We recently saw a patient that presented almost
three years after treatment for a gunshot wound to the abdomen with left nephrectomy
and primary descending colon repair for a left renal fracture extending to the
hilum and a graze wound to the descending colon respectively. Three years
following surgery, the patient presented with two weeks of left sided abdominal
and flank pain, fevers, and difficulty walking upright secondary to pain. The
patient denied any difficulty with diet and denied any urinary complaints. On
examination, the patient was febrile with tenderness in the left side of the
abdomen, but no rebound. Labs were
significant for a leukocytosis. CT scan showed a multiloculated abscess
extending from the left perinephric space. The abscess was percutaneously
drained and grew Escherichia coli and viridans streptococcus. The patient’s
pain and fever resolved. He was
discharged home.
Delayed presentations of psoas abscesses after
nephrectomy are not uncommon, and a review of the literature reveals abscesses
presenting three years to twenty-seven years following nephrectomy. Psoas
abscesses can be primary or secondary. A primary abscess occurs when the psoas
muscle is the focus of infection. A secondary abscess occurs from direct spread
from underlying infections generally intestinal in nature. Secondary abscesses
can result from Crohn’s disease, ulcerative colitis, appendicitis,
diverticulitis, colonic neoplasms, pyelonephritis, and postoperative
complications. Common organisms are staphylococcus aureus, Escherichia coli,
Proteus mirabilis, Kelbsiella pneumoniae, Pseudomonas aeruginosa, Bacterioides
gragilis, and Serratia marcescens.
Patients generally present with fever and flank
pain. Computed tomography is the best test to diagnosis a psoas abscess. Treatment
is drainage; percutaneous or surgical, followed by culture directed antibiotic
therapy.
Risk factors for development of a psoas abscess
following nephrectomy include: (1) enteric injury, (2) urinary tract infection
which can cause bladder retention and bacteria translocation from the ureteral
stump, (3) retained hematoma as culture medium for bacteria growth, immunodeficiency
(4), and (5) reaction against foreign bodies including silk suture, fractured
tissue, or stone fragments.
References
1. Di
Marco, et al. Psoas abscess ten years after ipsilateral nephrectomy for
pyonephrosis. G Chir 2007; 28(4):139-41.
2. Guillaume
MP, Alle JL, Cogan E. Secondary psoas abscess twenty-seven years after
nephrectomy. Eur Urol 1994; 25(2):171-3.
3. Lee et
al. Non-tuberculous cold abscess of the psoas muscle-an unusual manifestation
of colocutaneous fistula. Arch Orthop Trauma Surg 2000;120:224-5.
Figure legend: Computerized tomography image revealing
multiloculated abscess associated with left psoas muscle.
from Dr. Lindsay Petersen
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