PRIMARY PSOAS ABSCESS: CASE REPORT AND

REVIEW OF THE LITERATURE

P Sathyamoorthy
ABSTRACT
A case of primary non -tuberculous psoas abscess is reported and the literature reviewed. The aetiology of psoas abscess is varied and
there is a worldwide variation in the aetiology. Primarypsoas abscess is due to Staphylococcal infection. The pathophysio logy, clinical
features, diagnosis and treatment are discussed with emphasis on the changing pattern in the aetiology and diagnosis.

Keywords: psoas abscess, primary psoas abscess, retroperitoneal infection

SINGAPORE MED J 1992; Vol 33: 201-203

INTRODUCTION six days. The patient remained afebrile. Range of movement

Abscesses in the retroperitoneum are relatively common because of the lower extremity returned to normal. He was discharged
of the intimate association of this space with the gastrointestinal well after three weeks. When last seen after a month he was
tract and axial skeleton°. The psoas muscle as an integral part well.
of the retroperitoneal space is involved commonly in infec-
tions of this region. The aetiology is varied and there is a DISCUSSION
changing pattern in the pathology of psoas abscesses(?). This Anatomy
paper is presented to draw attention to the varied aetiology and The psoas muscle originates from the transverse processes and
the recent advances in the diagnostic techniques. bodies of the 12th thoracic and all the lumbar vertebrae. The
fibres insert on the lesser trochanter of the femur. Superiorly,
CASE REPORT
it passes beneath the arcuate ligament of the diaphragm. The
A 58 -year -old Malay diabetic man presented with a 10 -day
vertebral column lies medially, the quadratus lumborum is
history of pain in the right lower quadrant of the abdomen and
posterolateral and the peritoneum is anterior. Thus the psoas
femoral area. He had fever and difficulty in stretching his right
lies in close relationship to the kidney, ureter, pancreas, large
thigh and was unable to walk. He was being treated for diabe-
and small intestines and iliac lymph nodes. Furthermore, the
tes with daonil 2.5mg twice daily. There was no history of
space defined by the psoas fascia is a direct communication
trauma, cutaneous or other infection.
from the mediastinum to the thightJOt.
Physical examination revealed a febrile, dehydrated man
who was confined to bed and was in moderate distress. His Aetiology
temperature was 39.3°C, pulse 108/min and blood pressure The aetiology of psoas abscess is varied (Table I). It was for-
110/70mmHg. The abdomen was soft. A tender mass was felt merly synonymous with tuberculosis of the spine or sacro -iliac
in the right iliac fossa. The right thigh was in fixed flexion joint. In recent years, complicated tuberculous disease has be-
deformity. Rectal examination was normal. come rare and as a result the causes of psoas abscess have
Investigations done were:
Table I - Causes of Psoas Abscess
Haemoglobin = 11.2gm/d1, total white blood count was
25,200/uI with 92% neutrophils. Intestinal disorders:
Sedimentation rate was 106mm per hour. Crohn's disease
Random blood sugar was 24.Ommo1/1 and urine sugar was Diverticulitis
orange. Appendicitis
Chest X-ray : Normal. Carcinoma of colon
Plain abdominal X-ray: Bulging of the right psoas outline Primary Staphylococcal infection.
with scoliosis of the lumbar spine concave to the right. Osteomyelitis
Radiographs of the lumbosacral spine: Normal. Tuberculosis of the spine
Barium enema: Normal. Pancreatic abscess
Abdominal ultrasound: There was distortion of the homo- Perinephric abscess
geneous echo pattern. The muscle was filled with a Foreign body reaction
hypoechoic lesion. Post -operative complication:
Antibiotics were started and diabetes controlled. The pa- Anastamotic leak
tient was explored and a large abscess was seen in the right Appendectomy
psoas. There was no evidence of haematoma or lymphadenitis. Infected haematoma
1000m1 of pus was drained and culture of the pus subsequently
changed(?). There is a worldwide variation in the aetiology.
yielded Staphylococcus aureus. The drain was removed after Ricci et al (1986) reviewed the world literature and found that
the aetiology was related to the nation of origin. Three hun-
dred and seventy-six cases of psoas abscesses were reported of
Dept of Radiology which 286 (76.1%) were primary. In developing countries in
General Hospital
Asia and Africa, 99.5% were primary abscesses. In Europe
Kota Bahru
Malaysia only 18.7% were primary. In developed countries psoas ab-
scess now commonly occurs as a complication of intestinal
P Sathyamoonhy, FFRRCSI (Ireland) disorder(?). Leu et al (1986)reported 43 cases from Mayo Clinic
Radiologist from 1976 to 1984. Intestinal disease was the most frequent
cause (14 patients)m. Bartolo et al (1987) reported 16 cases

201
managed over a 10 -year period at the Bristol Royal Wumary. in the centre of the muscle, gas within the muscle and rim
Eight rases were due to intestinal diseases (o. enhancement after intravenous contrast. There are no distin-
Primary psoas abscess is a definite clinical entity. The guishing features between abscess with drainable pus and psoas
largest collective series is that of Lam and Hodgson who re- phlegmon. Psoas tumours also have diminished density and -

viewed 24 patients). Abscess culture yielded Staphylococcus may show rim enhancement after intravenous contrast«"). CT is
aureuS in 14 patients. This series and other reported cases essential in the early diagnosis(' 'n and is more conclusive than
show Staphylococcus aureus to be the most common aetiologic the other imaging modalities(").
organism in primary psoas abscess. Although antecedent skin In making the diagnosis bacterial culture of the pus aspi-
or soft tissue infection may be a predisposing factor, no such rated or drained from the abscess is important)°). If the culture
source is evident in the majority of cases. The aetiology of showed E coli, Streptococcus faecalis, Proteus or anaerobic
primary psoas abscess remains speculative. Suppurative Bacteroides the psoas abscess may be due to extension from
lymphadenitisn), trauma with haematoma formation and sec- inflammatory or neoplastic lesions of the gastrointestinal tract
ondary infection) and haematogenous seedling) have been or extension from perinephric abscess. In Staphylococcal in-
proposed as initiating factors. Most patients do not give a his- fection the psoas abscess may be due to extension from osteo-
tory of antecedent infection or trauma. Furthermore, Lam and myelitis of the spine, from an adjacent retroperitoneal infec-
Hodgson looked specifically for these factors at exploration. tion or it may be primary psoas abscess.
They found no evidence of haematoma or lymphadenitis even Treatment
in patients with a confirmatory history. Hence, the aetiology of The treatment for psoas abscess consists of adequate drainage
this disease remains uncertain; although the haematogenous and appropriate antibiotic coverage. Antibiotic coverage should
origin of this infection seems likely. be instituted at the time of the diagnosis. Selected cases may
Clinical features be treated with CT guided or ultrasound guided percutaneous
Psoas abscesses are characterised by pain in the iliac fossa, drainages""}' combined with antibiotic therapy.
groin or hip, flexion deformity of the thigh, a tender mass in The morbidity and mortality of psoas abscess are significant.
the flank, right or left iliac fossa or in the inguinal region, The insidious nature of the disease and frequent delay in diag-
fever and difficulty in walking. Pain is increased by nosis are contributory. Primary psoas abscess seems to have a
hyperextension of the hip. better prognosis than those secondary to other disease states.
Scoliosis with paravertebral spasm is a useful sign of a Most of the patients reviewed responded promptly to incision
retroperitoneal process rather than intraperitoneal infection"). and drainage and subsequently did well.
The abscess may point anteriorly above the outer portion of The case reported serves well to illustrate many of the
the inguinal ligament or may enter the adductor triangle and salient features observed in most of the cases of primary psoas
point in the upper third of the thigh("). Psoas abscess should not abscess reviewed in the literature. The source of infection was
be mistaken for septic arthritis of the hip. Toren et al (1989) not evident. The patient did not give any antecedent history of
reported a case of delayed diagnosis of primary psoas abscess infection or trauma. At exploration there was no evidence of
mimicking septic arthritis of the hip«'). Mistakes can be avoided haematoma or lymphadenitis. He was evaluated for
if hip movements are tested with the hip in the fully flexed gastrointestinal or renal disease, osteomyelitis of spine and
position. In this position the movements are relatively painless tuberculosis but none was detected. Bacterial culture of the
whereas in septic arthritis there is no change(1°). The symptoms pus yielded Staphylococcus aureus. The patient responded well
may be vague and delays in diagnosis and treatment are to drainage and antibiotics which is in keeping with most of
common. Lowe et al (1987) reported a 22 -year -old man with the patients reviewed.
a 2-year history of symptoms before the diagnosis was con-
firmed['). When the psoas abscess is secondary to bowel disor- CONCLUSION
der the patient may be debilitated with anaemia and loss of All patients presenting with psoas abscess should be thoroughly
weight. evaluated for gastrointestinal or renal diseases, osteomyelitis
of the spine and tuberculosis. Ultrasound with guided aspiration
Diagnosis is a useful investigation. CT is valuable in making early diag-
Routine laboratory evaluation is rarely useful in localising the
nosis. Bacteriologic culture is useful in determining the cause.
disease process. Anaemia, leucocytosis and elevation of the
Early diagnosis and prompt treatment will lead to a satisfactory
sedimentation rate are common.
outcome in most patients.
Chest radiograph may occasionally show elevation of the
hemidiaphragm or pleural effusion. Plain abdominal radiograph ACKNOWLEDGEMENT
may reveal abnormal psoas shadow with bulging of the out- The author wishes to thank the Director General, Ministry of
line, soft tissue mass, scoliosis to the affected side or gas in Health, Malaysia for granting permission to publish this article.
the soft tissues). An excretory urography may show medial
deviation of the lower third of the ureter. A barium enema REFERENCES
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202
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