Ruxolitinib associated psoas muscle tuberculosis abscess in a primary myelofibrosis woman: A case report and literature review.

RATIONALE: Primary myelofibrosis is a subtype of myeloproliferative neoplasm that leads to bone marrow fibrosis. Historically, the only curative option for primary myelofibrosis was allogeneic hematopoietic stem cell transplant. Ruxolitinib, a Janus kinase inhibitor, is now used for the treatment of primary myelofibrosis and polycythemia vera. It effectively improves symptoms related to splenomegaly and anemia. However, its association with the development of opportunistic infections has been observed in clinical studies and practical application. PATIENT CONCERNS: A 64-year-old female with primary myelofibrosis and chronic hepatitis B infection who received ruxolitinib treatment. She was admitted for spiking fever and altered consciousness. DIAGNOSIS: Tuberculosis meningitis was suspected but cerebrospinal fluid can't identify any pathogens. An abdominal computed tomography scan revealed a left psoas abscess and an enlarged spleen. A computed tomography-guided pus drainage procedure was performed, showing a strong positive acid-fast stain and a positive Mycobacterium tuberculosis polymerase chain reaction result. INTERVENTIONS: antituberculosis medications were administered. The patient developed a psoas muscle abscess caused by tuberculosis and multiple dermatomes of herpes zoster during antituberculosis treatment. OUTCOMES: The patient was ultimately discharged after 6 weeks of treatment without apparent neurological sequelae. LESSONS: This case underscores the importance of clinicians evaluating latent infections and ensuring full vaccination prior to initiating ruxolitinib-related treatment for primary myelofibrosis.

A comparative perspective on brucellar, pyogenic, and tuberculous spondylodiscitis.

OBJECTIVE: Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes. PATIENTS AND METHODS: A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features. RESULTS: Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis. CONCLUSIONS: Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Endovascular Therapy of Aortic Rupture Secondary to a Psoas Abscess.

Secondary infection of the aorta is a sporadic and life-threatening disease. It is usually caused by infection and abscess in an adjacent structure. The most common mechanism for secondary aortic infection is a psoas abscess eroding the aortic wall, which rarely results in non-aneurysmal aortic rupture. Primary treatment is surgical aortic reconstruction, but the risk of emergency surgical treatment is high. Endovascular aortic stent-graft implantation can be lifesaving in this setting by stopping the bleeding. However, the crucial question of durability and late infections remains unanswered and warrants long-term antibiotic treatment and follow-up. In this report, we present a case of primary psoas abscess, which resulted in non-aneurysmal aortic rupture and its endovascular treatment.

Emphysematous cystitis, iliopsoas abscess, and pneumorrhachis in an elderly woman: a case report.

BACKGROUND: Emphysematous cystitis is a well-described life threatening complication of urinary tract infection, most commonly seen in patients with diabetes and typically caused by gas forming bacterial or fungal pathogens. Pneumorrhachis is the rare finding of gas within the spinal canal, most commonly reported in the context of cerebrospinal fluid leakage secondary to trauma or spinal instrumentation. To our knowledge there is only one other reported case of pneumorrhachis in the setting of emphysematous cystitis. CASE PRESENTATION: This is a single case report of pneumorrhachis in the setting of emphysematous cystitis. An 82-year-old Asian female patient originally from East Asia, with no prior medical history besides hypertension, presented to hospital with a chief complaint of acute on chronic neck pain and functional decline. Examination revealed nonspecific neurosensory deficits and suprapubic tenderness. Laboratory investigations demonstrated leukocytosis and extended-spectrum beta-lactamase containing Escherichia coli bacteremia and bacteriuria. Computed tomography showed emphysematous cystitis with widespread gas within the cervical and lumbar spinal canal, as well as multiple gas-containing soft tissue collections in the bilateral psoas muscles and paraspinal soft tissues. Despite prompt antimicrobial therapy the patient passed away within 48 hours from septic shock. CONCLUSIONS: Our case adds to a growing body of literature showing that the spread of air to distant sites, including the spine, may be a poor prognostic indicator in patients with gangrenous intraabdominal infections. This report highlights the importance of recognizing the causes and presentation of pneumorrhachis to facilitate early diagnosis and treatment of potentially life threatening and treatable causes.

Disseminated Tuberculosis in an Immunocompetent State: A Case Report.

BACKGROUND: Tuberculosis is one of the major infectious diseases of mankind and remains a significant health concern, especially in developing countries. Clinical manifestations of TB are broad and sometimes very challenging for clinicians to diagnose early. Tuberculous psoas abscess was generally secondary to spinal tuberculosis or direct extension from adjacent structures in immunocompromised individuals, but tuberculous psoas abscess in the immunocompetent state is very infrequent. In addition, pancytopenia and new onset neck swelling simultaneously make this presentation a very unusual clinical entity in tuberculosis. CASE PRESENTATION: We now present a case of a 21-years-old, unmarried, otherwise healthy girl presented with fever, lower abdominal pain and weight loss for two months. She also noticed painless neck swelling for 15 days. She later had a tuberculous left sided psoas abscess with pancytopenia and a cold abscess on the left side of the neck with no sign of any other apparent focus, according to the evidence. Diagnosis of disseminated TB without lung involvement was established and ATT was started. The outcome was successful on follow up. CONCLUSION: Among the broad spectrum of atypical manifestations of TB, this case report draws attention to its rarity, diagnostic challenge and awareness of the clinical spectrum, especially in developing countries.

Rare extension of pancreatic pseudocyst with Mycobacterium abscessus into the iliopsoas muscle.

Pancreatic pseudocyst is a well-known complication of both acute and chronic pancreatitis. Although extension into other anatomical sites is common, extension into the retrofascial space causing an iliopsoas abscess is exceedingly rare. Although its low incidence creates a diagnostic challenge for clinicians, early diagnosis is essential to prevent significant complications and poor patient outcomes. We present a case of iliopsoas abscess with unusual culture fluid growth in the setting of acute on chronic pancreatitis secondary to extension of a pancreatic pseudocyst. We also offer a brief review of the literature and pathophysiology of the condition.

Recurrent Iliopsoas Abscesses Due to Migrated Appendicular Fecalith: A Case Report and Review of the Literature.

CASE: Appendicular fecaliths have been reported to migrate to nearby organs before or during surgical treatment and become a late source of infection. We report an extremely rare case of recurrent iliopsoas abscesses caused by appendicular fecaliths that have migrated to the psoas muscle before or during the previous appendicectomy for acute appendicitis. In this case, surgical removal of fecaliths cured the iliopsoas abscess. CONCLUSION: Orthopaedic surgeons and gastroenterologists should remember that appendicular fecaliths that migrated into the iliopsoas muscle may cause late-onset iliopsoas abscesses.

Severe disseminated Veillonella parvula infection including endocarditis, bilateral psoas abscess, discitis, and osteomyelitis but sparing spinal and hip prostheses: a case report.

BACKGROUND: Veillonella species are an opportunistically pathogenic commensal anaerobic Gram-negative coccus commonly found in the oral, genitourinary, respiratory, and intestinal tract of humans and some animals. Infection is rare, even in immunocompromised hosts, and has been identified to cause a wide array of different infections, including endocarditis, osteomyelitis, and meningitis. CASE PRESENTATION: An 82-year-old Caucasian male retired ex-gymnast presented to the emergency department with a 2-week history of acute on chronic lower back pain without clear precipitant. He displayed no systemic symptoms, and had not sustained any recent injuries. Initial blood and radiological investigation did not reveal an infective or mechanical cause for his pain; however, a few days into admission, he developed a fever and signs of sepsis. A thorough septic screen was performed, including a spinal magnetic resonance imaging scan, which did not reveal any abnormalities. Blood cultures revealed Veillonella parvula bacteremia, with subsequently repeated magnetic resonance imaging displaying rapid disseminated infection including bilateral psoas abscess, discitis, and osteomyelitis. Infective endocarditis was later identified with echocardiogram. He received intravenous ceftriaxone and later oral amoxicillin and clavulanic and recovered on 6-month follow-up. CONCLUSIONS: This case illustrates the potential pathogenicity and unexpected rapid course of Veillonella parvula infection even in an immunocompetent host presenting with back pain. This case highlights the critical importance of a thorough septic screen when investigating patients for early signs of sepsis.

A missed psoas abscess diagnosis: A forensic case report.

Psoas abscess is a rare pathology that usually presents with non-specific signs and rare clinical features. These characteristics can delay the diagnosis leading to complications and death. We report a forensic autopsy case of a 65-year-old male, alcoholic, smoker, with a history of hypertension, and urinary infection, who presented to the emergency room for anorexia and consciousness disorder. On physical examination, the patient was febrile and confused. Laboratory exams revealed leukocytosis and elevated C-reactive protein (CRP). Two days later, he died despite extensive resuscitation. Forensic autopsy revealed a large amount of green pus in the left psoas muscle extending to the muscles of the thigh of the same side with multiple cavities. The pus extended to the left kidney with destructive parenchyma and coralliform lithiasis. Histological examination showed destroyed renal tissue by lesions of chronic and acute pyelonephritis with dilatation of the pyelocaliceal cavities. Bacteriological analysis of the pus showed the presence of Escherichia coli. The psoas abscess was secondary to pyonephrosis favored by the immunodeficiency. Thus, death was attributed to a septic shock secondary to a psoas abscess complicating pyonephrosis.

Single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation for the treatment of lumbar tuberculosis and psoas major abscess.

PURPOSES: To investigate the feasibility and clinical efficacy of the treatment for lumbar tuberculosis with psoas major abscess with single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation. METHODS: This retrospective study evaluated the clinical data of 24 patients (14 males and 10 females) with lumbar tuberculosis and psoas major abscess admitted to the Comprehensive Surgery from June 2016 to June 2019. All patients were treated with the single-stage posterior approach to remove the transverse process combined with the intervertebral foramina approach for debridement, interbody fusion, internal fixation. The quadruple anti-tuberculosis drug therapy was given both pre-operatively and post-operatively. Clinical symptoms and complications were investigated and recorded. The visual analogue scale (VAS), American Spinal Injury Association (ASIA), degree of lesion fusion C-reactive protein (CRP) levels, and erythrocyte sedimentation rate (ESR) were evaluated. RESULTS: The average follow-up period was 16. 5 months (from 12 to 36 months). The average VAS score at three months post-operation was significantly declined than the pre-operative VAS score [(2.17 ± 0.87) points vs (5.46 ± 1.22) points, t = - 11.534, P < 0.01)]. At the last follow-up, the neurological function of 20 patients recovered to grade E, whereas four patients were still in grade D. The ESR and CRP returned to normal levels in all patients. Bone fusion was achieved in nine cases at six months, 11 cases at nine months, and four cases at 12 months. The incisions of 23 patients had healed nicely without chronic sinus. Poor incision healing only happened in one case at the day 12 post-operation. The bone grafts among the lesions obtained bony fusion. Besides, there was no recurrence of tuberculosis, loosening or fracture of internal fixation during the follow-up. CONCLUSION: Single-stage posterior resection of the transversal process combined with an intervertebral foramina approach for debridement, interbody fusion, internal fixation is probably an effective and safe approach of the treatment for lumbar tuberculosis combined with psoas major abscess, producing few complications. This technique provides an alternative method for the surgical treatment of lumbar tuberculosis combined with psoas major abscess.

Six-stage revision surgery of a triple periprosthetic joint infection due to a delayed diagnosis of a bilateral psoas abscess: a case report.

CASE: We present a case of a 70-year-old woman with simultaneous periprosthetic joint infection (PJI) of both hips and left knee due to a bilateral psoas abscess. The patient underwent debridement and implants removal with the consequent reimplantation in a sequential six-stage revision surgery. At four years of follow-up and in spite of the patient's comorbidities and current PJI presentation, she maintains full activities of daily living without restrictions. CONCLUSION: Accurate and early diagnosis of a psoas abscess is crucial. This case report provides experience of a complex scenario, the decision-making involved and the outcomes of an underdiagnosed complication.

Single-stage posterior-only debridement, decompression and interbody fusion for the treatment of thoracolumbar spinal tuberculosis complicated with psoas abscesses.

BACKGROUND: To explore the clinical safety and efficacy of single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion combined for the treatment of thoracolumbar spinal tuberculosis complicated with psoas abscesses. METHODS: A total of 38 patients diagnosed with thoracolumbar spinal tuberculosis complicated with psoas abscesses underwent surgery via single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion from January 2010 to September 2016 were enrolled in the study. The clinical efficacy of the approach was assessed based on parameters including operating time, blood loss, Cobb angle, visual analogue scale (VAS) scores, Frankel grade, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). RESULTS: The surgery duration was 224.4 ± 71.1 min with a blood loss of 731.8 ± 585.8 ml. The Cobb angle was corrected from 16.0 ± 15.4° preoperatively to 8.1 ± 7.4° postoperatively (P < 0.001, t = - 4.38), and returned to a level of 11.0 ± 8.5° at the final follow-up (P = 0.002, t = 3.38). Back pain was relieved, with the mean preoperative VAS of 3.5 ± 1.1 decreased to 0.7 ± 0.8 postoperatively (P < 0.001, t = 23.21) and then to 0.6 ± 0.5 at the final follow-up (P < 0.001, t = 17.07). Neurological function was improved in various degrees and psoas abscesses disappeared in all patients. The ESR and CRP decreased gradually after surgery and returned to normal at the final follow-up in all patients. All patients achieved bone fusion thoroughly and no recurrence of TB or surgical related complications was found at the final follow-up. CONCLUSION: Single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion is a safe and effective approach for the management of thoracolumbar spinal tuberculosis complicated with psoas abscesses.

Lumbosacral spondylodiscitis complicated by sepsis, osteomyelitis, epidural abscess formation and deep vein thrombosis.

A 71-year-old man presented with a 3-month history of low back pain radiating to his right hip and thigh associated with lower limb weakness and constitutional symptoms. Imaging confirmed a lumbosacral spondylodiscitis at L2-3 and L5-S1 as well as a right-side psoas abscess which was treated with urgent CT-guided drainage and intravenous antibiotics. His admission was complicated by a number of issues, including the development of osteomyelitis with vertebral body destruction at multiple sites, epidural abscess formation and deep vein thrombosis. Additionally, the patient developed severe sepsis which necessitated admission to the intensive care unit. The patient's clinical condition improved gradually with intravenous antibiotics until he was well enough for transfer to a rehabilitation centre, where he underwent regular occupational and physical therapy. Repeat imaging showed overall resolution of the aforementioned pathologies and is currently being followed up by the spinal surgeons on an outpatient basis.

Treatment of Psoas abscess related coxarthrosis due to salmonella infection in a patient with chronic renal failure. A case report.

INTRODUCTION: The most common microorganisms isolated from septic arthritis are staphylococcus aureus and streptoccocci. Septic arthritis due to Salmonella spp. is extremely rare. PRESENTATION OF CASE: A 55-year-old man, chronic renal failure, is admitted hip arthtritis with newly arised symptoms. The findings were not compatible with primary arthritis. The laboratory findings which include white blood cell count, erythrocyte sedimentation rate (esr) and c-reactive protein (crp) were elevated. In magnetic resonance (mr) imaging there were psoas abscess and septic arthritis of the hip. They were treated by drainage. The culture was confirmed as Salmonella spp. Antibiotic treatment were done. DISCUSSION: Uremia in patients with chronic renal failure is associated with a state of immune dysfunction. In our case, uremia may cause immunosuppressive conditions and hematogenous dissemination of salmonella. CONCLUSION: Salmonella infection in a patient with chronic renal failure may be occured. It must be kept in mind that early diagnosis, administration of appropriate systemic antibiotics and surgical intervention play a pivotal role in successful management. KEY WORDS: Arthritis, Failure, Psoas, Salmonella Renal Abscess.

Invasive pneumococcal disease confirmed in five different sites including Austrian syndrome in a male patient with methamphetamine abuse.

A 60-year-old man with no significant medical history was found unresponsive by his neighbour; he had neck stiffness on physical examination in the emergency department. He later developed acute hypoxic respiratory failure requiring endotracheal intubation. He is a binge drinker on weekends, and methamphetamine was detected in his urine. Contrast-enhanced CT of the chest, abdomen and pelvis revealed multifocal pneumonia, bilateral psoas abscesses and right infraspinatus muscle abscess. Blood, sputum and cerebrospinal fluid cultures grew Streptococcus pneumoniae Transthoracic echocardiography (TTE) revealed tricuspid endocarditis with mild valve insufficiency. He was initially treated with intravenous antibiotics and underwent incision and drainage of right psoas abscess. However, he still had recurrent fever and confusion. Repeat TTE showed larger vegetation, and he also developed septic emboli at the posterior basal right lower lobe pulmonary artery. The patient underwent tricuspid valve debridement and was finally discharged after completing 6 weeks of intravenous antibiotic treatment.

"There is more than what meets the eye" - Extensive spinal tuberculosis presenting as ocular tuberculosis.

Ocular tuberculosis (OTB) is a rare form of extrapulmonary Tuberculosis (EPTB) and a rare presenting feature of tuberculosis (TB) in children. We report such a case in a 3-year-old boy who presented with a painless swelling over left upper eyelid. Mycobacterium tuberculosis bacilli were isolated from the swelling by a Fine Needle Aspiration Cytology (FNAC) which confirmed the diagnosis. Investigating him for the extent of disease, we found him to have intracranial extension to involve the ethmoid sinus on contrast enhance Computed Tomography and Pott's disease causing a compression fracture of L3 with bilateral paravertebral collection, epidural extension and a left psoas abscess on Magnetic Resonance Imaging. After starting antitubercular therapy, the child is doing well and on regular follow up. We are presenting this case to highlight the fact that extensive spinal tuberculosis can present without any neurological deficit and may even present only as a benign looking orbital swelling.