A comparative study to evaluate the feasibility of preoperative percutaneous catheter drainage for the treatment of lumbar spinal tuberculosis with psoas abscess.

BACKGROUND: Spinal tuberculosis is a frequent cause of psoas abscess (PA), and PA largely negates the efficacy of antituberculosis therapy. This study aimed to investigate the clinical outcome of preoperative percutaneous catheter drainage (PCD) in patients with lumbar spinal tuberculosis and PA. METHODS: Between January 2015 and January 2017, 72 patients with lumbar spinal tuberculosis with PA were assigned to group A (preoperative PCD) and group B (n = 36 per group). All patients received posterior pedicle screw fixation and anterior focal debridement and fusion. Data on intraoperative blood loss, the duration of the surgery, and the length of the anterior incision were recorded, as well as the postoperative anal exhaust time, visual analogue scale (VAS), Cobb angle, lumbar vertebra function, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and sinus tract formation. RESULTS: Sixty-eight patients were followed up for an average time of 13 months (range 6-21 months). Until the final follow-up, no mixed infections, recurrence of tuberculosis, pedicle screw loosening, or screw pullout had occurred. There were significant between-group differences in blood loss, surgery duration, anterior incisional length, postoperative anal exhaust time, and sinus tract formation. As compared with group B, the ESR and CRP levels of the patients in group A were markedly improved following 3 weeks of antituberculosis therapy and 1 week postsurgery. CONCLUSION: Preoperative PCD helps to increase the efficacy of antituberculosis therapy prior to surgery, reduce surgical trauma, and avoid postoperative complications, making it a safe and feasible treatment option for lumbar spinal tuberculosis with PA.

Surgical management of psoas abscess in the Human Immunodeficiency Virus era.

OBJECTIVES: Thai aims of this study were to provide an epidemiological and microbiological analysis of psoas abscess in the human immunodeficiency virus (HIV)-infected population, and to describe the optimal investigative and management approach of this condition. METHODS: A retrospective chart analysis of 20 patients with a diagnosis of psoas abscess admitted to a regional academic hospital from January 2012 to December 2014 was performed. RESULTS: Twenty patients with psoas abscess were identified, of which 14 were HIV positive (70%) and five HIV negative (25%). One patient remained untested (5%). The mean CD4 count was 402 cells/mL (range 150-796 cells/mL, median 367 cells/mL). Acid fast bacilli were positive in psoas abscess aspirates in 13 cases (65%). Staphylococcus aureus and Escherichia coli were identified in 15% of cases. The radioisotope bone scan showed increased vertebral uptake in 10 patients (62.5%), with the lumbar spine (L1-L4) being most commonly involved (31%). There was a statistically significant increase in radioisotope uptake in the lumbar vertebrae in tuberculous psoas abscess than in pyogenic psoas abscess (p=0.003). Ultrasound-guided percutaneous drainage was used in 16 patients (80%) with a success rate of 87.5%; only two cases required repeat drainage (12.5%). Open drainage was used in four patients (30%) with a 100% success rate. There were no mortalities at 30-day follow-up. CONCLUSION: Tuberculous psoas abscess from underlying vertebral osteomyelitis is more common than pyogenic psoas abscess. Ultrasound has high diagnostic accuracy and guides percutaneous drainage with excellent success rates. Ultrasound-guided percutaneous drainage should be regarded as the first-line therapeutic modality.

Variabilidad en el origen del absceso del músculo iliopsoas a lo largo del tiempo. ¿Sesgo de publicación o una auténtica realidad? / Worldwide variations over the years in etiology of iliopsoas abscess. Reality or a selection bias?

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Etiology and outcome of iliopsoas muscle abscess in Korea; changes over a decade.

OBJECTIVES: Iliopsoas muscle abscess (IPA) is considered a rare disease whose etiology has changed depending on the country and antibiotic selection pressure. This study evaluates the changes in etiology, clinical outcome, and risk factors for mortality for IPA. METHODS: We reviewed the medical records of a total of 116 patients with IPA who were admitted to 4 university hospitals in Korea over the 11 years, and compared the etiology between 2001 and 2006 (period 1, n = 44) and 2007­2012 (period 2, n = 72). RESULTS: Among 75 cases with a definitive microbial diagnosis, the predominant etiological organisms were Staphylococcus aureus (45.3%), followed by Mycobacterium tuberculosis (14.7%) and Klebsiella pneumoniae (9.3%). The percentage of MRSA in period 2 increased remarkably compared to period 1, from 25% to 44.4%, and incidence of M. tuberculosis from 7.1% to 19.1%, although these were not statistically significant. The overall mortality was 6.8% in period 1, and 13.9% in period 2, and sepsis as an initial manifestation (OR 293.5, CI 7.1­12,034.4, P = 0.003) and serum creatinine level (OR 0.43, CI 0.23­0.80, P = 0.008) were independent predictors of mortality. Invasive procedure improved the prognosis in cases with microbiologic confirmed pyogenic psoas abscess (46/50 [92%] vs. 9/14 [64.3%], P = 0.008). CONCLUSION: The incidence of MRSA as a cause of IPA is on the increase. Although the overall prevalence of tuberculosis is decreasing, tuberculosis is still an important cause of IPA. Initial clinical status and invasive intervention can lead to favorable outcomes.

[Primary psoas abscesses of the psoas muscle in children]. / Les abcès primitifs du psoas chez l'enfant.

BACKGROUND: Primary psoas abscesses of the psoas muscle are relatively rare in childhood and can determine problems of diagnosis and therapeutic assumption. AIM: To demonstrate that ultrasonography is an excellent means in diagnosis and treatment of psoas abscess in children limiting the use of CT more costly and radiant and the surgery that is decaying. METHODS: Over a 15 years period (January 1995-december 2009), 16 children with psoas abscess were studied retrospectively. The diagnosis gait was based on questioning, clinical examination and imaging techniques and, in first sight, ultrasonography. RESULTS: Median age of our patients was 6.4 years (extremes 18 months-14 years) and mean delay of evolution was 12 days. Fever and lumbar pain were both constants, associated with another signs like painful boitery, psoitis, mictional burns and lumbar mass. The ultrasonography made in 16 patients allowed to the diagnosis in all cases. The tomodensitometry, made in 3 patients, confirmed the ultrasonography. Echo guided percutaneous drainage, made in 14 cases, was successful in 12. The examination of pus showed S Aureus in 11 cases and E coli in the other. CONCLUSION: Ultrasonography is a very important means in the primary psoas abscess in children. In addition to give diagnosis, this technique allows the drainage and the cure of the collection, limiting the open surgery to some particular cases.

[Iliopsoas abscess: therapeutic approach and outcome in a series of 35 patients]. / Absceso del músculo iliopsoas: tratamiento y evolución en una serie de 35 pacientes.

INTRODUCTION: The present study was aimed at reviewing the iliopsoas abscess (IPA) from a contemporary perspective, on the basis of experience from two tertiary referral centres. MATERIAL AND METHODS: We performed a retrospective analysis of 35 cases of IPA diagnosed between 1998 and 2009. Their clinical and microbiological features were recorded, as well as their long-term outcome according to the type of treatment: antibiotics alone (10 patients), or antibiotics plus percutaneous drainage or surgery (25 patients). RESULTS: Primary abscess occurred in 8 patients. The most frequent source of secondary abscesses was spondylodiscitis. The classic clinical triad (fever, pain and functional impairment) was present in 10 patients, with a median duration of symptoms before diagnosis of 12 days. Staphylococcus aureus was the most frequently isolated microorganism. At the end of a median follow-up of 454 days, the risk of poor outcome (related death and/or relapse) was higher among patients with diabetes mellitus (44.4% vs. 7.7%; P=.027), with no significant differences according to the therapeutic approach (20.0% in the group of antibiotics alone vs. 28.0% in the group with drainage or surgery). CONCLUSIONS: In our series, most cases of IPA were due to S. aureus and secondary to a skeletal source. Antibiotic therapy seems effective in the long-term, although diabetic patients had a higher risk of relapse.

Increasing incidence of iliopsoas abscesses with MRSA as a predominant pathogen.

OBJECTIVES: Iliopsoas abscesses (IPAs) are rare infections involving purulence within the muscles of the iliopsoas compartment, seldom due to Methicillin-resistant Staphylococcus aureus (MRSA) historically. This study was designed to evaluate the clinical characteristics and outcomes of patients with IPAs. METHODS: A retrospective analysis of the demographics, clinical presentation, microbiologic data and treatment modalities among patients with IPAs from 1993 to 2007 at The Johns Hopkins Hospital was performed. RESULTS: Among 61 patients with IPAs, infection rates increased from 0.5 cases/10,000 admissions (1993-2004) to 6.5 cases/10,000 admissions (2005-2007) (P < 0.001). An adjacent infectious focus was identified in 80% of patients, from skeletal (48%), intra-abdominal (23%), vascular (5%), genitourinary (3%), and cutaneous sources (2%). During 2005-2007, MRSA became a predominant pathogen, accounting for 25% of all cases and 37% of cases with a definitive microbiologic diagnosis (P = 0.006). Patients with IPAs >2 cm were more likely to undergo drainage, with trends toward longer hospitalizations, longer antibiotic courses, and increased odds of securing a definitive microbiologic diagnosis. CONCLUSIONS: Since 2005, rates of IPA have dramatically increased, with MRSA now the leading cause of infection. Knowledge of common pathogens should guide antimicrobial therapy including empiric coverage for MRSA in institutions with similar populations, especially if culture data are not available.

[Retrospective evaluation of 15 cases with psoas abscesses]. / Psoas apsesi olan 15 hastanin retrospektif olarak degerlendirilmesi.

Psoas abscesses are suppurative collections within the fascia surrounding the psoas and iliacus muscles. In this retrospective study it was aimed to evaluate the demographic characteristics, clinical and laboratory findings and treatment outcomes of 15 psoas abscess cases admitted to Baskent University Hospital, Ankara, Turkey during June 2003-January 2008 period. The mean age of the patients was 55.8 years (range 18 to 70 years) with a female to male ratio of 5/10. Thirteen of the cases (86.5%) were admitted with the complaints of fever and back pain. Thirteen of the cases were diagnosed by abdominal computerized tomography while the other two by abdominal ultrasonography. One of the 15 patients was considered as primary psoas abscess, while the remaining 14 as secondary psoas abscess. The most common accompanying disease was diabetes mellitus (66.6%). Fourteen patients with secondary psoas abscess had vertebral osteomyelitis which was due to tuberculosis in five cases, to urinary tract infection in five cases, to pneumoniae in two cases, to surgical infection in one case and to brucellosis in one case. The cultivation of the abscess material from the 14 secondary psoas abscess cases revealed growth of bacteria in 11 of them (5 Mycobacterium tuberculosis, 1 Escherichia coli, 1 methicillin-sensitive Staphylococcus aureus, 1 methicilin-resistant S. aureus, 1 Acinetobacter baumannii, 1 Brucella melitensis, 1 Serratia marcescens). The biochemical parameters of the cases (mean leukocyte counts: 14.500 cell/mm3; mean erythrocyte sedimentation rates: 78 mm/hour; mean C-reactive protein levels: 108 mg/dl) were also high. Thirteen patients underwent percutaneous drainage and received appropriate antibiotic treatment and the other two patients were treated with open surgical debridement. The duration of antimicrobial treatment was one year for M. tuberculosis cases and about 4-6 weeks in the others. One of the cases died due to complicating meningitis and sepsis. It is remarkable that in our series none of the psoas abscess cases were secondary to the diseases of the digestive tract unlike the series indicated in the literature. The isolation of M. tuberculosis as the causative agent in 5 (33.3%) cases emphasizes the fact that tuberculosis is still an important public health problem in Turkey.

Septic arthritis of the hip with psoas abscess caused by Non-typhi Salmonella infection in an immunocompetent patient.

Osteoarticular infections caused by Non-typhi Salmonella are exceptionally encountered. We report a case of a bacteriologically documented hip infection associated with a psoas abscess due to Non-typhi Salmonella. A 64-year-old immunocompetent male was admitted in our department for pain and motion range limitation in the right hip with fever. Non-typhi Salmonella was recovered in joint fluid obtained by needle aspiration. Antimicrobial chemotherapy combined with surgical intervention was necessary for eradication of the infection. Physicians should be aware of this rare manifestation of Non-typhi Salmonella infections in non-debilitated patients.

Psoas abscess - not as rare as we think?

OBJECTIVE: Iliopsoas abscess (IPA) is a rare condition with a reported worldwide incidence of 12 new cases per year with primary abscesses now predominating. The presentation is often vague and the diagnosis not considered. METHOD: The medical records of 15 consecutive patients presenting to our hospital in a 3-year period with IPA were reviewed. Demographic data, presenting features, predisposing factors and the investigations performed were recorded. Abscesses were classified as primary or secondary and the treatment provided and eventual outcomes were analysed. RESULTS: Fifteen patients (eight males) were included. Nine patients were pyrexial on admission, 14 were anaemic and all had raised inflammatory markers. Only five patients presented with the classical triad of pain, fever and limp. The median time to diagnosis was 3 days with a median hospital stay of 27 days (range 7-243 days). Fourteen patients were diagnosed by computed tomographic scan. Three patients were treated with antibiotics alone whilst 11 received percutaneous drainage (PCD) as well. Of these, five had recurrence following initial drainage, needing further PCD procedures but none needed open drainage. Only one patient underwent open drainage initially. The mortality rate was 20%. CONCLUSION: The incidence of IPA is probably under-reported. The vague presentation leads to delays in diagnosis and increases morbidity and a high index of suspicion is the key to early diagnosis. Percutaneous drainage with antibiotics is the first line of treatment although recurrence rate is high. Open drainage allows simultaneous treatment of underlying pathology in secondary abscesses.

Iliopsoas abscess: analysis and perspectives from an endemic region of Eastern Nepal.

OBJECTIVE: To evaluate the clinical profile and outcome in patients with iliopsoas abscess. METHODS: A descriptive study was carried out in B.P. Koirala Institute of Health Science, Dharan, Nepal from February 2005 to March 2006. The medical records of all thirty six patients admitted in surgery ward with diagnosis of iliopsoas abscess during the study period were analyzed. RESULTS: Thirty six patients were included the study. There were 22 (61.1%) males and 14 (38.9%) females with a mean age of 24.33 +/-19.19 years. Demographic distribution of the patients revealed the highest number 13 (36.1%) from Sunsari district, eastern part of the country. Right sided unilateral involvement was the most common presentation and only 2 cases had bilateral involvement. In none of our patients the dorsolumbar spine radiograph revealed any involvement of the bone. The most common complaints were pain in lower abdomen and lump in iliac fossa with flexion deformity at hip joint. All the patients underwent open surgical drainage and their outcomes were analyzed in term of cure, morbidity and mortality. Staphylococcus aureus was the most common organism 24 (61.5%) isolated. Twenty two (91.66%) of Staphylococcus aureus samples were sensitive to ciprofloxacin. There was one mortality in the group who died of septicaemia secondary to necrotizing fascitis. Six patients had wound infection, which were cured by regular dressing. CONCLUSION: On the basis of our experience and review of available relevant literature, we can conclude that a high index of suspicion and awareness of the varying clinical picture are required to diagnose this condition properly. Ultrasonography should still be the preferred imaging modality as it is cheap, safe, cost effective and readily available. Ciprofloxacin should be used as a first line drug. Image guided aspiration may be practical in selected cases having little pus and traditional open drainage should be considered without hesitation.

[Psoas abscesses. An up-dated perspective]. / Abscesos del psoas. Una perspectiva actual.

OBJECTIVE: To analyze the characteristics of abscesses of the psoas muscle and assess the differences between pyogenic and tuberculous abscesses. METHODS: Retrospective descriptive study of all patients with psoas abscess in our hospital over the period 1994 to 2004. RESULTS: Fourteen patients were studied (10 males), with a mean age of 42 years. Half of them had had an underlying disease. The most frequent clinical manifestations were abdominal pain (64%), fever (57%), and back pain (43%). All the abscesses were secondary. In 7 patients the origin was gastrointestinal, in 6 osteoarticular, and 1 was related with infection of an aortobifemoral bypass. Computed tomography was the diagnostic imaging method in all patients. Culture of drainage specimens was positive in 92% of patients undergoing this procedure. Causal microorganisms included Mycobacterium tuberculosis (5), Streptococcus intermedius (4), Staphylococcus aureus (3), Escherichia coli (3) and Bacteroides fragilis (2). Tuberculous abscesses originated in spondylitis and the clinical presentation was longer prior to diagnosis. Drainage was performed in 12 patients (8 percutaneous and 4 surgical). Mean duration of antimicrobial therapy was 4 weeks. The infection resolved in all patients. CONCLUSIONS: Psoas abscess commonly had a gastrointestinal and osteoarticular origin. We underscore the high percentage of tuberculous etiology, which had a more insidious clinical and analytical presentation and was usually secondary to spondylitis. Prolonged antimicrobial treatment associated with drainage was effective therapy.

Abscesos del psoas. Una perspectiva actual / Psoas abscesses. An up-dated perspective

Objetivo. Analizar las características de los abscesos del músculo psoas y evaluar las diferencias entre los abscesos piógenos y tuberculosos. Métodos. Estudio retrospectivo descriptivo de los pacientes con absceso de psoas en nuestro hospital en el período 1994-2004. Resultados. Se incluyeron 14 pacientes, 10 varones, con una edad media de 42 años. El 50% tenía una enfermedad de base subyacente. Las manifestaciones clínicas más frecuentes fueron dolor abdominal (64%), fiebre (57%) y dolor lumbar (43%). Todos los abscesos fueron secundarios. En siete el origen fue gastrointestinal, en seis óseo y uno en relación con infección de un by-pass aortobifemoral. La tomografía computarizada fue la prueba de imagen diagnóstica en todos los pacientes. El cultivo del drenaje fue positivo en el 92% de los casos realizados. Los microorganismos causales fueron Mycobacterium tuberculosis (5), Streptococcus intermedius (4), Staphylococcus aureus (3), Escherichia coli (3) y Bacteroides fragilis (2). Los abscesos tuberculosos tuvieron su origen en una espondilitis y presentaron una duración mayor de la sintomatología previa al diagnóstico. En 12 casos se realizó drenaje (8 percutáneos y 4 quirúrgicos). La duración media del tratamiento antimicrobiano fue de 4 semanas. Se produjo la curación en todos los pacientes. Conclusiones. El absceso de psoas suele tener un origen gastrointestinal y osteoarticular. Destacamos la elevada proporción de etiología tuberculosa, con un carácter más insidioso en su presentación clínica y analítica, y habitualmente secundario a una espondilodiscitis. La antibioterapia prolongada asociada a drenaje representa una terapia eficaz (AU)

Objective. To analyze the characteristics of abscesses of the psoas muscle and assess the differences between pyogenic and tuberculous abscesses. Methods. Retrospective descriptive study of all patients with psoas abscess in our hospital over the period 1994 to 2004. Results. Fourteen patients were studied (10 males), with a mean age of 42 years. Half of them had had an underlying disease. The most frequent clinical manifestations were abdominal pain (64%), fever (57%), and back pain (43%). All the abscesses were secondary. In 7 patients the origin was gastrointestinal, in 6 osteoarticular, and 1 was related with infection of an aortobifemoral bypass. Computed tomography was the diagnostic imaging method in all patients. Culture of drainage specimens was positive in 92% of patients undergoing this procedure. Causal microorganisms included Mycobacterium tuberculosis (5), Streptococcus intermedius (4), Staphylococcus aureus (3), Escherichia coli (3) and Bacteroides fragilis (2). Tuberculous abscesses originated in spondylitis and the clinical presentation was longer prior to diagnosis. Drainage was performed in 12 patients (8 percutaneous and 4 surgical). Mean duration of antimicrobial therapy was 4 weeks. The infection resolved in all patients. Conclusions. Psoas abscess commonly had a gastrointestinal and osteoarticular origin. We underscore the high percentage of tuberculous etiology, which had a more insidious clinical and analytical presentation and was usually secondary to spondylitis. Prolonged antimicrobial treatment associated with drainage was effective therapy (AU)

Seventy cases of non-tubercular psoas abscess at a rural referral centre in South Bengal.

About 70 patients admitted with psoas abscess are reviewed. The ratio of non-tubercular to tubercular psoas abscess was 6:1 and left-to-right psoas involvement was 1.6:1. Iliac fossa mass and neutrophilic leucocytosis were found in all the patients without any underlying bony involvement. Ultrasonography and needle aspiration of pus were followed by surgical drainage. Staphylococcus aureus was the most common organism cultured.

Successful treatment of a ruptured infected aneurysm of the lumbar artery with transcatheter embolization.

We report a patient who had an infected aneurysm of the lumbar artery caused by prolonged psoas abscess-forming spondylitis due to methicillin-resistant Staphylococcus aureus and who was treated successfully with transcatheter arterial embolization. This case suggests that an infected aneurysm can be treated successfully by transcatheter arterial embolization in emergent situations (active bleeding or septicemia) even if surgery is contraindicated.

Psoas abscess: a rare complication of Crohn's disease.

UNLABELLED: Psoas abscess is a rare complication of Crohn's disease. METHODS AND MATERIALS: We evaluated the incidence of psoas abscess on 312 patients with Crohn's disease, seen at our institution between 1992-2001. RESULTS: We encountered three cases of psoas abscess (0.9%). One patient was managed with ileocolic resection and immediate anastomosis, while in two patients a percutaneous drainage was first performed and then, after 12 days of total parenteral nutrition, a resection of the diseased bowel with immediate reconstruction was carried out. CONCLUSIONS: A correction of the nutritional deficiencies is mandatory. Percutaneous computed-tomography guided drainage of the abscess with intestinal resection with immediate anastomosis, performed after a parenteral hyperalimentation, should be the method of choice in the management of such patients.