Ilio-psoas abscess in the paediatric population: treatment by US-guided percutaneous drainage

Ultrasound-Guided Percutaneous Drainage of Iliopsoas Abscess With Septicemia in an Adolescent: A Case Report and Literature Review

Introduction

Iliopsoas abscess with septicemia in the pediatric population is rare. Early diagnosis and effective management of this emergent disorder remain challenging for clinicians.

Case Presentation

A 14-year-old girl presented with right lateral and posterior hip pain and fever for 7 days before admission. Blood culture was positive for Staphylococcus aureus. Enhanced magnetic resonance imaging revealed abscesses located in the right iliopsoas muscle and on the surface deep to the fascia of the right sacroiliac joint that were 6.8 cm × 6.2 cm × 5.7 cm and 3.7 cm × 3.5 cm × 2.1 cm, respectively. A diagnosis of right iliopsoas abscesses with septicemia was made. The patient received intravenous antibiotics, underwent ultrasound-guided percutaneous catheter drainage, and recovered uneventfully. Medical literature regarding this issue published in the English language during the last two decades was reviewed.

Discussion

Primary synchronous psoas and iliacus muscle abscesses are rare and emergent disorders in the pediatric age group. The diagnosis is generally delayed owing to the deep anatomic location and nonspecific signs and symptoms. A comprehensive medical history, meticulous physical examination, and judicious use of imaging studies could establish a timely and accurate diagnosis. Surgeons should be aware of the occurrence of multiple abscesses. Prompt and adequate antibiotic therapy accompanied by a mini-invasive approach, such as ultrasound-guided, laparoscopic, or video-retroperitoneoscopic drainage of the infectious focus, if indicated and feasible, is important to achieve a good outcome in the management of iliopsoas abscess.

Key role of magnetic resonance imaging in the diagnosis of infections around the hip and pelvic girdle mimicking septic arthritis of the hip in children

Infections around the hip and the pelvic girdle mimicking septic hip arthritis are rare conditions in the pediatric population requiring urgent treatment. They are not readily diagnosed because of rarity, resemblance to septic hip, and unclear pathophysiology, which often results in misdiagnosis, delayed diagnosis, and delayed treatment. The aim of this study was to prove the key role of magnetic resonance imaging (MRI) as the first-line modality in making a early definite diagnosis of an uncommon perihip infection in children. We retrospectively reviewed 20 children with a provisional diagnosis of unilateral septic hip who were confirmed finally to have perihip infections and combined with concomitant osteomyeltis using MRI. All patients were treated with intravenous antibiotics with or without abscess aspiration until normalization of clinical symptoms and laboratory tests including serum C-reactive protein and erythrocyte sedimentation rate. All infections healed successfully and the final C-reactive protein was recovered to a mean of 0.37 mg/dl (range 0.01-0.78 mg/dl) without recurrence or complication. Although the MRI is costly and limited in practical application, it was found to be effective as a primary diagnostic tool for an early, accurate diagnosis of infections around the hip and the pelvic girdle in children to correctly guide the decision and the approach for treatment.

Primary Psoas Pyomyositis Presenting as Subluxation of the Hip: A Case Report

CASE

An eight-year-old girl presented with a septic subluxation of the right hip secondary to spontaneous drainage of a psoas pyomyositis. The course of the infection was protracted, and the symptoms were mild relative to the magnitude of the psoas abscess and the volume of purulence in the hip that caused subluxation of the femoral head. At the time of surgical drainage, the hip capsule directly communicated with the psoas abscess along the course of the iliopsoas tendon sheath. Methicillin-sensitive Staphylococcus aureus (MSSA) was the microorganism that was isolated from the abscess and from the hip joint.

CONCLUSION

Drainage of the psoas abscess and septic arthritis coupled with antibiotic treatment eliminated the infection, and the child returned to normal activities. At the five-year follow-up, she was asymptomatic, but the subtle changes in the sphericity of the femoral head as well as the slight joint-space narrowing may be associated with problems in the future.

Outcome of percutaneous continuous drainage of psoas abscess: A clinically guided technique

BACKGROUND

Percutaneous aspiration of abscesses under ultrasonography (USG) and computer tomography (CT) scan has been well described. With recurrence rate reported as high as 66%. The open drainage and percutaneous continuous drainage (PCD) has reduced the recurrence rate. The disadvantage of PCD under CT is radiation hazard and problems of asepsis. Hence a technique of clinically guided percutaneous continuous drainage of the psoas abscess without real-time imaging overcomes these problems. We describe clinically guided PCD of psoas abscess and its outcome.

MATERIALS AND METHODS

Twenty-nine patients with dorsolumbar spondylodiscitis without gross neural deficit with psoas abscess of size >5 cm were selected for PCD. It was done as a day care procedure under local anesthesia. Sequentially, aspiration followed by guide pin-guided trocar and catheter insertion was done without image guidance. Culture sensitivity was done and chemotherapy initiated and catheter kept till the drainage was <10 ml for 48 hours. Outcome assessment was done with relief of pain, successful abscess drainage and ODI (Oswestry Disability Index) score at 2 years.

RESULTS

PCD was successful in all cases. Back and radicular pain improved in all cases. Average procedure time was 24.30 minutes, drain output was 234.40 ml, and the drainage duration was 7.90 days. One patient required surgical stabilisation due to progression of the spondylodiscitis resulting in instability inspite of successful drainage of abscess. Problems with the procedure were noticed in six patients. Multiple attempts (n = 2), persistent discharge (n = 1) for 2 weeks, blocked catheter (n = 2) and catheter pull out (n = 1) occurred with no effect on the outcome. The average ODI score improved from 62.47 to 5.51 at 2 years.

CONCLUSIONS

Clinically guided PCD is an efficient, safe and easy procedure in drainage of psoas abscess.

Paediatric Iliopsoas abscess: A case report

Introduction: Iliopsoas abscess is an uncommon condition in the paediatric population. The clinical presentation is variable and may be confused with other conditions such as septic arthritis, osteomyelitis and appendicular abscess. A suspicion of iliopsoas abscess requires a prompt diagnosis so that rapid management and treatment can be undertaken. Discussion: This case describes the presence of an iliopsoas abscess in a paediatric patient presenting to the emergency department within a rural community. Due to the variability in clinical presentation imaging studies are necessary to distinguish an iliopsoas abscess from other inflammatory processes. Ultrasound is often the modality of choice. Imaging guided percutaneous drainage and/or aspiration and the administration of intravenous antibiotics are minimally invasive modern techniques providing a safe treatment options in the presence of an iliopsoas abscess. Conclusion: Iliopsoas abscess is an uncommon condition in the paediatric population. Due to the variability in clinical presentation, imaging, and in particular, ultrasound play a vital role in the diagnosis of cases with a high suspicion of abscess formation. Accurate diagnosis leads to a rapid treatment plan, avoiding further insult.

Percutaneous drainage of large tuberculous iliopsoas abscess via a subinguinal approach: a report of two cases

Two patients who had large tuberculous abscesses that were successfully treated with percutaneous drainage alone are reported. A new approach, called the "subinguinal approach," was used. This new technique avoids the bowel loops and pelvic organs (which can be limitations when using the anterior abdominal approach) by inserting the catheter through the subinguinal portion of the psoas muscle into the abscess. Compared to the posterior approach, this technique is more comfortable for the patient (who prefers a supine position) and is not limited by the iliac bone. The technique, clinical course, and outcome are described.

Ilio-psoas abscess caused by methicillin-resistant Staphylococcus aureus (MRSA): a rare but potentially dangerous condition in neonates

We report a case of methicillin-resistant Staphylococcus aureus ilio-psoas abscess (IPA) in a neonate. This case has clinical importance because this neonate had toxic shock syndrome-like exanthematous disease, known as NTED, before developing IPA. A high index of suspicion is required for IPA if a neonate presents with limb disuse and fever of unknown origin. Our case required surgical drainage, since ultrasound-guided percutaneous needle aspiration failed.

A rare case of Salmonella-mediated sacroiliitis, adjacent subperiosteal abscess, and myositis

We report the case of a 16-year-old female who was ultimately diagnosed with Salmonella sacroiliitis, adjacent subperiosteal abscess, and myositis of the left iliopsoas, gluteus medius, and obturator internus muscles. Early and accurate recognition of this syndrome and other infectious musculoskeletal syndromes can prove difficult for the emergency physician, as these disease processes require special attention to pain of proportion to physical findings and a high index of suspicion.

Unusual presentation of psoas abscess in a child

Primary abscess of the psoas muscle is relatively rare in infants and young children. The clinical presentation of the disease, with limping, fever, and abdominal pain, may be confused with conditions such as septic arthritis of the hip, osteomyelitis, or appendicitis. The authors present an unusual case of a ruptured left psoas abscess presenting as generalized peritonitis in a child. J Pediatr Surg 36:1859-1860.

Acute pyogenic iliopsoas abscess in Taiwan: clinical features, diagnosis, treatments and outcome

OBJECTIVES

To study the variations of aetiology in the patients with acute pyogenic iliopsoas abscess and identify the appropriate diagnostic modalities as well as therapeutic alternatives (e.g. extraperitoneal or retrofascial percutaneous catheter drainage, PCD) other than surgery.

METHODS

We carried out a retrospective review and analysis of 25 patients with acute pyogenic iliopsoas abscess in our institution from August 1988 to July 1998. Blood and urine cultures, imaging studies of the plain films of the abdomen (KUB), ultrasonography (echo) and computed tomography (CT scan) were performed in all patients. The therapeutic regimens included antibiotics only, PCD or aspiration, and surgery.

RESULTS

The male to female ratio was 7: 18. The mean age was 64 years old. Diabetes mellitus (64%) was the dominant predisposing or associated factor. The most common aetiological source was urinary tract infection (52%) with enteric micro-organisms (Escherichia coli: 44% and Klebsiella spp.: 24%). Nineteen patients (76%) had pain in the abdomen, flank or back. Six cases (24%) were classified as 'primary' abscess, and only two patients survived. Nine cases were treated with antibiotics alone, only four responded and the others expired. Of the 15 cases receiving PCD or aspiration, five cases received subsequent surgical drainage or nephrectomy and survived. Another one case of Clostridia gas gangrene received emergency fasciotomy and expired. The total mortality was extremely high (11/25, 44%).

CONCLUSIONS

We concluded that: (i) the aetiology of iliopsoas abscess may vary with the country of origin, with a preponderance of urinary tract infection in our Taiwanese series; (ii) a high index of suspicion is mandatory to enable early diagnosis of acute pyogenic iliopsoas abscess, particularly for older diabetic patients with fever, pain in the abdomen or flank, limp or flexion of the ipsilateral hip; (iii) CT scan can confirm the diagnosis and define the extent of the abscess; (iv) effective management should include appropriate antibiotic therapy and drainage of the abscess; (v) image-guided PCD should be tried first because of its low morbidity. However, should it fail, subsequent surgical drainage should be performed.