A review of worldwide literatures published from 1881 through 1990 has revealed that the incidence of psoas ab scesses is around 4 cases per year However a recent en demic study in Taiwan reported that the rate of occur rence was 25 cases annually D ID: 46359
Download Pdf The PPT/PDF document "n uncommon clinical phenomenon psoas mus..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
nuncommonclinicalphenomenon,psoasmuscleabscessisextremelydifficulttodiagnoseandneedstobeinvestigatedwithconsiderablethoroughness.Areviewofworldwideliteraturespublishedfrom1881through1990hasrevealedthattheincidenceofpsoasabscessesisaround4casesperyear.However,arecentendemicstudyinTaiwanreportedthattherateofoccurrencewas2.5casesannually. Hsin-PeiYinYun-AnTsaiSu-FenLiaoPei-HisnLinTien-YowChuangDepartmentofPhysicalMedicineand KeyWordsfeverofunknownorigin(FUO);inflammatorygalliumscan;CaseReportTheChallengeofDiagnosingPsoas Received:April10,2003.Accepted:October2,2003. Correspondenceto:Tien-YowChuang,MD,DepartmentofPhysicalMedicineandRehabilitation,TaipeiVeteransGeneralHospital,201,Sec.2,Shih-PaiRoad,Taipei112,Taiwan.Tel:+886-2-2875-7296,Fax:+886-2-2875-7359,E-mail:tychuang@vghtpe.gov.tw CASEREPORTA39-year-oldmancheckedinattheemergencyfacilityofTaipeiVeteransGeneralHospitalon15June,1999,complainingofseverelowbackpain.Hehadbeeninhisusualstateofhealthuntil2daysbeforethevisit,whenhebegantosufferfromalumbarstrainduringalongdistanceflight.Thepatientspainwasrecordedassharpandofprogressivelymountingintensity.Thepatienthadnohistoryofrecentinfectionandwasfreeofmedication.Acompletebloodcountandcomprehensiveserumbiochemicalanalysisrevealedmoderatebacteriuria.PlainradiographsoftheKUBandlumbarspinesalsorevealedunremarkableresults.Thepatientwasconsequentlydischargedwithoralantibioticsandnonsteroidanti-inflammatorydrugs.Twoweekslater,thepatientsoughtmedicalattentionagainforsimilarcomplaints,aswellasforabdomenpainovertherightquadrant.Furtherlaboratorytestswereadministered,whichrevealednousefulinformationthatmightcontributetoadiagnosis.AnabdominalultrasonographyandCTofthelumbosacralspineswithoutcontrastmediumadministration(Fig.1A)didnotdemonstrateanysignificantfindingsexceptbulgingdisksatmultiplelevels.Thepatientwasadmittedtotherehabilitationunitthefollowingdaywithflankpainandalimp.Atthispoint,thepatientmentionedthathehadsufferedfromaminorlowbackpainamonthearlier.Intherehabilitationunit,aphysicalexaminationconfirmedthatthepatientwasapyrexial.Hehadnormalbloodpressureandaheart,lungandabdomenexaminationwhichrevealednothingunusual.Wefoundthatspineextension,bendingandsupinestraightlegraisingcausedthepatientsignificantpain.Aknockingpainovertherightlowerbackandtendernessoverthelowerabdomenwerealsodisclosed.Thepatientalsohaddifficultyinputtingafootforward.Histemperatureroseto38.31dayafteradmission.Acompletebloodexaminationshowedawhitebloodcell March2004PsoasAbscess Fig.1.)IsodenseinfectivetissuemightbemergedwithdiscontheinitialunenhancedCTatL2/3.()T2-weightedimagesshowsL2-3disc(arrow)and()psoasabscesses(arrow).()SagittalT1-weightedimagefollowingcontrastadministrationdemonstrateshyperintensevertebralbodiesalongtheL2/L3segment(arrow). countof13,700/mm(89%neutrophils),C-reactiveprotein(CRP)of11.0mg/dLandnormalhemoglobin.Aurineanalysisandotherroutinebiochemicaltestresultswerewithinnormallimits.AWidaltest,Well-Felixtest,Anti-HIVandbloodcultureallproducednegativeresults.Anelectrodiagnostictestrevealednormalfindings.Repeatultrasonographyoftheabdomenandbackwasunremarkable.Broad-spectrumantimicrobialtherapy(cefmetazole1gmivq6h)wasadministeredundertheimpressionoffeverofunknownorigin(FUO).Afollow-upwhitebloodcellcountrevealed11,100/mm(85%neutrophils)onthetenthdayafteradmission.After2weeksofhospitalization,backpainandlow-gradefeverpersisted;therefore,aninflammatorygalliumscanwasperformed,whichrevealedactiveinfectionattheL2vertebraandsofttissueoftheL3paraspinalregion.Inordertoconfirmthediagnosis,MRIwasthenperformed.ThisshowedabnormalenhancementatthevbodiesoftheL2andL3vertebrae,prevertebralsofttissueandbi-lateralpsoasmuscles(Figs.1B,1C,1D).ACT-guidedpercutaneousaspirationrevealed10ccyellowishpus,butyieldednomicro-organisms,includingacid-faststain,bacteriaandfungusculture.However,oxacilliniv500mgq6hwasinitiated,owingtoasuspiciouspsoasmuscleab-scessandlumbarosteomyelitis.Thefeverabatedandwhitecellcountsrecoveredtonormalvalues.Thebackpaindiminishedafter7daysofantibiotictherapy.Twoweekslater,theantibioticwasshiftedtoteicoplanineiv400gmqdbecauseofelevatedAST.After3weeksofantibiotictherapy,thefollow-upMRIpostGd-DTPAadministrationrevealedaresolutionofthepsoasabscess.However,therestillremainedabnormalenhancementintheL2-3disc,thelowerpartoftheL2vertebralbody,theupperpartoftheL3vertebralbody,theprevertebralareaandatthebilateralparaspinalregion.Thepatientrecoveredwellwithmildlowbackpainandwasdischargedafter2monthsofhospitalization.Hecompletedanoutpatientantibioticcourseafterwards,andanexamination8monthslaterconfirmedthathehadremainedwell.Psoasabscessisclassifiedasprimaryorsecondary,dependingonitsunderlyingcauses.Primarypsoasabscessismostprevalentinolderpatients.InTaiwan,2retrospectivereviewswerecarriedout,and20percent(8outof40patients)wereclassifiedashavingprimaryabSeveralpointsdeservediscussionwithrespecttothediseasecourseandimagestudiesofouryoungpatient.Firstly,hewalkedtotheemergencyfacilityindependentlyandstressedhisascendantlumbarstrainduringtheflight.Onexamination,therewerenofeverandnolongtractsigns,andhedemonstratednormalreflexes.BoththeplainfilmsofL-spineandabdomenwereunremarkable.Theonlyabnormalfindingwasamoderatebacteriuria.Afterreceivingadiagnosisofurinarytractinfection,thepatientwasdischarged.Aswiththiscase,patientsdonotnecessarilydisplaytheclassiccombinationsymptomsoffever,flank/abdominalpainandbackpain.Othersigns-aheightenedsedimentationrate,limitationintheflexingandexternalrotationoftheipsilateralhip,leukocytosisandanemia-mayappearonlyslightlyornotatall,aswasthecasewithourpatient.Fewphysicians,con-frontedwithcircumstancessuchasthese,wouldcon-siderpsoasabscessandlumbarosteomyelitisatthefirstSecondly,ifalesionweretoosmalltorevealsofttis-suegas,spinaldestruction,masseffectsorunusualiliopsoas,plainfilmswouldonlyrevealnegativefind-ings.Ultrasoundhasbeenrecognizedasthefastest,leastexpensiveandsafediagnosticimaging.Itcanalsodifferentiatebetweensolidsandfluids.nately,ultrasoundislesssensitive,asitcannotpenetrategasorbonesituatedinthesuspiciousarea.Inthiscase,wepostulatedthatthesourceofthepsoasabscessmightarisefromcontiguousstructuresofL2-3discinfectionandosteomyelitisandspreaddirectly.Attheinitialstage,theabscesswouldbesmalland/orlimitedatthevertebrae.Thismayexplaininpartthenegativeresultsoftheradiograph,ultrasoundandtheCTscan.MRIismoreeffectivethanCTindisplayingmuchclearertissuecontrastresolutionandinscreeningoutboneinterference.Italsoprovidessuperiormultiplanarimages.AnalternativepossibilityforthenegativeCTresultsisthatunenhancedCTisincapableofshowingpositivefindings.Thirdly,accordingtotheexperienceofSimonetal. Hsin-PeiYinetal.JournaloftheChineseMedicalAssociationVol.67,No.3 plainfilmsshouldbemadebeforeotherimagingmodalitiesforpatientswhohaveasuspectedpsoasabscessorosteomyelitis.Findingsonplainabdominalfilmsincludemasseffect,abnormaliliopsoasmargin,softtissuegas,bonydestructionofthespineandscoliosis.Bonescansshouldbecarriedoutifplainfilmsshownegativeorunverifiableresults.Furthermore,bonescansareusefulandimportantfordetectingunexpectedconcomitantinfectiousfoci,especiallyinpatientswithOurcasealsoillustratesthevalueofGa-67scanningforidentifyingpyogenicfoci.Whenpatientssufferingfromprimarypyogenicvertebralosteomyelitissuccumbtogenitourinaryinstrumentation,skinandvisceralinfections,hematogenousseedingmayfollow.Thelumbarspineismostcommonlyaffected,andtheStaphylococcusaureusbacteriumisthemostrecurrentlyculturedorganism.Theaverageageofpatientsisbetween30and40years,andmalepatientsareaffectedmorethanfemales,ataratioof2:1.Inourcase,thepatientsosteomyelitiscouldbeac-countedforbythepresenceofaurinarytractinfection,whichwasdetectedintheER2weeksbeforeadmission.Indeed,anendemicstudyinTaiwanrevealedthatmostpsoasabscesspatientshadurinarytractinfections.Becausealltheculturesinthiscaseweresterile,therealpathogenwasstillinquestion.Accordingtothetreatmenteffectofoxacillin,Staphylococcuswasthemostpossiblepathogen.Moreover,thepatientsage,genderandlesionlocationwerecompatiblewiththedistributionofprimaryosteomyelitis.Atthetimeofthiscase,herefusedsurgicaldrainage,andwedecidedthatthemostappropriatetreatmentwasacompletecourseofantibiotictherapy.Inadditiontoantibiotics,thepatientwasmonitoredthroughCT-guidedaspirationsandaseriesofMRimages.3weeksafterthepatientbegantakingtheantibiotics,theMRIrevealedthatthebilateralpsoasabscesshadbeencompletelycleared.ThepatientfullyrecoveredafterthissuccessfulConfirmingadiagnosisofpsoasabscessandlumbarosteomyelitisisoftendelayedowingtoitslowincidence,insidiouscourseandnon-specificsymptoms.Thiscaseillustratedthatwemighthavemissedthediagnosisofpsoasabscesshadwenotinvestigatedbeyondtheinitialnormalfindingsofplainfilm,ultrasoundandCTwithouttheaidofradionuclidescanningandMRI.Asevidencedinthiscase,wemayconsiderthebonescanasanimperativeexaminationwhileapatientpresentswithlowbackpainandFUOorotherinfectioussigns.Moreover,MRImightbefurtherreliedupontoincreasediagnosticaccuracyanddecreasethemorbidityandmortalityofpatientssufferingfrompsoasabscesses.1.GruenwaldI,AbrahamsonJ,CohenO.Psoasabscess:casereportandreviewoftheliterature.JUrol2.HuangJJ,RuaanMK,LanRR,WangMC.AcutepyogeniciliopsoasabscessinTaiwan:clinicalfeatures,diagnosis,treat-mentsandoutcome.JInfect3.KaoPF,TzenKy,TsuiKh,TsaiMF,YenTC.Thespecificgal-lium-67scaleuptakepatterninpsoasabscesses.EurJNucl4.DesandreAR,CottoneFJ,EversML.Iliopsoasabscess:etiol-ogy,diagnosis,andtreatment.AmSurg5.SimonsGW,StyJR,StarshakRJ.Primarypyogenicabscessofthepsoasmuscle.JBoneJointSurgAm6.RoystoneDD,CreminBJ.Theultrasonicevaluationofpsoasabscess(tropicalpyomyositis)inchildren.PediatrRadiol7.ChiuNt,YaoWJ,JouIm,WuCC.Thevalueof67Ga-citratescanninginpsoasabscess.NuclMedCommun1189-93.8.LebouthillierG,LetteJ,MoraisJ,AubinB,PicardM.Ga-67imaginginprimaryandsecondarypsoasabscess.ClinNucl9.LeeBF,ChenCJ,YangCC,YuHS.Psoasmuscleabscesscausingfeverofunknownorigin:thevalueofTc-99m(V)DMSimaging.ClinNuclMed10.WisneskiRJ.Infectiousdiseaseofthespine.OrthopClinofNorthAme March2004PsoasAbscess