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*Manoj
Todkar
*Nuffield
Orthopaedic Centre, Windmill Road,
Headington,
Oxford, OX3 7LD
Address for Correspondence:
Manoj Todkar,
17 Girdlestone Close,
Headington, Oxford,
OX3 7NS
Tel: 07792404268
E-mail: mtodkar@hotmail.com
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ABSTRACT:
Suppurative psoas abscess is a rare lesion and lack of
familiarity with it remains major difficulty in diagnosis. The
symptoms often involve hip rather than abdomen or spine. We
report a case of non-tuberculous suppurative psoas abscess in a
25 year old man who presented with hip pain. Septic arthritis of
hip was ruled out by aspiration of hip and diagnosis of psoas
abscess was made on MRI scan.
CASE REPORT:
Diagnosing psoas abscess in patients
presenting with groin pain might be delayed by their atypical
symptoms. We report a 25-year-old man who presented to our
emergency department with two-week history of right groin pain.
He was apyrexial and was holding his hip in 80 degrees of
flexion while walking with increased lumbar lordosis. He had
painful and restricted movements of the hip joint. Extension and
internal rotation was associated with extreme pain. Internal and
external rotation in 90 degrees of flexion of hip were painless.
His CRP was 344 and white cell count was 18. Mild tenderness was
present over right lower quadrant of abdomen.Initial X rays and
ultrasound study were inconclusive. We suspected septic
arthritis of the hip but aspiration of hip under anaesthesia
yielded a dry tap. So MRI scan was performed which revealed
abscess in right psoas muscle of 8 x 4 cm size and high signal
on STIR imaging in right psoas and iliacus muscle. It also
revealed moderate effusion in hip joint. The psoas abscess was
drained under CT guidance. 45 ml of pus was aspirated and sent
for microbiology examination. A drain was inserted.
Staphylococcus aureus was cultured from the specimen and
appropriate intravenous antibiotics were given for two weeks
followed by oral antibiotics for six weeks. Drain was removed
after it stopped draining in 72 hours. His symptoms subsided and
the flexion deformity in hip disappeared few days after
aspiration and antibiotics.Detailed examination revealed that
patient had caries tooth which probably was the
source of
infection. Later he underwent excision of infected tooth.
DISCUSSION:
Psoas abscesses are uncommon and can be
difficult to diagnose. It may present as back pain, pyrexia of
unknown origin, groin pain mimicking septic hip, frequency of
micturition, lump in abdomen or pain. The onset is usually sub
acute and symptoms are usually present for few weeks. (2) Psoas
abscess is usually seen in patients having infective spondylitis,
infections of sacroiliac joint, renal infections and those who
have diabetes mellitus. Patient usually presents with flexion of
the hip and lumbar lordosis. Distal extension of psoas abscess
may present as mass in inguinal region. The close proximity to
hip capsule causes symptoms like septic hip.The iliopectineal
bursa that separates the tendon from hip joint communicates with
the capsule of hip in 15% of population.(4) In this way
infection may spread to hip. Clinically it may be possible to
distinguish septic hip from psoas abscess.(5) Movements of hip
in flexion are painless in psoas abscess while they are very
painful in either flexion or extension in septic arthritis.
Retroperitoneal or intraperitoneal lesions may cause irritation
of psoas muscle like retrocaecal appendicitis. (1) All these
lesions produce pain on stretching the muscle.
These lesions are difficult to distinguish
from psoas abscess clinically. Diagnosis of psoas abscess
depends upon high degree of suspicion and carrying out
appropriate imaging studies. In this case initial ultrasound
examination could not localise the psoas abscess. This case
showed the importance of MRI in patients presenting with such
symptoms. It also suggests that repeated imaging study and/or
other modality should be considered when the initial imaging
result is not compatible with the clinical presentation of psoas
abscess. MRI or CT scan cannot
distinguish between haematoma or abscess. Clinically it is
possible to distinguish between infection and haematoma in
patients having clotting disorders.
Drainage and appropriate antibiotic coverage
are mainstay of treatment in suppurative psoas abscess.(2) In
past open drainage of abscess through McBurney or iliac crest
incision was carried out. Now-a-days percutaneous CT guided
drainage
of psoas abscess
is accepted method of treatment.(8)
REFERENCES:
1.
Cope, Zachary : 1972 The early diagnosis of
acute abdomen. Ed. 14. London. Oxford University Press,
1972.
2. Finnerly, Vordermark, Modarelli,
Buck. 1981 Primary psoas abscess : Case report and review of
literature. J Urol., 126:108-109, 1981
3. Hosalkar HS, Chatoo MB, Jones S,
McHugh K, Monsell F, Jones DH., 2004 Hip pain in a 6--old
girl., Clin Orthop. 2004 Feb;(419):311-5
4. Simon, Sty, Starshak 1966:
Retroperitoneal and retrofascial abscesses. A review. J Bone
and Joint Surg., 48-A : 867-877, July 1966
5. Song J, Letts M, Monson R., 2001
Differentiation of psoas muscle abscess from septic
arthritis of the hip in children., Clin Orthop. 2001
Oct;(391):258-65
6. Toren A, Ganel A, Lotan D, Graif
M., 1989 Delayed diagnosis of a primary psoas abscess mimicking
septic arthritis of the hip., J Pediatr Surg. 1989
Feb;24(2):227-8.
7. Ulrich S, Gunthard H, Nigg Ch, Bohm
T, Greminger P, Vetter W.2002, 22-year-old patient with left
groin pain, Schweiz Rundsch Med Prax. 2002 May 22;91(21):928-32.
8.Vatandaslar F, Alemdaroglu A., 1987 CT-guided percutaneous
drainage of psoas abscess., Urology. 1987 Apr;29(4):450-3
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