined as being secondary to gastrointestinal or genitourinary causes or trauma, and seven patients with primary abscess, defined as the absence of the above causes.Patient characteristics, presenting symptoms and signs, microbiologic characteristics, treatment, and clinical course of patients with primary iliopsoas abscesses compared with those in patients with secondary abscesses.In the primary group, six patients (86%) were intravenous drug users and four (57%) were positive for human immunodeficiency virus. Staphylococcus aureus grew from cultures from five of seven patients with primary abscesses, whereas secondary abscesses had enteric flora. The typical patient presentation included fever, with complaints of pain in the flank, hip, or abdomen. Comparison of abscess drainage options showed shorter hospitalizations for surgical drainage than for percutaneous drainage (15.9 vs 28.5 days; P < or = .01).A patient who presents with pain in the flank, hip, or abdomen may have a primary iliopsoas abscess. Computed tomography is the standard method of diagnosis. Antibiotic regimens for patients with primary iliopsoas abscess should include coverage for S aureus, and patients with secondary abscesses should have antibiotic regimens tailored for enteric bacteria. Drainage of abscess is essential for appropriate treatment, and surgical drainage is superior to percutaneous drainage in achieving prompt recovery.
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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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<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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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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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.
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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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