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Psoas Abscess

Psoas Abscesses

A psoas abscess is a relatively rare condition that usually presents with nonspecific signs and symptoms. Without prompt diagnosis and treatment, it may cause serious complications.


Presentation

A classic triad consisting of psoas spasm, fever and back pain is characteristic of psoas abscess but is only present in 30% of patients. Nonspecific symptoms such as abdominal and flank pain, fever, malaise, weight loss and nausea predominate and complicate the picture. Back pain remains the most common symptom, appearing on average 10 days before the patient usually presents to the clinician. Pain associated with psoas abscess tends to radiate to the anterior sides of the thigh and the hip, as a result of the innervation of the muscle with L2, L3 and L4 nerves.

The physical exam is very important in the diagnostic workup of the disease. Signs that are particularly suspicious include a palpable mass in the inguinal area, a limp and severe pain after the performance of certain maneuvers. Pain that occurs after the patient attempts to lift his or her thigh against pressure caused by the examiner's hand is especially suspicious. Furthermore, pain that occurs while the patient hyperextends the hip while lying on the non-affected side is also suggestive [6]. It is worth noting that these two tests tend to be also positive in appendicitis or any condition that involves inflammation of the psoas muscle. Another important sign is when the patient favors the supine position while keeping the knee slightly flexed and the hip externally rotated.

A psoas abscess can be difficult to diagnose and is commonly confused with lumbar strain, arthritis, osteomyelitis of the vertebra, as well as other urologic and abdominal conditions. Furthermore, patients who present with septic shock or with evidence of a Mycobacterium tuberculosis infection do not commonly present with classic symptoms and diagnosis may be very difficult to establish.

Weight Loss
  • A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss.[ncbi.nlm.nih.gov]
  • This was accompanied by a month long history of flank pain, back pain, vague abdominal pain, limp, fever and weight loss. On examination, there was extensive erythaema, heat, tenderness, oedema and crepitus over his right buttock and thigh.[ncbi.nlm.nih.gov]
  • The authors report the case of a 69-year-old man with chronic obstructive pulmonary disease and previous pulmonary tuberculosis, who presented to the emergency department with abdominal and low back pain, anorexia and weight loss, rapidly evolving into[ncbi.nlm.nih.gov]
  • Other symptoms are nausea, malaise and weight loss . Psoas muscle abscess may be classified as primary or secondary depending on the presence or absence of underlying disease.[radiopaedia.org]
Fatigue
  • We report a case of a caecal tuberculosis (TB) presented initially with an appendicular mass and systemic symptoms of fever and fatigue and 3 weeks after, with right-sided anterior thigh pain and found to have an ilio-psoas abscess.[ncbi.nlm.nih.gov]
  • […] presentation along with nonspecific symptoms and signs makes the diagnosis of psoas abscess difficult. 1 Patients may be referred to the department of rheumatology for back pain. 4 Limping, a positive psoas sign, flexion deformity of the hip joint, fatigue[ajnr.org]
  • The clinical signs and symptoms may include limping, a positive psoas sign, flexion deformity of the hip joint, fatigue, fever, night sweating, and weight loss [17].[jpmsonline.com]
Inguinal Mass
  • Mass : in some cases, psoas abscess may extend to present as a painful/painless mass below the inguinal ligament Painless mass is more common with a tuberculosis-related psoas abscess Limp Lower Extremity Edema (28% of cases) Lower Extremity/Hip Pain[mdnxs.com]
Abdominal Pain
  • This was accompanied by a month long history of flank pain, back pain, vague abdominal pain, limp, fever and weight loss. On examination, there was extensive erythaema, heat, tenderness, oedema and crepitus over his right buttock and thigh.[ncbi.nlm.nih.gov]
  • Predisposing factors were found in 16 (80%): trauma, skin and soft tissue infect and myelomeningocele Although it is unspecific, the triad of fever, lumbar/abdominal pain and limp was observed in 12(60%) pts; however, 2 of them alone or in combination[academic.oup.com]
  • Case of the Week: April 7-April 14, 2006 8 month old girl with fever and abdominal pain (Click for a larger image.) Case Details Multiple abscesses involve the left psoas muscle and extend into the pelvis along the ileopsoas muscle.[pedsradiology.com]
  • Psoas muscle abscess may present with fever , flank pain, abdominal pain or limp. Other symptoms are nausea, malaise and weight loss .[radiopaedia.org]
Abdominal Mass
  • mass in the right iliac fossa and presence of a limp two months before presentation are the signs of a psoas abscess that have been widely described in literature.3,5 But in our case, the limp had progressed to paraparesis with the right hip flexed and[jpma.org.pk]
  • Mass (13% of cases) Weight Loss (11% of cases) Complications Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis , [[Deep Venous Thrombosis]]): due to extrinsic compression of the iliac vein Hydronephrosis : due to compression of the ureter Paralytic[mdnxs.com]
  • A palpable flank or abdominal mass is present in about half of the cases. The mass may be better appreciated by examination of the patient in the knee–chest position. There may also be signs of psoas muscle irritation with flexion of the thigh.[urologysurgery.wordpress.com]
Kehr's Sign
  • The pain was interpreted as Kehr's sign when complementary investigations revealed a perisplenic collection, leading to the irritation of the diaphragm; the collection was extended to the left psoas muscle and resulted in psoas abscess.[ncbi.nlm.nih.gov]
Tachycardia
  • Tachycardia is usually present. The classic abdominal signs are tenderness on palpation, guarding and rebound tenderness. The tenderness will be maximal over the area of pathology.[patient.info]
  • On examination, she was pyrexial of 37.8 C with a tachycardia of 105 beats/min. Abdominal examination revealed a localized tenderness with gaurding in the left iliac fossa, and normal bowel sounds.[ispub.com]
Back Pain
  • Psoas abscess is commonly regarded as an unusual cause for back pains and usually associated with significant risk factors or co-morbidities.[ncbi.nlm.nih.gov]
  • At 1-, 6-, 12- and 24-months-follow-up, neither fever nor lower back pain were reported. According to our experience, laparoscopic drainage of iliopsoas abscess is safe and effective.[ncbi.nlm.nih.gov]
  • We report on a patient who developed persistent low back pain, pyrexia and neurological deficit soon after she underwent a laparotomy under combined general and epidural anaesthesia.[ncbi.nlm.nih.gov]
  • This was accompanied by a month long history of flank pain, back pain, vague abdominal pain, limp, fever and weight loss. On examination, there was extensive erythaema, heat, tenderness, oedema and crepitus over his right buttock and thigh.[ncbi.nlm.nih.gov]
  • The authors report the case of a 69-year-old man with chronic obstructive pulmonary disease and previous pulmonary tuberculosis, who presented to the emergency department with abdominal and low back pain, anorexia and weight loss, rapidly evolving into[ncbi.nlm.nih.gov]
Hip Pain
  • She experienced three weeks of worsening right hip pain, which was initially misdiagnosed as degenerative joint disease. This led to admission to the Intensive Care Unit for severe sepsis.[ncbi.nlm.nih.gov]
  • A 12-month-old infant presented with the complaints of fever, left hip pain and limp. Magnetic resonance imaging revealed left psoas abscess accompanied by septic arthritis of the hip.[ncbi.nlm.nih.gov]
  • We report a patient presenting with a total hip replacement complaining of sepsis and right hip pain. No focus for the infection was isolated and an open washout of the right hip was performed due to suspected prosthesis infection.[ncbi.nlm.nih.gov]
  • A 78-year-old woman presented 28 days after a low-impact fall, where she sustained a right pubic ramus fracture, with increasing left hip pain and fever. Her blood results showed a high white cell count and deranged urea and electrolytes.[ncbi.nlm.nih.gov]
  • (see Hip Pain , [[Hip Pain]]) Palpable Abdominal Mass (13% of cases) Weight Loss (11% of cases) Complications Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis , [[Deep Venous Thrombosis]]): due to extrinsic compression of the iliac vein Hydronephrosis[mdnxs.com]
Low Back Pain
  • We report on a patient who developed persistent low back pain, pyrexia and neurological deficit soon after she underwent a laparotomy under combined general and epidural anaesthesia.[ncbi.nlm.nih.gov]
  • The authors report the case of a 69-year-old man with chronic obstructive pulmonary disease and previous pulmonary tuberculosis, who presented to the emergency department with abdominal and low back pain, anorexia and weight loss, rapidly evolving into[ncbi.nlm.nih.gov]
  • When enlargement of the iliopsoas with a vertebral lesion is detected in a child with low back pain, Ewing sarcoma should be included in the differential diagnosis.[ncbi.nlm.nih.gov]
  • While most patients with acute low back pain have a benign etiology, this case report demonstrates the challenge of diagnosing a patient with bilateral psoas abscess who had few known risk factors and symptoms typical of mechanical low back pain.[ncbi.nlm.nih.gov]
  • This article describes the case of a 14-year-old boy with spontaneous lumbar vertebral osteomyelitis who initially presented with low back pain and was successfully treated nonoperatively.[healio.com]
Thigh Pain
  • We report a case of a caecal tuberculosis (TB) presented initially with an appendicular mass and systemic symptoms of fever and fatigue and 3 weeks after, with right-sided anterior thigh pain and found to have an ilio-psoas abscess.[ncbi.nlm.nih.gov]
  • The most common presenting symptom in community-onset cases was back, hip, or thigh pain (43% [16/37]). Fever was present at presentation in 41% (15/37) of these patients, four of whom presented with fever only.[ncbi.nlm.nih.gov]
  • In the present case the classical signs of psoas abscess (lower back pain, thigh pain, limping and psoas sign) were absent. The clinical image was dominated by peritoneal inflammation expressed by nausea, vomiting and watery stools.[tmj.ro]
Limping Gait
  • Unfortunately, 4 months later, she was readmitted with a 2-day history of fever, limping gait and pain in the right groin.[omicsonline.org]
  • Back pain, limping gait, and refusal to walk are not specific to vertebral osteomyelitis.[healio.com]
Adnexal Mass
  • We report an unusual presentation of bilateral psoas abscess in pregnancy presenting as an acute abdomen and adnexal mass.[ncbi.nlm.nih.gov]
Polyuria
  • A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss.[ncbi.nlm.nih.gov]

Workup

Workup is broad and includes blood tests, although findings on the latter can be variable. Nonetheless, a Johns Hopkins study showed that almost all patients will have an elevated ESR (erythrocyte sedimentation rate) with a mean of 90 mm/hr, elevated blood urea nitrogen (BUN) with a mean of 30.5 mg/dL and leukocytosis with a mean count of 15,900/mm3 [2]. Furthermore, pyuria is occasionally reported [7].

Imaging tests are critical in establishing the diagnosis. CT is generally used to confirm diagnosis and is considered more sensitive and specific than ultrasound. Ultrasound may only be able to diagnose 60% of patients, whereas CT can detect and confirm a psoas abscess in 80 to 100% of all cases [8]. Magnetic resonance imaging (MRI) is not part of the workup of the condition. This is due to the associated high costs, the high level of discomfort for the patient, in addition to the fact that it does not improve sensitivity and specificity relative to CT.

On the other hand, the gold standard for diagnosis remains blood culture or direct aspiration of the abscess. The latter in general has better sensitivity and specificity.

X-Ray Abnormal
  • Abscesses near the diaphragm may result in chest x-ray abnormalities such as ipsilateral pleural effusion, elevated or immobile hemidiaphragm, lower lobe infiltrates, and atelectasis. CBC and blood cultures should be done.[merckmanuals.com]
Elevated Sedimentation Rate
  • Laboratory studies showed an elevated sedimentation rate (ESR) of 55 mm/h, white cell count (WBC) 10.4 109/L and C-reactive protein (CRP) 183 mg/L. Stool and urine tests were normal.[bmcmusculoskeletdisord.biomedcentral.com]
Erysipelothrix Rhusiopathiae
  • The authors report a patient with a rare manifestation of invasive septic Erysipelothrix rhusiopathiae infection without endocardial involvement. Our patient presented with progressive paraparesis and subacute fever for ten days.[ncbi.nlm.nih.gov]
Actinomyces Israelii
  • Since P. propionicum is indistinguishable from Actinomyces israelii by morphological features or routine biochemical tests, 16S rRNA gene sequencing was useful to discriminate these two species in this case.[ncbi.nlm.nih.gov]

Treatment

Treatment of a psoas abscess consists of antibiotic administration and drainage of the abscess. The choice of the antibiotic is based initially on the most likely pathogens involved and is subsequently adjusted according to culture sensitivity tests.

The choice of empiric antibiotic treatment depends on whether the condition is primary or secondary. Treatment for primary psoas abscess is targeted initially against S. aureus. Antistaphylococcal antibiotics are initiated even before diagnosis is conclusively established, given that approximately 90% of all cases of primary psoas abscess involve S. aureus. The chosen antibiotic should also act against methicillin resistant S. aureus and is usually one of the following: vancomycin, linezolid and clindamycin.

On the other hand, a secondary psoas abscess is most commonly associated with enteric bacteria, with involvement of both anaerobic and gram negative organisms. Antibiotics that are frequently administered in such cases include fluoroquinolones, third and fourth generation cephalosporins, metronidazole and anti-pseudomonal penicillins [4].

It is important to note that these are broad guidelines and that many cases involve enteric bacteria in primary cases and S. aureus in secondary cases [2]. Appropriate broad spectrum antibiotics such as aminoglycosides, clindamycin or an antistaphylococcal penicillin should be used in either form [9].

Abscess drainage can be performed either percutaneously with CT assistance or open surgery. Indications for surgical management include patients in whom percutaneous intervention cannot be performed (such as the presence of coagulopathies), failure of CT-assisted percutaneous drainage or the concomitant presence of a pathology within the abdomen that also necessitates open surgery. CT-assisted percutaneous drainage is generally the favored approach because it is a non-invasive procedure, is associated with low morbidity and mortality and can effectively treat uniloculated as well as multiloculated psoas abscesses [10]. Nonetheless, some patients may require repeated aspirations for effective treatment, defined as clinical improvement and complete obliteration of the abscess [11].

Prognosis

Prompt diagnosis and treatment improves outcomes. Drainage of the abscess and antibiotic administration are the most important interventions that have proven to reduce both mortality and morbidity.

Etiology

Causes responsible for the development of a psoas abscess can be divided into primary and secondary. Primary abscesses are not caused by an underlying disease but usually result from hematogenous spread of bacteria from sources of infection in other locations. Secondary psoas abscesses most commonly occur in the context of Crohn's disease. Interventional procedures in the hip, groin and lumbar regions can also substantially increase the risk.

A wide range of bacterial species are involved in the etiology of the disease and usually vary depending on whether the abscess is primary or secondary. Around 80% cases of primary psoas abscesses involve Staphylococcus aureus, including methicillin resistant S. aureus [2]. Other bacterial species, such as Pseudomonas aeruginosa, Haemophilus aphrophilus, Proteus mirabilis and Serratia marcescens, have also been reported [2] [3]. On the other hand, enteric bacteria play the most important role in the secondary form of the disease, particularly Salmonella enteritidis, Escherichia coli and Streptococcus and Enterobacter species. Tuberculosis has also been isolated in cases where the disease is still prevalent.

Epidemiology

Studies have found that the prevalence of psoas abscess has increased worldwide from 3.9 cases to 12 cases per year from 1985 to 1992 [4]. These studies also report that epidemiological characteristics vary depending on the underlying cause. Primary psoas abscess is more common in young patients. Around 83% of all cases are diagnosed in patients younger than 30. On the other hand, 40% of all cases of secondary psoas abscess are found in patients older than 40. Elderly patients rarely present with either form of the condition [3].

Nonetheless, more recent studies contest prior findings. A case series of 18 patients in the Johns Hopkins University School of Medicine found that secondary psoas abscess is more frequent than primary psoas abscess, with patient age ranging at diagnosis from 2 to 78 years, in comparison to an age range of 27 to 81 years in primary psoas abscess.

HIV infection and drug use are significant risk factors for primary psoas abscess. Around 57% of all patients are HIV positive and up to 86% have a history of IV drug use [2]. These associations have not been reported in patients with secondary psoas abscess. Studies have also found other important associations that include diabetes, renal failure and immunosuppression [5].

Sex distribution
Age distribution

Pathophysiology

The psoas muscle is a very well vascularized structure, thus explaining hematogenous spread of infectious organisms from an original nidus of infection. Furthermore, the psoas muscle is located very close to numerous vital organs and structures such as the pancreas, the colon, the jejunum, the aorta, the renal pelvis, the ureters, the spine and the iliac lymph nodes. Consequently,  infections in these sites can easily reach the psoas muscle. 

Primary psoas abscess occurs subsequent to spread from the lymphatic or vascular systems and tends to be more common in patients with AIDS, diabetes mellitus, IV drug abuse or renal failure. On the other hand, secondary psoas abscess results from direct spread from nearby structures. It is most frequently related to gastrointestinal disease and infections such as perforated colon carcinoma, Crohn's disease, appendicitis and diverticulitis. Kidney disease is also an important cause.

Prevention

Prevention is mostly directed at addressing the complications before they arise, through early diagnosis and prompt and effectice treatment. The most relevant complications associated with psoas abscess are sepsis and pulmonary emboli.

Summary

Psoas abscess is a medical condition first identified by Mynter in 1881 [1]. It can be either primary or secondary. Primary psoas abscess results from direct hematogenous or lymphatic spread from other sources of infection in the body whereas a secondary psoas abscess occurs subsequent to spread from adjacent structures and organs. The most common organism involved in primary psoas abscess is S. aureus, in contrast to enteric bacteria in secondary psoas abscess. Patients usually present with nonspecific symptoms that include nausea, vomiting, weight loss, abdominal and back pain, fever, a limp and malaise. A classic triad consisting of fever, back pain and a psoas spasm can be identified in only 30% of patients. The pain tends to radiate to the anterior surfaces of the thigh and the hip due to innervation by the L2, L3 and L4 nerves which also innervate the psoas muscle. The physical exam is very important in the workup. In particular, pain elicited with specific procedures may be strongly suggestive of the disease. In addition, the patient usually prefers to lie in a supine position with slight external rotation of the hip to alleviate the pain. Diagnostic workup further includes blood and imaging tests. Most patients will show leukocytosis, elevated erythrocyte sedimentation rate and blood urea nitrogen. Computed tomography (CT) is the imaging test of choice and has higher sensitivity and specificity than ultrasound. Magnetic resonance imaging (MRI) is rarely used because it is associated with discomfort and costs more than other tests without an increase in specificity or sensitivity. Treatment of psoas abscess consists of antibiotic administration and surgical drainage. The type of antibiotic administered depends on whether the condition is primary or secondary, and is subsequently adjusted when the culture and sensitivity tests are performed. Drainage of the abscess can be surgical or percutaneous under CT guidance. The latter method is preferred because it is non-invasive and is associated with decreased mortality and morbidity. Early diagnosis and treatment is critical to avoid serious complications like septic shock or pulmonary embolism.

Patient Information

A psoas abscess is a medical condition in which a collection of microorganisms form pus over the psoas muscle, which sits in the lumbar - pelvic area. This collection usually has well defined borders and is referred to as an abscess. It can result from spread of infection through the blood from other sites in the body or due to extension from structures that sit close to the psoas muscle. Patients will usually present with very nonspecific symptoms such as malaise, nausea, vomiting, pain in the abdomen, malaise and a limp. The pain tends to also occur in the anterior part of the thigh, because many of the nerves that innervate the psoas muscle also innervate the anterior thigh. The physician will perform specific maneuvers that elicit pain and that may help in establishing the diagnosis. In addition, patients usually like to lie in the supine position with a slightly externally rotated hip to decrease the pain associated with the condition. The physician will also perform particular laboratory and imaging tests. Computerized tomography (CT) is considered the imaging test of choice and is used to establish the diagnosis. Treatment of psoas abscess is managed with antibiotics and drainage. Drainage of the abscess is performed either with open surgical intervention or percutaneously, with CT assistance. The latter method is preferred because it is associated with less complications.

References

Article

  1. Mynter H. Acute psoitis. Buffalo Med Surg J. 1881;21 :202- 210
  2. Santaella RO, Fishman EK, Lipsett PA. Primary versus secondary psoas abscess. presentation microbiology and treatment. Arch Surg 1995; 130:1309-1313
  3. Simms V, Musher DM. Psoas muscle abscess due to Mycobacterium kansasii in an apparently immunocompetent adult. Clin Infect Dis. 1998; 27:893-894
  4. Gruenwald I, Abramson J, Cohen O. Psoas abscess: case report and review of the literature. J Urol 1992; 147:1624-1626
  5. Font C, Casals C, Kaifi T, et al. Constitutional syndrome and lumbar pain. Postgrad Med J. 1997; 73:599-601
  6. Ricci MA, Meyer KK. Psoas abscess complicating Crohn's disease. Am J Gastroenterol. 1985; 80:970-977
  7. Desandre A, Cottone F, Evers M. Iliopsoas abscess: etiology, diagnosis and treatment. Am Surg. 1995; 61:1087-1091
  8. Breese JS, Edwards M. Psoas abscess in children. Pediatr Infect Dis J. 1990; 9:201
  9. Dinc H, Onder C, Turham AU, et al. Percutaneous drainage of tuberculous and nontuberculous psoas abscesses. Eur J Radiol. 1996; 23:130-134
  10. Mueller PR, Ferrucci JT, Wittenberg J, et al. Iliopsoas abscess: treatment by CT-guided percutaneous catheter drainage. AJR. 1984; 142:359-362.
  11. Procaccino JA, Lavery IC, Fazio VW, et al. Psoas abscess: difficulties encountered. Dis Colon Rectum 1992; 35:513-514

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Last updated: 2018-06-22 11:52