Diagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning

doi:10.1016/S0090-4295(00)00923-7

Urology

Volume 57, Issue 2, February 2001, Pages 246-251

https://doi.org/10.1016/S0090-4295(00)00923-7 Get rights and content

Abstract

Objectives. To examine retrospectively the clinical presentations, microbiologic characteristics, and treatment outcomes of psoas abscess in patients with diabetes mellitus (DM) and to assess the usefulness of computed tomography and gallium-67 scanning in its early diagnosis.

Methods. During a 9-year period, psoas abscesses in patients with DM were collected at a medical center. The clinical history and associated etiologic factors, microbiologic results, clinical outcomes, and hospitalization days were recorded. The use of imaging in the diagnosis of psoas abscess and other concomitant infectious lesions was also studied.

Results. Fifteen patients with DM and psoas abscess (13 women and 2 men; mean age 58.7 ± 9.0 years) were found. The most frequent symptom was fever (12 of 15). Of the six different microorganisms that grew in the blood and/or abscess cultures, Staphylococcus aureus was the most frequent (7 of 15). The most commonly associated pathologic finding was vertebral osteomyelitis (5 of 15). Computed tomography and/or magnetic resonance imaging confirmed the diagnosis of psoas abscesses in all 15 patients. The gallium-67 scan especially aided in the diagnosis of the patients who had initially been diagnosed as having fever of unknown origin (4 of 5) and in the diagnosis of concomitant lesions (9 of 12). Debridement or surgical drainage of the abscess was done in 12 patients. All the patients received adequate antibiotic treatment. However, the mortality rate was 20%. The average hospitalization stay was 42.7 ± 20.7 days.

Conclusions. Psoas abscess in patients with DM is a disease with both diagnostic and therapeutic challenges. We found the infecting microorganisms to be variable and the mortality rate high.

Section snippets

Material and methods

During a 9-year period, 15 patients (13 women and 2 men, age range 42 to 77 years, mean age 58.7 ± 9.0) with DM and psoas abscess were collected from the computer system of Chang Gung Memorial Hospital, a medical center with 3600 admission beds. Charts of these patients were reviewed thoroughly, with special attention to the clinical symptoms and blood laboratory data on admission, method of diagnosis and treatment, associated etiologic factors, bacteriologic results, clinical course and

Results

The patients with DM and psoas abscesses were all older than 50 years, except for 1 patient who was 42 years old (Table I). Women were predominant (n = 13, 86.7%). The most frequent clinical symptom was fever (n = 12, 80%). The triad of fever, flank pain, and limitation of hip movement was present in only 2 patients (13.3%). Blood glucose concentrations were all abnormal on admission, with the level in 11 patients (73.3%) greater than 250 mg/dL.

At least six different microorganisms were grown

Comment

DM is responsible for immunocompromising host defenses and consequently increases the relative risk of infection. The mechanisms of DM in the pathogenesis of predisposing skeletal muscle damage has been reviewed.8 Inadequate serum glucose control is associated with decreased neutrophil bactericidal action, cell-mediated immunity, and serum opsonic activity and resultant infection.8, 9 On the other hand, bacterial infections during a febrile phase may cause fasting hyperglycemia.9 As all the

Conclusions

Psoas abscess in patients with DM is a disease with both diagnostic and therapeutic challenges. The infecting microorganisms were found to vary. Ga-67 scanning may help in the early diagnosis of psoas abscess, especially in patients with FUO, and in the diagnosis of unexpected concomitant multiple infectious lesions. However, even with the diagnostic studies and treatment in our study, the hospital stay was long, with a 20% mortality rate.

Acknowledgements

To Kathleen Ahrens, Ph.D. for her help in preparing this report.

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Pyogenic and tuberculous abscesses of the psoas muscle
2011, Revista Clinica Espanola
Precisar las características clínicas de los pacientes con absceso del músculo psoas (AP) y las posibles diferencias existentes entre los AP piógenos o tuberculosos.
Revisión retrospectiva de los pacientes diagnosticados de AP en un hospital (1983-2009). Se establecieron dos grupos, piógenos y tuberculosos, y se compararon sus hallazgos clínicos, analíticos y evolución.
Se incluyeron 30 pacientes con AP, 25 piógenos y 5 tuberculosos, En 9 ocasiones fueron primarios y en 21 secundarios (a patología esquelética en 8 a patología urológica en 8 y a gastrointestinal en 8). No se observaron diferencias clínicas entre ambos grupos. Los pacientes con AP piógenos tendieron a tener mayores cifras de leucocitos (13.871 vs. 8.560/mm³, p = 0,018) y de velocidad de sedimentación globular (VSG) (108 vs. 17 mm/h, p < 0,0001) y menores de hemoglobina (11 vs. 14 g/dL, p = 0,008) Se diagnosticaron por tomografía computarizada (TC) en 29 pacientes y por resonancia magnética en 1, ambas con una sensibilidad diagnóstica del 100%, frente al 50% de la ecografía. La lateralidad izquierda fue menos frecuente en los AP piógenos (44 vs. 100%, p = 0,031). Los hemocultivos y el cultivo de pus del absceso fueron positivos en el 22% y 82% de las ocasiones en las que se realizó. Los gérmenes aislados con más frecuencia fueron bacilos gramnegativos, Streptococcus spp. y S. aureus. El 50% de los casos fueron drenados percutáneamente, el 13% quirúrgicamente y el 3% por ambas técnicas. Fallecieron 2 pacientes, ambos con absceso piógeno.
Los abscesos piógenos secundarios constituyen el grupo de AP más frecuente. La TC es el procedimiento diagnóstico de elección. La presencia de leucocitosis, anemia, VSG elevada y la lateralidad derecha sugieren etiología piógena. El drenaje percutáneo está sustituyendo al quirúrgico y permite obtener muestras diagnósticas.
To describe the clinical characteristics of patients with abscess on the psoas muscle (PA) and to identify the possible differences existing between pyogenic and tuberculous etiologies.
A retrospective review of patients diagnosed of PA in one hospital was conducted (1983-2009). Two groups were established, that is pyogenic and tuberculous, and the clinical findings, analyses and evolution were compared.
Thirty PA were included, 83% pyogenic and 17% tuberculous, average age 53 years. On 9 occasions, 30% were primary and on 21 occasions, 70% secondary (to skeletal pathology in 8, to urological in 8 and to gastrointestinal in 8). No clinical differences were observed between both groups. Pyogenic and tuberculous etiologies were differentiated analytically through leukocyte values (13,871 vs. 8,560/mm³, p = 0.018), hemoglobin (11 vs. 14 g/dL, p = 0.008) and erythrocyte sedimentation rate (ESR) (108 vs. 17 mm/h, p < 0.0001). Abscesses were diagnosed by computed tomography (CT) in 29 patients (97%) and by magnetic resonance in 1 (3%), both with a diagnostic sensitivity of 100%, as opposed to 50% for ultrasound scanning. Left laterality was less frequent in pyogenic abscesses (44% vs. 100%, p = 0.031). The blood cultures were positive in 22% and abscess pus culture in 82%. Gram negative bacilli, Streptococcus spp. and S. aureus were the most frequent isolations. A total of 67% were drained: transcutaneously 50%, surgically 13% and both techniques 3%. Two patients died (7%), both with pyogenic abscess.
Secondary pyogenic abscesses constitute the most frequent PA group. CT is the diagnostic procedure of choice. Leukocytosis, anemia, raised ESR and right laterality suggest pyogenic etiology. Transcutaneous drainage is substituting surgical drainage and also makes it possible to obtain diagnostic samples.
Clinical Applications and Usefulness of Integrated Single Photon Emission Computed Tomography/Computed Tomography Imaging
2008, Tzu Chi Medical Journal
Radiopharmaceuticals reflect physiologic and pathologic functions rather than anatomical abnormalities. In the clinical setting, it is often necessary to correlate these functional studies using anatomical imaging. The advent of single photon emission computed tomography (SPECT) and positron emission tomography (PET) provides tomographic images for direct correlation to anatomic modalities such as X-ray, computed tomography (CT) and magnetic resonance imaging. Correlation of anatomic and functional information can aid in the decision-making process by enabling better localization and definition of organs and lesions and improving the precision of surgical biopsies. The advantages of combining SPECT with CT are primarily due to the anatomical referencing and the attenuation correction capabilities of CT. Depending on the system design, there are varying technical issues surrounding the different SPECT/CT devices. The principle of the integrated SPECT/CT instrumentation and the use of attenuation correction and anatomical referencing are discussed in this review. The specific disease processes where SPECT/CT has had a positive impact on diagnostic accuracy will be illustrated in this review. Although it is starting more slowly than PET/CT, SPECT/CT has many existing and potential areas of clinical application and has significantly added to the diagnostic power of nuclear medicine. Through literature review and case presentation, the authors illustrate the applications and uses of SPECT/CT as experienced at Tzu Chi General Hospital. The most common uses of SPECT/CT were for the diagnoses of infections focused with gallium-67 citrate, ^99mTc-sulfurcolloid sentinel lymph node mapping, thyroid cancer survey with ¹³¹I-sodium iodide, parathyroid scan with ^99mTc-Sestamibi, abdominal diseases, and bone imaging with ^99mTc-methylene diphosphonate. Through this review, the authors also highlight the current comprehensive clinical use of SPECT/CT in our hospital.
Psoas abscess rarely requires surgical intervention
2008, American Journal of Surgery
Citation Excerpt :
Secondary abscesses generally are considered to be caused by enteric organisms (82%),1 and this was indeed the case in our series (58%). Psoas abscess traditionally has been treated with surgical drainage via an extraperitoneal approach.1–11 Recent case series are advocating PCD as the first line of treatment.20–24
Surgeons are increasingly encountering psoas abscesses.
We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm.
Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography–guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%.
Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.
Pyogenic psoas abcess: case reports and review of the literature
2006, Revue de Medecine Interne
L'abcès du psoas est une pathologie rare dans les pays développés. Généralement d'origine secondaire, son diagnostic est difficile et tout retard dans la prise en charge diagnostique et thérapeutique peut grever le pronostic fonctionnel. Les objectifs sont de définir la conduite diagnostique et thérapeutique la plus adaptée.
Étude rétrospective portant sur six cas d'abcès pyogènes du psoas secondaires sur une période de six mois.
Les six cas d'abcès du psoas sont associés à une spondylodiscite dans trois cas, une arthrite interapophysaire, une arthrite coxofémorale et à une infection gynécologique pour les trois autres cas. Le diagnostic anatomique est apporté dans tous les cas par la tomodensitométrie. La documentation bactériologique a été obtenue par les hémocultures ou prélèvements directs de l'abcès. L'antibiothérapie a été associée à un drainage percutané dans deux cas, une ponction simple dans un cas et une prise en charge chirurgicale dans un cas. L'évolution locale a été favorable dans tous les cas. Les complications les plus graves sont survenues chez les patients les plus âgés et n'étaient pas directement liées à l'abcès du psoas.
● Les abcès du psoas sont une pathologie à ne pas méconnaître du fait de leur incidence croissante ; ● si l'origine des abcès secondaires est classiquement digestive, les causes osseuses (en particulier rachidiennes) sont probablement aussi fréquentes ; ● la ponction ou le drainage percutané guidés par tomodensitométrie ont un réel intérêt tant diagnostique, que thérapeutique ; ● l'antibiothérapie, systématique dès les prélèvements infectieux effectués, doit être active vis-à-vis des bacilles à Gram négatif et des anaérobies, mais aussi vis-à-vis de Staphylococcus aureus ; ● la chirurgie doit être envisagée rapidement si le foyer d'origine le nécessite, en cas d'abcès volumineux, et si le drainage a été insuffisant ou en cas d'échec de l'antibiothérapie adaptée initiale.
Psoas abscess is a rare disease in developed countries. Its diagnosis is difficult and any delay could lead to a worsen prognosis. The aim of this study is to determine the best diagnostic and therapeutic practices.
A retrospective study of psoas abscess that occurred during six months was performed.
Six cases of secondary psoas abscess are reported. They were associated with spondylodiscitis in three cases, arthritis and gynaecologic infection in the three remaining cases. Anatomic diagnosis was performed by tomodensitometry. Microbiologic diagnosis was obtained by blood culture or direct puncture of the abscess. Antibiotics were associated with percutaneous drainage in two cases, with simple puncture in one case, and with surgery in one case. A local improvement w observed in all cases. The oldest patients presented the worst complications which were not directly caused by the abscess.
● Physicians must be aware of psoas abscess because of their increasing incidence. ● Despite the fact that digestive pathologies are the main cause of secondary psoas abscess, bone infections, particularly spine infections, should be taken into consideration. ● Tomodensitometry guided puncture or percutaneous drainage are of diagnostic and therapeutic interest. ● Infectious samples must be taken before starting antibiotics, which have to be efficient against Gram negative bacillus, anaerobes and Staphylococcus aureus. ● Surgery must be quickly performed when the primary infection localisation need it, in case of voluminous abscess or when antibiotics and drainage are inefficient.
Psoas and spinal epidural abscess in a diabetic patient - Case report
2005, Diabetes Research and Clinical Practice
Pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with diabetes mellitus: A case report
2021, Journal of Diabetes Investigation

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Adult urologyDiagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning

Abstract

Section snippets

Material and methods

Results

Comment

Conclusions

Acknowledgements

Diabetes Res Clin Pract

Am J Emerg Med

Am J Med

J Urol

Radiol Clin North Am

Arch Phys Med Rehabil

Lancet

Clin Radiol

Impaired immune responses in diabetes mellitusanalysis of the factors and mechanisms involved. Relevance to the increased susceptibility of diabetic patients to specific infection

Diabetes Metab