Two cases of pott disease associated with bilateral psoas abscesses: case report

Pott's disease presenting with bilateral psoas abscesses in a resource-poor setting: Case report and literature review

INTRODUCTION AND IMPORTANCE

Tuberculosis (TB) primarily affects the lungs, but can cause extrapulmonary TB (EPTB), including spinal TB (Pott's disease), which presents with variable symptoms. Tuberculous psoas abscesses, a complication of Pott's disease, are increasingly reported due to improved diagnostics.

CASE PRESENTATION

A 32-year-old male from the Somalia region of Ethiopia presented with a history of chronic lower back pain that had worsened over the preceding month, with lower back swelling, unquantified weight loss, and a slight limp. He also reported intermittent, mild lower quadrant abdominal pain. Physical examination revealed a chronically ill with stable vital sign. A 7 × 5 cm soft tissue swelling, localized to the lumbar area. Due to late presentation and the lack of advanced imaging capabilities such as CT scans at our facility, the diagnostic process was challenging. Spinal swelling was noted, and after incision and drainage, the discharge was analyzed using GeneXpert and Mycobacterium tuberculosis was detected by GeneXpert confirming a diagnosis of spinal tuberculosis, and an abdominal ultrasound showed a psoas abscess. The patient was started on anti-TB therapy and is improving, CASE DISCUSSION: Tuberculous psoas abscess, a known complication of Pott's disease (spinal tuberculosis), is relatively uncommon, occurring in about 5 % of cases despite modern anti-TB treatment. Psoas abscesses can arise primarily or secondarily, the latter resulting from TB spread from nearby structures, as seen in our patient. Diagnosis of psoas abscess and spinal TB typically necessitates advanced imaging, which is currently unavailable in our setting. Timely management is crucial for improved patient outcomes. Management involves prolonged anti-TB therapy with pyridoxine supplementation and surgical intervention for neurological complications. Most patients respond well to this approach.

CONCLUSION

Psoas TB abscess, while rare, poses a significant clinical challenge, particularly in resource-limited settings due to the patient's late presentation and the limited availability of advanced imaging, such as CT scans. Timely diagnosis, appropriate anti-tuberculosis therapy, and, when necessary, surgical interventions are crucial for optimizing patient outcomes.

Psoas Abscess and Pott's Disease Masked by Concomitant Invasive Staphylococcus aureus Disease: A Case of Misleading Diagnosis

Psoas abscess is a rare infection classified as primary or secondary depending on the etiology of infection. Staphylococcus aureus is considered the most frequent causative agent. Nevertheless, psoas abscess persistent lack of improvement or any relapse after successful treatment should remind us to exclude other potential diagnoses. Although less frequently, Pott's disease is still one of the predisposing causes, especially in patients with immunocompromised status. This clinical condition has an indolent course and requires a high index of suspicion to avoid severe morbidity. Early recognition and targeted treatment are the principal means of ensuring tuberculosis control. Here we report a very interesting case of a psoas abscess and Pott's disease in a patient suffering from a misleading diagnosis of invasive staphylococcal disease.

Pathogenesis, Diagnostic Challenges, and Risk Factors of Pott's Disease

Tuberculosis (TB) prevalence is increasing in developed nations and continuing to cause significant mortality in low- and middle-income countries. As a result of the uptick in cases, there also exists an increased prevalence of extrapulmonary TB. TB is caused by Mycobacterium tuberculosis (M. tb). When M. tb disseminates to the vertebral column, it is called Pott's disease or spinal TB. The frequency, symptoms, and severity of the disease range by the location of the spine and the region of the affected vertebrae. While the current literature shows that timely diagnosis is crucial to reduce the morbidity and mortality from Pott's disease, there is a lack of specific clinical diagnostic criteria for Pott's disease, and the symptoms may be very non-specific. Studies have shown that novel molecular diagnostic methods are effective and timely choices. Research has implicated the risk factors for the susceptibility and severity of Pott's disease, such as HIV and immunosuppression, poverty, and malnutrition. Based on the current literature available, our group aims to summarize the pathogenesis, clinical features, diagnostic challenges, as well as the known risk factors for Pott's disease within this literature review.

Retroperitoneoscopic Drainage of Psoas Abscess: A Systematic Review

BACKGROUND

Psoas abscess is a relatively rare clinical condition that can occur worldwide, is difficult to diagnose, and has a severe clinical course. Conventional treatment ranges from antibiotic therapy alone to computed tomography (CT)-guided and/or open surgical drainage. Retroperitoneoscopic drainage represents a minimally invasive and potentially definitive therapeutic option.

MATERIALS AND METHODS

A systematic review of the literature on minimally invasive extraperitoneal access for drainage of psoas abscess was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the PRISMA statement guidelines. We considered only studies in English and with a full text. The quality of all selected articles was assessed for the risk of methodological bias. Additional literature sources were used to put into context the indications and limits of retroperitoneoscopic drainage.

RESULTS

Seven papers published between 2004 and 2020, including a total of 56 patients, met the eligibility criteria and were included in the qualitative analysis. Causative agents of psoas abscess included Mycobacterium tuberculosis, Klebsiella pneumoniae, Enterobacter aerogenes, Staphylococcus aureus, and Streptococcus spp. Tuberculous abscess was more common than pyogenic abscess (92.8% vs. 7.2%). Main clinical findings were back pain (76.8%) and fever (53.6%). All patients were preoperatively evaluated by CT or magnetic resonance imaging. Only 4 patients (7.1%) had previously undergone CT-guided percutaneous drainage. Retroperitoneoscopic drainage was combined with antibiotic therapy in all cases. No Clavien-Dindo grade >3 complications occurred, and there was no 30-day postoperative mortality. The recurrence rate was 1.8% at a mean follow-up of 21 months.

CONCLUSION

Retroperitoneoscopic surgical drainage is a safe and effective approach for the treatment of psoas abscess.

Extensive Paraspinal Tuberculosis Masquerading Malignant Tumor in an Elderly Male

Paraspinal tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis, and in rare cases, these lesions can mimic malignant lesions. We report a case of an elderly man where imaging showed extensive left paraspinal lesion which was mimicking malignant neoplasm. The patient underwent L3–L4 unilateral partial laminotomy, there was grayish, relatively avascular lesion in the left paraspinal region, involving the left psoas muscle and going into the neural foramina, and a subtotal resection of the lesion could be performed. However, after biopsy, it turned out to be tuberculoma, and the patient was on antitubercular therapy and doing well. The present case illustrates that extensive involvement of the paraspinal soft tissue and adjacent bony structures on imaging in tuberculosis can mimic malignant tumors. Conservative surgical excision will help in preserving the bony elements and in establishing the diagnosis.

A Pain in the Psoas

General medical conditions are an important part of the differential diagnosis in athletes presenting with pain or injury. A psoas abscess is a collection of pus in the iliopsoas muscle compartment and is a rare cause of hip, low back, or groin pain. Psoas abscesses may have significant morbidity and mortality, as 20% progress to septic shock. Presenting symptoms are generally nonspecific and the onset may be subacute. Clinical presentation may have features suggestive of other diagnoses, including septic hip arthritis, iliopsoas bursitis, and retrocecal appendicitis. Proper diagnosis and management is critical to prevent complications of septic shock and death. In this unique case, a 19-year-old Division 1 collegiate football player presented to the emergency department 4 days following injury to his right groin during football practice. He complained of severe right groin pain accompanied by fatigue, fevers, nausea, and diarrhea. He later developed septic shock with multisystem organ dysfunction, requiring advanced life support. Imaging revealed an abscess located in the right iliopsoas compartment. After proper treatment, the athlete eventually made a complete recovery, returning to collegiate football 4 months postinjury. A literature review found no described cases of psoas abscess related to athletes with acute hip flexor strain. This athlete had no known risk factors for psoas abscess. This case highlights the importance of maintaining a broad differential in an athlete presenting with pain after injury. Making the diagnosis of psoas abscess often requires a high degree of suspicion and timely acquisition of imaging studies. In this particular case, imaging was key to making a proper diagnosis and tailoring treatment not only to return him to sport but also to save his life.

Case Series of Iliopsoas Abscesses Treated at a University Hospital in Japan: Epidemiology, Clinical Manifestations, Diagnosis and Treatment

OBJECTIVE

The incidence of iliopsoas abscesses has been increasing due to advances in diagnostic imaging techniques and the increased number of elderly individuals and immunodeficient patients with co-morbidities. Our aim was to investigate the management and treatment of iliopsoas abscesses, particularly the effectiveness of computed tomography (CT)-guided drainage in the era of interventional radiology.

METHODS

A retrospective analysis was performed at a university hospital between January 2009 and March 2014. Patients There were 15 patients (eight men, seven women) 50-85 years of age (average: 70 years) diagnosed with an iliopsoas abscess.

RESULTS

The etiology of the disease was investigated in 14 of the 15 patients, each of whom had a secondary iliopsoas abscess. The primary condition in nine of these patients (64.3%) was an orthopedic infection (spondylodiscitis); the most common symptom was fever (12 patients, 80%). Altogether, 10 patients (66.7%) had a multilocular abscess and five (33.3%) had bilateral abscesses. The most common pathogen was Staphylococcus aureus (seven patients, 50%). All 14 patients underwent drainage: 11 received CT-guided drainage, two underwent postdrainage surgery and one received ultrasonography-guided drainage. Poor drainage was overcome by inserting multiple drainage tubes (six patients) or performing transmembrane drainage with a guidewire. All but one patient survived.

CONCLUSION

Based on the high success rate of CT-guided drainage in this study, this technique is expected to continue to play a major role in cases requiring drainage, even in patients with bilateral or multilocular abscesses. However, this modality cannot be used in cases of gastrointestinal perforation.

Central nervous system tuberculosis

Tuberculosis (TB) has shown a resurgence in nonendemic populations in recent years and accounts for 8 million deaths annually in the world. Central nervous system involvement is one of the most serious forms of this infection, acting as a prominent cause of morbidity and mortality in developing countries. The rising number of cases in developed countries is mostly attributed to factors such as the pandemic of acquired immunodeficiency syndrome and increased migration in a globalized world. Mycobacterium TB is responsible for almost all cases of tubercular infection in the central nervous system. It can manifest in a variety of forms as tuberculous meningitis, tuberculoma, and tubercular abscess. Spinal infection may result in spondylitis, arachnoiditis, and/or focal intramedullary tuberculomas. Timely diagnosis of central nervous system TB is paramount for the early institution of appropriate therapy, because delayed treatment is associated with severe morbidity and mortality. It is therefore important that physicians and radiologists understand the characteristic patterns, distribution, and imaging manifestations of TB in the central nervous system. Magnetic resonance imaging is considered the imaging modality of choice for the study of patients with suspected TB. Advanced imaging techniques including magnetic resonance perfusion and diffusion tensor imaging may be of value in the objective assessment of therapy and to guide the physician in the modulation of therapy in these patients.

Pott's Spine: Diagnostic Imaging Modalities and Technology Advancements

Spinal tuberculosis (TB) or Pott's spine is the commonest extrapulmonary manifestation of TB. It spreads through hematogenous route. Clinically, it presents with constitutional symptoms, back pain, tenderness, paraplegia or paraparesis, and kyphotic or scoliotic deformities. Pott's spine accounts for 2% of all cases of TB, 15% of extrapulmonary, and 50% of skeletal TB. The paradiscal, central, anterior subligamentous, and neural arch are the common vertebral lesions. Thoracic vertebrae are commonly affected followed by lumbar and cervical vertebrae. Plain radiographs are usually the initial investigation in spinal TB. For a radiolucent lesion to be apparent on a plain radiograph there should be 30% of bone mineral loss. Computed tomographic scanning provides much better bony detail of irregular lytic lesions, sclerosis, disc collapse, and disruption of bone circumference than plain radiograph. Magnetic resonance imaging (MRI) is the best diagnostic modality for Pott's spine and is more sensitive than other modalities. MRI frequently demonstrates disc collapse/destruction, cold abscess, vertebral wedging/collapse, marrow edema, and spinal deformities. Ultrasound and computed tomographic guided needle aspiration or biopsy is the technique for early histopathological diagnosis. Recently, the coexistence of human immunodeficiency virus infections and TB has been increased globally. In recent years, diffusion-weighted MRI (DW-MRI) and apparent diffusion coefficient values in combination with MRI are used to some extent in the diagnosis of spinal TB. We have reviewed related literature through internet. The terms searched on Google scholar and PubMed are TB, extrapulmonary TB, skeletal TB, spinal TB, Pott's spine, Pott's paraplegia, MRI, and computed tomography (CT).

Tuberculosis-Associated Immune Reconstruction Inflammatory Syndrome (TB-IRIS) in HIV-Infected Patients: Report of Two Cases and the Literature Overview

We describe two HIV-infected patients with tuberculosis-associated immune reconstruction inflammatory syndrome (TB-IRIS): one with “paradoxical” IRIS and the other with “unmasking” IRIS. TB-IRIS in HIV-infected subjects is an exacerbation of the symptoms, signs, or radiological manifestations of a pathogenic antigen, related to recovery of the immune system after immunosuppression. We focused on the radiological characteristics of TB-IRIS and the briefly literature review on this syndrome.

Harvey Cushing, the spine surgeon: the surgical treatment of Pott disease

STUDY DESIGN

Review of historical archival records.

OBJECTIVE

Describe Harvey Cushing's patients with spinal pathology.

SUMMARY OF BACKGROUND DATA

Harvey Cushing was a pioneer of modern surgery but his work on spine remains largely unknown.

METHODS

Review of the Chesney Medical Archives of the Johns Hopkins Hospital from 1896 to 1912.

RESULTS

This is the first time that Cushing's spinal cases while he was at the Johns Hopkins Hospital, including those with Pott disease, have been described.Cushing treated three young men with psoas abscesses secondary to Pott disease during his residency: he drained the abscesses, debrided any accompanying necrotic vertebral bodies, irrigated the cavity with salt, and left the incision open to close by secondary intention. Although Cushing used Koch's "tuberculin therapy" (of intravenous administration of isolated tubercular bacilli) in one patient, he did not do so in the other two, likely because of the poor response of this first patient. Later in his tenure, Cushing performed a laminectomy on a patient with kyphosis and paraplegia secondary to Pott disease.

CONCLUSION

These cases provide a view of Cushing early in his career, pointing to the extraordinary degree of independence that he had during his residency under William Steward Halsted; these cases may have been important in the surgical upbringing both of Cushing and his coresident, William Stevenson Baer, who became the first professor of Orthopedics at Johns Hopkins Hospital. At the turn of the last century, Pott disease was primarily treated by immobilization with bed rest, braces, and plaster-of-paris jackets; some surgeons also employed gradual correction of the deformity by hyperextension. Patients who failed a trial of conservative therapy (of months to years) were treated with a laminectomy. However, the limitations of these strategies led to the development of techniques that form the basis of contemporary spine surgery-instrumentation and fusion.

A challenging case of bilateral iliopsoas abscess

BACKGROUND

Bilateral iliopsoas abscess is very rare and has never been reported in cases of aortic graft infections. To date, only cases of unilateral abscess have been reported in association with aortic graft infection, and even these are uncommon.

METHODS

Case report and literature review.

RESULTS

We present the first report of an infected abdominal aortic graft, secondary to an ileal perforation, in a 76-year-old woman presenting with bilateral iliopsoas abscess. The presence of lumbar spondylodiscitis initially led us to suspect this as the primary cause of the abscess. Hence, she was treated initially with drainage of the abscess, percutaneously and surgically. This proved to be unsuccessful. A laparotomy, excision of the aortic graft, and in situ revascularization with a femoral venous conduit was performed subsequently. The bilateral iliopsoas abscess was found to be caused by a perforation of the ileum. Despite the surgery, the patient finally succumbed.

CONCLUSIONS

Bilateral iliopsoas abscess secondary to infected aortic graft is extremely rare and challenging. Drainage of the abscess, percutaneously or surgically, and excision of graft with or without revascularization must be considered carefully based on the individual case.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.