Basics

Collection of purulent fluid in the iliopsoas compartment; high morbidity and mortality if not promptly diagnosed and treated

Description

  • The iliopsoas compartment is a retroperitoneal anatomic space composed of the psoas major, psoas minor, and iliacus muscles, which mediate hip flexion and are innervated by L2 to L4.
  • The muscle group originates from the lateral borders of the 12th thoracic to 5th lumbar vertebrae, passes posterior to the inguinal ligament and anterior to the hip joint, inserting on the lesser trochanter.
  • Abscesses are primary (hematogenous or lymphatic spread) or secondary (extension of nearby infection).
  • Synonym(s): iliopsoas abscess

Epidemiology

Incidence
  • Incidence increased with HIV, IV drug use, and immunosuppressant therapy (1).
  • Improved imaging contributes to increases in diagnosis (1).

Prevalence
  • Primary abscesses account for ~30% of cases worldwide; most are in developing countries (1,2).
  • Primary abscesses more common in infants associated with Staphylococcus aureus (1,2)
  • Secondary psoas abscesses are more common, (particularly in developed countries); often associated with gastrointestinal (GI) or skeletal infection (1,2)
  • Secondary abscesses in the elderly commonly associated with age-related diseases (e.g., diverticulitis)

Etiology and Pathophysiology

  • Primary psoas abscess results from hematogenous or lymphatic spread of infection from a distant source.
    • Iliopsoas has a rich blood supply, predisposing to primary infection.
    • Primary abscesses are often monomicrobial, with S. aureus as the predominant organism (1).
    • Mycobacterium tuberculosis and S. aureus are the most common causative organisms in HIV patients (2).
  • Secondary psoas abscess results from contiguous spread from nearby musculoskeletal, GI, genitourinary (GU), and vascular structures.
    • S. aureus from musculoskeletal source; Escherichia coli, Bacteroides sp., Enterococcus faecalis, Streptococcus viridans from GI source, and Klebsiella pneumoniae from GI and GU sources (1,2)
    • Secondary psoas abscesses from GI and GU sources may be polymicrobial (1,2).
    • M. tuberculosis can cause secondary psoas abscess from vertebral, GI, and GU spread.
  • Methicillin-resistant S. aureus (MRSA) accounts for up to 25% of cases (3,4).
  • Most psoas abscesses are unilateral and solitary (1).

Risk Factors

  • Primary psoas abscess is associated with:
    • IV drug use
    • Diabetes
    • HIV/AIDS
    • Active malignancy
    • Renal failure
    • Prior psoas muscle trauma
  • Secondary psoas abscess: skeletal infections, intra-abdominal infection (1,2,5)
    • Recent surgery near the iliopsoas compartment

Diagnosis

Diagnosis is often difficult.

  • CT scan is the preferred imaging modality; definitive diagnosis through image-guided drainage and culture
  • Definitive organism isolated in ~75% of cases (1)

History

  • Symptoms often nonspecific
  • The most common symptoms are fever, flank pain, abdominal pain, and limp; >50% present with pain and 25–75% low-grade fever (1,2).
  • Pain may radiate to anterior hip and thigh.
  • Guarding, rebound, or other signs of peritoneal inflammation are less common (1,2,5).
  • Other symptoms may include nausea, anorexia, malaise, weight loss, and groin swelling.

Physical Exam

  • Maneuvers manipulating the inflamed psoas compartment result in pain on the affected side.
  • Pain with extension and internal rotation of the hip (the “psoas sign”; 95% specific but only 16% sensitivity) is the most common (6).
    • Place a hand proximal to the knee on the affected side and ask the patient to raise the thigh against resistance.
    • Alternative: Lay on the unaffected side and hyperextend the contralateral hip to stretch the psoas muscle—positive test if painful.
  • Psoas maneuvers may be positive in other conditions causing iliopsoas inflammation (e.g., retrocecal appendicitis).
  • Rectal examination helps differentiate psoas abscess from retrocecal appendicitis; pain on rectal examination is more consistent with appendicitis.
  • Patients often hold the hip flexed to relieve pain.
  • Extension of a psoas abscess below the inguinal ligament may result in a palpable mass.
  • Common findings in neonates include leg or groin swelling, limitation of leg motion, pain, and fever.

Differential Diagnosis

Retrocecal appendicitis, diverticulitis, septic arthritis, avascular necrosis of the hip, renal colic, pyelonephritis, arthritis, lumbar disc herniation, inflammatory bowel disease, epidural abscess, vertebral osteomyelitis, endometriosis, pelvic inflammatory disease, hematoma, tumor, and inflammation of the iliopsoas compartment

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)
  • WBC (>10,000/mL)
  • Anemia (hemoglobin <11 g/L)
  • Elevated ESR and CRP
  • Liver enzymes and creatinine kinase may be elevated (1).
  • Contrast enhanced CT is recommended for imaging (7)[B].
    • Sensitivity of 88–100%
    • Typically reveals a focal, hypodense lesion
    • May also demonstrate enlargement of the iliopsoas muscle; air-fluid levels within the muscle; fat stranding and/or rim enhancement
  • CT helps guide percutaneous drainage.
  • MRI similar sensitivity to contrast CT; cannot be used to guide percutaneous drainage (7)
  • Plain abdominal radiographs may outline an inflammatory mass.
  • Chest plain films may identify small pleural effusions or raised hemidiaphragm.
  • Ultrasound (US) is recommended as the initial imaging modality for suspected pediatric or neonatal psoas abscess.
  • US and MRI preferred for pregnant women (7)[C]

Diagnostic Procedures/Other
  • Culture of abscess fluid confirms diagnosis and guides antimicrobial treatment.
  • AFB stain and mycobacterial culture if TB suspected

Treatment

  • Most cases require percutaneous (PCD) or open surgical drainage and parenteral antibiotic treatment (16–20% success rate with antibiotics alone) (3,4)[B].
  • CT-guided PCD is initial procedure of choice (3,4)[B].
  • Open drainage indicated for large, complex, or multiloculated abscesses, significant involvement of adjacent structures, or if PCD fails
    • Primary surgical intervention more likely to succeed with gas-forming abscesses (4)[B]
  • Open drainage and surgical treatment of the underlying disease in cases associated with inflammatory bowel disease, ruptured appendicitis, or infected aortic ruptures
  • Consider US-guided percutaneous drainage as an alternative to surgical drainage for neonatal and pediatric psoas abscess.

Medication

  • Culture results should guide antibiotic coverage as drug resistance is becoming more common.
  • Broad-spectrum empiric antibiotics targeting staphylococcal (primary and secondary due to skeletal infections) and enteric organisms (secondary to intra-abdominal infection)
  • IV monotherapy with ticarcillin clavulanic acid 3.1 g IV q6h, piperacillin-tazobactam 3.375 g IV q6h, or meropenem 1 g q8h is effective as initial treatment.
  • Dual therapy with a 3rd-generation cephalosporin, such as ceftriaxone 1 g IV q12–24h with metronidazole 500 mg IV q8h, is also adequate.
  • Treat MRSA infection with vancomycin 15 mg/kg IV q8–12h. Daptomycin 6 mg/kg IV once daily or linezolid 600 mg IV/PO twice daily are alternatives (8)[C].
  • Although most psoas abscesses require drainage, some ≤3 cm have been managed by antibiotics alone.
  • Treat TB per USPSTF and IDSA guidelines.

Ongoing Care

Following drainage, pigtail catheter placement permits continued decompression of the abscess cavity and monitoring of purulent output.

Follow-up Recommendations

Most patients require 3 to 6 weeks of antibiotic treatment. TB requires 9 to 12 months.

Patient Monitoring
Follow-up imaging to verify resolution if necessary

Diet

NPO for percutaneous and surgical drainage procedures

Prognosis

  • A high index of suspicion is important for early intervention and improved outcomes.
  • Delays in diagnosis contribute to complications, including septic shock and death.
  • Mortality in adults ranges from 5% to 25% with prompt treatment. Untreated cases have ~100% mortality (1,3,4).
  • Mortality increases with advanced age, multiple comorbidities, delayed diagnosis, bacteremia/sepsis, and underlying secondary causes (1,3,4).
  • Children have a favorable prognosis with prompt diagnosis and treatment.

Complications

  • Inadequate treatment associated with unfavorable outcomes. About 40% of patients require >1 drainage procedure for full recovery.
  • Incomplete drainage or suboptimal antibiotic treatment may lead to relapses up to a year after initial presentation in 16% of cases (1).
  • Spinal cord compression has been reported via direct extension of psoas abscess.
  • Most relapses occur within 6 months of treatment; can occur over a year after treatment

Codes

ICD-10

  • K68.12 Psoas muscle abscess

ICD-9

  • 567.31 Psoas muscle abscess

SNOMED

  • 235997006 Abscess iliopsoas non-tuberculous (disorder)
  • 266463007 Iliopsoas abscess (disorder)

Clinical Pearls

  • Psoas abscesses are rare, retroperitoneal collections of pus resulting from hematogenous, lymphatic, or contiguous spread of infection.
  • Primary and secondary psoas abscesses have different underlying causes.
  • A high level of suspicion is necessary for diagnosis. Fever and pain are the most common presenting symptoms.
  • CT is the imaging modality of choice to diagnose psoas abscess and guide percutaneous drainage.
  • Culture of aspirated abscess fluid provides definitive diagnosis and guides antibiotic therapy.
  • Prompt drainage and appropriate antibiotic therapy improve outcomes. Percutaneous drainage is the preferred approach.
  • Patients with underlying comorbidities such as inflammatory bowel disease, skeletal infection, HIV, or other immunocompromised states are at higher risk for psoas abscesses.

Authors


Adriane E. Bell, MD

Bibliography

  1. Navarro López V, Ramos JM, Meseguer V, et al. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine (Baltimore). 2009;88(2):120–130.  [PMID:22960467]
  2. Shields D, Robinson P, Crowley TP. Iliopsoas abscess—a review and update on the literature. Int J Surg. 2012;10(9):466–469.  [PMID:19282703]
  3. Tabrizian P, Nguyen SQ, Greenstein A, et al. Management and treatment of iliopsoas abscess. Arch Surg. 2009;144(10):946–949.  [PMID:19841363]
  4. Hsieh MS, Huang SC, Loh el-W, et al. Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study. BMC Infect Dis. 2013;13:578.  [PMID:17298628]
  5. Alonso CD, Barclay S, Tao X, et al. Increasing incidence of iliopsoas abscesses with MRSA as a predominant pathogen. J Infect. 2011;63(1):1–7.  [PMID:19950852]
  6. Navarro Fernández JA, Tárraga López PJ, Rodríguez Montes JA, et al. Validity of tests performed to diagnose acute abdominal pain in patients admitted at an emergency department. Rev Esp Enferm Dig. 2009;101(9):610–618.  [PMID:3776220]
  7. Yaghmai V, Rosen MP, Lalani T, et al. ACR Appropriateness Criteria®: Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess. Reston, VA: American College of Radiology; 2012:10. https://acsearch.acr.org/docs/69467/Narrative/. Accessed January 9, 2018.  [PMID:24466586]
  8. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133–164.  [PMID:21641042]


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TY - ELEC T1 - Abscess, Psoas ID - 117383 Y1 - 2019 PB - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117383/all/Abscess__Psoas ER -