We describe a series of twelve patients with a psoas abscess seen in a
      three-year period in a university hospital and a large teaching hospital
      in the Netherlands. In our series, five of the 12 patients had a primary
      psoas abscess. The predisposing conditions were intravenous drug use,
      diabetes mellitus, prostate carcinoma and haematoma in the psoas muscle in
      a patient with haemophilia A. Seven of the 12 patients had a secondary
      psoas abscess. Five cases were due to vertebral osteomyelitis including
      two cases of tuberculosis. In the other two cases it was due to colitis
      and urinary tract infection. It is remarkable that in our series there was
      only one patient with a psoas abscess secondary to a disease of the
      digestive tract, while this is the most common cause of a secondary psoas
      abscess in the literature. There were two cases of tuberculosis which is
      an emerging disease again

Berge, M. van den

Bravenboer, B. (Bert)

Jansz, A.R.

Kuipers, T.

Marie, S. (Siem) de

Berge, M

de Marie, S (Siem)

Kuipers, T

Jansz, AR

Bravenboer, B

EUR Research Repository

N O V E M B E R  2 0 0 5 ,  V O L .  6 3 ,  N O .  1 0A B S T R A C TWe describe a series of 12 patients with a psoas abscess seen in a three-year period in a university hospital and a large teaching hospital in the Netherlands. In our series, five of the 12 patients had a primary psoas abscess. The predisposing conditions were intravenous drug use,  diabetes mellitus, prostate carcinoma and haematoma in the psoas muscle in a patient with haemophilia A.  Seven of the 12 patients had a secondary psoas abscess. Five cases were due to vertebral osteomyelitis including two cases of tuberculosis. In the other two cases it was due to colitis and urinary tract infection.  It is remarkable that in our series there was only one patient with a psoas abscess secondary to a disease of the digestive tract, while this is the most common cause of a secondary psoas abscess in the literature. There were two cases of tuberculosis which is an emerging disease again. K E Y W O R D SCase series, psoas abscessI N T R O D U C T I O NPsoas abscess is regarded as a rare disease in the medical literature. The incidence is not known but it has probably increased in recent years. The causes of psoas abscess in the Western world have also changed in the last decades. At the beginning of the 20th century psoas abscess was  mainly caused by tuberculosis of the spine (Pott’s disease). C A S E  R E P O R TPsoas abscess: report of a series and review of the literatureM. van den Berge1*, S. de Marie1, T. Kuipers2, A.R. Jansz3, B. Bravenboer41Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Centre Rotterdam, Dr. Molenwaterplein 40, 3015 GD Rotterdam, the Netherlands, Departments of 2Radiology and 4Internal Medicine, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven,  the Netherlands, 3Department of Clinical Microbiology, PAMM, Public Health Laboratory, PO Box 2, 5500 AA Veldhoven, the Netherlands, *corresponding author© 2005 Van Zuiden Communications B.V. All rights reserved.With the decline of M. tuberculosis as a major pathogen in developed countries a psoas abscess was mostly seen secondary to diseases of the digestive tract.1 In recent years a primary psoas abscess due to haematogenous spread from an occult source is more common, especially in immunocompromised and older patients.2,3 In addition, tuberculosis is on the increase again because of immigra-tion and HIV infections in risk groups. In this report we describe four patients out of 12 seen in the last three years in a university hospital and a large teaching hospital in the Netherlands. We present four clinical case histories, demonstrating the various clinical presentations.M E T H O D SWe reviewed clinical data from patients who were classi-fied with a psoas abscess in the period from June 2001 to June 2004 at the Erasmus Medical Centre Rotterdam and Catharina Hospital, Eindhoven in the Netherlands.R E S U LT SIn this period 12 cases met the diagnosis of psoas abscess, five from Catharina Hospital and seven from Erasmus Medical Centre. The average age was 55 years (range 25 to 82) with a male-female ratio of 5:7. Five of the 12 patients had a primary psoas abscess, while seven had a secondary psoas abscess. Two of the 12 patients died. Characteristics of the patients are shown in table 1. 413N O V E M B E R  2 0 0 5 ,  V O L .  6 3 ,  N O .  1 0Table 1 Characteristics of patients with a psoas abscess seen in the period June 2001 to June 2004 in Erasmus Medical Centre Rotterdam (EMCR) and Catharina Hospital, Eindhoven (CHE)No. Sex Age Hospital Predisposing conditionLocation Micro- organismPrimary/ secondaryOutcome1 M 46 CHE No Right Staphylococcus aureusPrimary Favourable2 V 38 EMCR IV drug user Both sidesStaphylococcus aureusPrimary Favourable3 M 67 CHE Prostate  carcinomaRight Staphylococcus aureusPrimary Favourable4 V 80 CHE DM Right Staphylococcus aureusPrimary Died5 M 59 EMCR Haematoma in psoas muscleLeft Staphylococcus aureusPrimary Favourable6 V 82 CHE No Both sidesStaphylococcus aureusSecondary to osteomyelitis of the spineFavourable7 V 43 EMCR Homeless Left Mycobacterium tuberculosisSecondary to osteomyelitis of the spineFavourable8 V 25 EMCR No Left Mycobacterium tuberculosisSecondary to osteomyelitis of the spineFavourable9 M 48 EMCR IV drug user Left Enterobacter cloacaeSecondary to osteomyelitis of the spineFavourable10 V 55 EMCR DM Both sidesEscherichia coli Secondary to osteomyelitis of the spineFavourable11 V 48 EMCR No Left Escherichia coli Secondary to urinary tract infectionFavourable12 M 75 CHE CLL, DM Right Klebsiella  pneumoniaeSecondary to colitisDiedCLL = chronic lymphatic leukaemia; DM = diabetes mellitus. Clinical case historiesPatient AA 46-year-old man was admitted with fever and pain in the right buttock radiating to the right leg, which started after a strenuous walk in the mountains two weeks before admission. Physical examination was normal. Laboratory studies showed an ESR of 80 mm/h, haemoglobin 8.8 mmol/l, white cell count 8.7 x 109/l and C-reactive protein 159 mg/l. The other chemistry tests performed were normal.Blood cultures yielded a growth of Staphylococcus aureus. A CT scan of the abdomen showed an abscess of 2.5 cm in the right iliac muscle (figure 1). MRI scan of the thor-acic and lumbar spine did not reveal a spondylodiscitis. An echocardiogram did not show vegetations. He was treated with flucloxacillin 6 g/day intravenously for six weeks. A CT scan after six weeks showed that the abscess had disappeared.Patient BAn 80-year-old woman was admitted with pain in the right buttock for one month. Her medical history included hypothyroidism and type 2 diabetes mellitus complicated by nephropathy, peripheral arterial disease and coronary heart disease. On physical examination her temperature was 38 °C. There was no heart murmur. Pain could be provoked by applying pressure to the right side of the sacral area. Laboratory studies showed an ESR of >140 mm/h, haemoglobin 4.2 mmol/l, white cell count 17.1.x 109/l, C-reactive protein 245 mg/l, glucose 9.1 mmol/l and cre-atinine 180 mol/l. Other chemistry tests were normal. All six blood cultures were positive for S. aureus. A trans-oesophageal echocardiogram did not show any vegetation.An MRI scan of the pelvis showed a psoas abscess of 5 x 12 cm on the right side (figure 2). There was no imaging of the thoracic spine. The abscess was drained percutaneously Van den Berge, et al. Psoas abscess.414N O V E M B E R  2 0 0 5 ,  V O L .  6 3 ,  N O .  1 0and the patient was treated with flucloxacillin 6 g/day iv. After four weeks the flucloxacillin was switched to oral medication for another two weeks because of several episodes of phlebitis. A CT scan after six weeks showed disappearance of the abscess. After one month she was admitted again because of rectal bleeding. She had fever and a blood culture was again positive for Staphylococcus aureus. An MRI scan of the spine revealed a spondylodiscitis between the 9th and 10th thoracic vertebrae. She was treated with flucloxacillin 12 g/day iv. After one month she died of a cerebrovascular accident. Autopsy was refused.Patient CA 48-year-old man was admitted with pain in the back, and fever. His medical history included epilepsy and a nephrect-omy after a shoot wound. He was an intravenous drug user.On physical examination he had a temperature of 37.5 °C. He had pain when applying pressure to the lumbar spine. Laboratory results showed haemoglobin 6.9 mmol/l, white cell count 10.5 x 109/l, and C-reactive protein 154 mg/l. MRI of the spine showed an osteomyelitis of L3 to L5 and a small psoas abscess with a diameter of 2 cm to the left. A blood culture yielded Enterobacter cloacae. Urinary cultures were sterile. He was treated successfully with ciprofloxacin 750 mg twice a day orally for six weeks. Patient DA 43-year-old woman was referred to the gynaecologist with amenorrhoea for seven months and a distention of her abdomen. She is a homeless prostitute who uses cocaine.She lost 20 kg in weight in four months time but had no fever. She complained of having pain in her left leg for more then one year. A sonography showed a process with multiple cysts in the lower left abdomen. A laparotomy was performed and a large psoas abscess of 10 to 20 cm was found. The abscess was drained and cultures showed Mycobacterium tuberculosis. MRI of the lumbar spine showed osteomyelitis of L2 and L3 with a paravertebral abscess. She was treated with rifampicin, ethambutol, isoniazid and pyrazinamide, and ethambutol for nine months. D I S C U S S I O NIn our series, five out of 12 patients had a primary psoas abscess. In all of them S. aureus was the causative agent. The predisposing conditions were intravenous drug use, diabetes mellitus, prostate carcinoma and haematoma in the psoas muscle in a patient with haemophilia A. In literature S. aureus is found in 88% of the cases of primary psoas abscess followed by streptococci (5%) and Escherichia coli (3%). A history of recent muscle trauma was revealed in 20% of the cases.4 Experimental data have shown that only after a muscle is injured an intravenous injection with Staphylococcus aureus can produce a pyomyositis.5 Van den Berge, et al. Psoas abscess.Figure 1 Transverse contrast-enhanced CT scan of patient A, showing a hypodense lesion with enhancing rim in the right iliac muscle, typically an abscessFigure 2 Coronal and transverse T2-weighted MRI scan of patient B, showing a septated abscess in the right psoas muscle415N O V E M B E R  2 0 0 5 ,  V O L .  6 3 ,  N O .  1 0Patient A had no known predisposing condition. He was possibly susceptible to developing a primary psoas abscess due to a muscle trauma after a strenuous walk in the mountains. A primary psoas abscess is predominant in developing countries; however, in the Western world primary psoas abscess has become more prevalent, especially in immuno-compromised patients.2,3 This group includes intravenous drug abusers, HIV-infected persons and patients with chronic illness or malignancies. Seven of the 12 patients had a secondary psoas abcess. In five cases this was due to vertebral osteomyelitis including two cases of tuberculosis. In the other two patients it was secondary to colitis and urinary tract infection.6 In a large review the most common cause of secondary psoas abscess was Crohn’s disease (60%). Other causes are appendicitis (16%), ulcerative colitis, diverticulitis, colon cancer (together 11%) and vertebral osteomyelitis (10%).4In secondary psoas abscess cultures are often mixed, with E. coli and Bacteroides spp predominating. Other organ-isms include enteric pathogens, Staphylococcus spp and Streptococcus spp.4It is remarkable that in our series there is only one patient with a psoas abscess secondary to a disease of the digestive tract, although the Erasmus Medical Centre is a referral centre for Crohn’s disease.In our series there were five patients with a psoas abscess secondary to an osteomyelitis of the spine.7 Vertebral osteomyelitis is primarily a disease of adults; the major-ity of patients are over 50 years of age.8 Haematogenous spread from an occult source is the most common route of infection. S. aureus accounts for more than 50% of the cases of vertebral osteomyelitis. Psoas abscess is regarded as secondary to vertebral osteomyelitis in most cases, but since both infections are caused by haematogenous spread from an occult source, they may also have developed simultaneously. In addition, secondary infection of the spine due to a psoas abscess has also been described.9 In patient B the relationship between the psoas abscess and the vertebral osteomyelitis is not clear since at presentation no MRI of the thoracic spine was performed. Two of the patients in our series had a psoas abscess secondary to tuberculous osteomyelitis. Although this used to be the most common cause, it had almost dis-appeared until recently. Tuberculosis of the spine without a psoas abscess was diagnosed in at least five additional cases in the selected study period in the Erasmus Medical Centre in Rotterdam (data not shown).In our series four patients were treated with antibiotics only. Two patients had a small psoas abscess which was less than 3 cm. One patient with a psoas abscess of 7.5 cm  was successfully treated with antibiotics only, while the other patients who had a psoas abscess of 5 cm died of comorbidity. Six patients underwent percutaneous drainage which was successful in all cases. However, one patient died of a cerebrovascular accident. Two patients were treated with surgical drainage.Percutaneous drainage has the advantage of being less invasive. However, in one case series surgical drainage was correlated with a shorter hospital stay compared with percutaneous drainage.3 In the case of secondary psoas abscess, surgical drainage can be combined with resection of diseased bowel. Antibiotics are given guided by blood cultures, Gram stains and cultures of the abscess. If antibiotics are given empirically, S. aureus should be covered in the case of primary psoas abscess, and in secondary abscess broad-spectrum antibiotics should be given covering aerobic and anaerobic bowel flora.The duration of antibiotic therapy must be individualised, guided by clinical signs, involvement of other structures and laboratory results. In any case antibiotics should be continued for at least two to three weeks after subsiding of fever or after drainage.9 In our series two of the 12 patients died (17%). In a review of 367 cases the mortality rates for primary psoas abscess were 2.5% and for secondary psoas abscess 18.9%.4In conclusion, this series demonstrates that psoas abscess is not a very rare condition in major hospitals. Our small series is in accordance to other recent series showing an emerging of primary psoas abscess due to S. aureus. In addition, tuberculosis is also emerging again while second-ary psoas abscess due to diseases of the digestive tract was remarkably rare in our series.R E F E R E N C E S1.  Leu S-Y, Leonard MB, Beart RW, Dozois RR. Psoas abscess: changing patterns of diagnosis and etiology. Dis Colon rectum 1986;29:694-8.2.  Walsh TR, Reilly JR, Hanley E, Webster M, Peitzman A, Steed DL. Changing etiology of iliopsoas abscess. Am J Surg 1992;163:413-6.3.  Santaella RO, Fishman EK, Lipsett PA. Primary vs Secondary iliopsoas abscess. Arch Surg 1995;130:1309-13.4.  Ricci MA, Rose FB, Meyer KK. Pyogenic psoas abscess: worldwide variations in etiology. World Surg 1986;10:834-43.5.  Levin MJ, Gardner P, Waldvogel RA. “Tropical” pyomyositis. An unusual infection due to Staphylococcus aureus. N Engl J Med 1971;284:196-8.6.  Huang JJ, Ruaan MK, Lan RR, Wang MC. Acute pyogenic iliopsoas abscess in Taiwan: clinical features, diagnosis, treatments and outcome. J Infect 2000;40:248-55.7.  Kao PF, Tsui H, Leu HS, Tsai,MF, Tzen KY. Diagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning Urology 2001;57:246-51.8.  Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979;5:754-6.9.  Gordin F, Stamler C, Mills J. Pyogenic psoas abscesses: noninvasive diagnostic techniques and review of the literature. Rev Infect Dis 1983;5:1003-11.Van den Berge, et al. Psoas abscess.416

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Psoas abscess: report of a series and review of the literature

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Psoas abscess: report of a series and review of the literature

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