Retroperitoneal abscess presenting as emphysema of the thigh

Retroperitoneal abscess: an extra-abdominal manifestation

Retroperitoneal abscesses are unusual occurrences with occult and insidious presentations. There is often a lack of abdominal signs, leading to delays in drainage and high mortality rates. We report a case of thigh emphysema in an 88-year-old patient with diabetes. Prior to admission the patient reported a vague 4-week history of left thigh pain and an inability to fully weight bear. She presented to our emergency department with sepsis and acute kidney impairment. An X-ray of her left femur revealed widespread gas between muscular planes. A retroperitoneal abscess involving the left renal fossa, psoas, iliacus and upper thigh muscles was revealed on an urgent CT scan. The patient was transferred to intensive care unit (ICU) and underwent an emergency drainage. Despite ICU the patient died 2 days after admission.

Pneumomediastinum and pneumoretroperitoneum: an extremely rare presentation of acute appendicitis

A 22-year-old woman presented with abdominal pain for 12 days. On examination, the abdomen was slightly distended and painful to palpation in the right flank. Subsequent abdominal imaging showed inflammation in the right iliac fossa, retroperitoneal air pockets with inflammation, and signs of pneumomediastinum. Exploratory laparotomy revealed a perforated retrocaecal appendix with abscess extending to the retroperitoneum. Surgical intervention involved a right hemicolectomy followed by end-to-side anastomosis of the ileum to the transverse colon. Histopathological examination of the resected specimen revealed intense inflammation of the caecum and no signs of malignancy. The patient was discharged in good condition 54 days after surgery.

Pelvic primary staphylococcal infection presenting as a thigh abscess

Intra-abdominal disease can present as an extra-abdominal abscess and can follow several routes, including the greater sciatic foramen, obturator foramen, femoral canal, pelvic outlet, and inguinal canal. Nerves and vessels can also serve as a route out of the abdomen. The psoas muscle extends from the twelfth thoracic and fifth lower lumbar vertebrae to the lesser trochanter of the femur, which means that disease in this muscle group can migrate along the muscle, out of the abdomen, and present as a thigh abscess. We present a case of a primary pelvic staphylococcal infection presenting as a thigh abscess. The patient was a 60-year-old man who presented with left posterior thigh pain and fever. Physical examination revealed a diffusely swollen left thigh with overlying erythematous, shiny, and tense skin. X-rays revealed no significant soft tissue lesions, ultrasound was suggestive of an inflammatory process, and MRI showed inflammatory changes along the left hemipelvis and thigh involving the iliacus muscle group, left gluteal region, and obturator internus muscle. The abscess was drained passively via two incisions in the posterior left thigh, releasing large amounts of purulent discharge. Subsequent bacterial culture revealed profuse growth of Staphylococcus aureus. The patient recovered uneventfully except for a moderate fever on the third postoperative day.

Lower-extremity soft tissue infections with intra-abdominal sources

This article describes a series of 3 patients who presented with lower-extremity soft tissue infections. Each patient was treated with prompt debridement by an orthopedic surgeon (J.F.G.) and required at least 1 additional procedure by another surgeon.These infections vary from superficial cellulitis to rapidly advancing necrotizing fasciitis. At times, the source of these infections is clear. Other times, no obvious source of infection exists, in which case the abdomen must be considered as a possible source of infection. A high level of suspicion, complete history and physical examination, and appropriate ancillary studies are required to make an accurate and prompt diagnosis. Options for the treatment of the intra-abdominal source of infection depend on the etiology of the infection and anatomic location of the process. Psoas abscesses can often be decompressed by an interventional radiologist using computed tomography guidance. In the case of bowel involvement, such as suspected carcinoma or diverticulitis, a general surgeon is necessary. When the appropriate diagnosis is made, soft tissue infections of the thigh often respond to appropriate surgical debridement and antibiotic therapy. It is important to remember the whole patient when evaluating soft tissue infections, especially in the thigh. A low threshold for imaging of the abdomen and pelvis is important, especially when the physical examination or medical history reveals the abdomen as a possible source of infection.

Diverticular disease presenting as subcutaneous emphysema of the thigh

A normally fit and well 79-year-old lady presented acutely confused and shocked after a few months history of atypical left-sided back and thigh pain. She was unable to tolerate movement of her left leg and soft tissue crepitus was palpable over her thigh. Emergency incision and drainage of the leg was performed with intraoperative swabs growing Streptococcusmilleri and coliforms. Postoperatively, in the Intensive Care Unit (ICU) deep faecal contamination of the wound was noted. Contrast imaging revealed severe diverticular disease and colocutaneous fistula. Abdominal examination was unremarkable throughout her admission and initial CT scan had not revealed the underlying pathology. A defunctioning colostomy was fashioned and after a prolonged period of rehabilitation the patient returned to being functionally independent.

Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis: An extremely fulminant form of a common disease

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.

Diverticular abscess presenting as prostate abscess and missed by abdominal CT scan

This is a case report of sigmoid diverticular abscess presenting as prostate abscess. Helical computed tomography (CT) scan revealed the prostate abscess but failed to demonstrate the underlying diverticular abscess. Colonic diverticular abscess can have many unusual presentations, and multiple imaging modalities may be required to reveal the underlying pathology. Abdominal CT scan is not always a definitive and absolute imaging modality for abdominal pain evaluation and cannot supplant clinical judgment in the evaluation of confusing cases.