CASE REPORT

Giant Primary Psoas Abscess: Masquerading Peritonitisfor Diagnosis and Treatment

Rikki Singal1, Amit Mittal2, Samita Gupta2, Bikash Naredi1, Maihail Singh1
Department of Surgery, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana, (DisttAmbala) Pin code133201, Haryana, India. 2 Department of Radiodiagnosis and Imaging, Maharishi Markandeshwer
Institute of Medical Sciences and Research, Mullana (Distt-Ambala) Pin code133201, Haryana, India.
1

Correspondence mail:
dr. Kundan Lal Hospital, Ahmedgarh, Distt-Sangrur, Pin code-148021, Punjab, India. email: singalsurgery@yahoo.com.

ABSTRAK
Abses primer otot psoas merupakan kesatuan klinis tersendiri dengan gambaran klinis dan patogenesis
yang masih samar dan belum jelas. Kepustakaan tentang hal ini pun masih sangat sedikit. Abses otot psoas
merupakan fenomena klinis yang jarang terjadi, sangat sulit didiagnosis dan perlu pemeriksaan yang teliti.
Artikel ini menekankan pada pentingnya pemeriksaan ultrasonografi dan tomografi komputer serta peranan
pengobatan dalam kasus ini. Pada kasus ini, seorang pasien perempuan berusia 15 tahun datang dengan nyeri
dan kembung di bagian perut. Kami melaporkan suatu kasus yang sangat jarang terjadi, yakni abses psoas
raksasa bilateral yang didiagnosis sebagai peritonitis. Pemeriksaan ultrasonografi menunjukkan bahwa abses
pada otot psoas kiri ternyata mengalami ruptur ke arah anterior dalam rongga peritoneum dan menyebabkan
abses intraperitoneal, tetapi pemeriksaan tomografi komputer menunjukkan gambaran yang berbeda. Pada
kasus ini, pemeriksaan tomografi komputer memiliki peranan penting dalam tatalaksana abses psoas. Kasus
ini ditatalaksana dengan baik secara konservatif, yakni dengan drainase dan pengobatan antibiotik. Pasien
pulang dari rumah sakit dalam kondisi yang baik dan memuaskan. Pada evaluasi lanjut 9 bulan kemudian,
kondisi pasien baik dan tidak mengalami gejala lagi.
Kata kunci: peritonitis, bilateral, ultrasonografi, tomografi komputer, drainase pembedahan.
ABSTRACT
Primary psoas abscess is a distinct clinical entity with vague clinical presentation and obscure pathogenesis,
although the literature regarding it is sparse. Psoas muscle abscess is an uncommon clinical phenomenon,
extremely difficult to diagnose and needs to be investigated with considerable thoroughness. We emphasize
the importance of ultrasonography and computed tomography along with role of the treatment. A 15-year old
female presented with pain and distention of the abdomen. We report an extremely rare case of bilateral giant
psoas abscess diagnosed as peritonitis. Ultrasonography showed abscess of the left psoas muscle which ruptured
anteriorly into the peritoneal cavity and caused intraperitoneal abscess but computed tomography revealed
different picture. In our case, computed tomography has the main role in the diagnosis/management of the psoas
abscess. Conservative treatment was given using antibiotics and drainage. The patient was discharged in good
condition. In follow-up period of 9 months, she remained well and asymptomatic.
Key words: peritonitis, bilateral, ultrasonography, computed tomography, surgical drainage.

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INTRODUCTION

Primary psoas abscess (PPA) potentially

carries high mortality and morbidity, if diagnosis
is delayed.1 It carries a good prognosis provided
early drainage is performed and parenteral
antibiotic therapy is administered to the patient.
The worldwide incidence was 12 cases per
100,000 per year in 1992, but the current
incidence is unknown.
The psoas muscle has a rich vascular supply
that is believed to predispose it to hematogenous
spread from sites of occult infection. Psoas abscess
(PA) can also be secondary to gastrointestinal
or renal pathology through direct infection of
adjacent structures. The most common causes
are appendicitis, diverticulitis, Crohns disease
and carcinoma. The organisms responsible for
infection are Gram-negative germs (Escherichia
coli, Klebsiella spp., Pseudomonas aeruginosa,
Proteus mirabilis, Enterobacter spp.) and
Gram-positive cocci (Staphylococcus aureus,
Staphylococcus epidermidis, Streptococcus
agalactiae, -hemolytic streptococci, especially
Streptococcus mitis). It can also be of tuberculous
etiology and associated with cold abscesses of
lower thoracic and upper lumbar vertebral bodies,
as the psoas is attached to these vertebrae.2
Psoas muscle abscess is an uncommon clinical
phenomenon, which needs to be investigated
thoroughly for the proper management. Modern
imaging techniques such as ultrasonography,
computed tomography (CT), magnetic resonance
imaging (MRI) and radionuclide scans allow
more rapid diagnosis and decrease the morbidity
and mortality of patients with PA.3 However, at
the initial stage of the disease, the negative results
of image studies often make the physicians
ignore the possibility of psoas pathology.
PPA carries a good prognosis, if early
drainage is performed and parenteral antibiotic
therapy administered which provide a safe
alternative to more invasive surgical drainage
in most of patients. High index of clinical
suspicion is required for the diagnosis of psoas
abscess. Rarely, psoas abscess can extend to the
abdominal compartment presenting as peritonitis
as giant abscess bilaterally, as seen in our patient.
Awareness of this disease entity, careful physical
examination and appropriate imaging studies

Giant primary psoas abscess: Masquerading peritonitis

such as ultrasonography, computed tomography

and magnetic resonance imaging are the key to
make a correct diagnosis.
CASE ILLUSTRATION

A 15 year-old female presented with pain in

the abdomen, fever, vomiting. The pain was more
present in the right pelvic region and limping
occured of a few days duration. There were no
history of diarrhea or any urinary symptoms.
She complained of tenderness on palpation or
percussion of his lumbar vertebrae. She had
taken treatment from in the form of analgesics
and antibiotics but her condition was worsened
and reported to our institute in emergency. She
also gave a past history of lung tuberculosis 2
years back for which she took complete course.
Physical examination revealed a temperature
of 38C, a pulse rate of 110/minute and a
blood pressure of 110/70 mm Hg. She was
pale and toxic. The chest X-ray was clear with
normal heart sounds. Abdominal examination
revealed generalized tenderness and swelling in
bilateral lumber region. The swelling was larger
approximately 8x10 cm in size on the left side
compared to the right side. She had physical
signs of psoas inflammation. Bowel sounds were
absent. Diagnosis was kept as peritonitis.
On blood tests, the white cell count was
16.3x109/l, and his urine was clear. The ESR
was 81 mm/hour. Liver enzymes, serum
creatinine, blood urea, and nitrogen values
were normal. Plain X-ray of the abdomen
showed obliteration of the right psoas shadow.
Radiography of the lumbar spine and hip was
normal. Ultrasonography (USG) revealed
evidence of large abscess seen in left psoas
muscle ruptured anteriorly in the peritoneal
cavity and caused intraperitoneal abscess.
Abscess was also present over right psoas
muscle but was less as compared to left. Bilateral
hydronephrosis was present due to psoas abscess.
Contrast enhanced computed tomography
(CECT) scan of the abdomen and pelvis showed
bilateral psoas abscess with huge collection on
left side of psoas region as dimensions could be
possible to measure. The collection extends in
the bilateral retroperitoneal areas of the abdomen
superiorly from hypochondrium to inferiorly

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extending in the pelvic area. There are also

posteriorly extensions in the posterior abdominal
wall muscles and paravertebral muscles with
evidence of air in the collection also.
The patient was resuscitated and third
generation cephalosporin antibiotics were
started. An oblique incision was given on
bilateral sides. Abscess was drained of 2 liter
on left side and 1 liter on right sided which was
foul smelling. Pus was sent for tubercular and
culture sensitivity tests, which came as negative.
She went into renal failure in early stage but
managed with antibiotics and dressings. She was
discharged in a satisfactory condition after two
weeks of the treatment.

Figure 1. Bilateral retroperitoneal psoas abscess and huge

size on left side marked by arrow

Figure 2. Contrast enhanced computed tomography (CECT)

showing site of rupture on left side marked by dotted arrow

DISCUSSION

PPA is a rare condition with an often vague

and non-specific clinical presentation, which
may be classified as primary or secondary,
depending on the presence or absence of
underlying disease. PPA occurs primarily in
young males; secondary abscesses are observed
in a somewhat older age group. A psoas (or
iliopsoas) abscess is a collection of pus in the

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Figure 3. Axial CECT and coronal multiplanar reconstruction

(MPR) images are showing bilateral psoas abscesses (solid
arrows) with rupture seen on left side (dotted arrow) with
formation of large bilateral retroperitoneal collections

iliopsoas muscle compartment. Mynter first

described psoas abscess in 1881 referring as
psoitis. 4 A review of worldwide literatures
published from 1881 through 1990 has revealed
that the incidence of PPA is around 4 cases per
year.5 PPA is most prevalent in older patients.
In Taiwan, 2 retrospective reviews were carried
out, and 20 percent (8 out of 40 patients) were
classified as having primary abscesses.6 A recent
endemic study in Taiwan reported that the rate
of occurrence was 2.5 cases annually.6
The psoas muscle is a fusiform muscle
which blends with those of the iliacus muscle in
30% of cases to form the iliopsoas, due to their
common insertion and actions. The muscle takes
origin from transverse processes, intertubercular
processes and intervertebral discs of vertebrae
T12 to L5 and inserts at the tip and medial part
of the anterior surface of the lesser trochanter
of the femur.
PPA can be classified as either primary
infection of the psoas muscle or secondary
abscess from the direct extension of infection
from adjacent organs.7 The etiology of psoas
abscess remains uncertain. It results from either
hematogenous spread from occult infection
or local trauma with resultant intramuscular
hematoma formation which predisposes to
abscess formation. PPA occur most commonly
in patients with history of diabetes, injection
drug use, alcoholism, AIDS, renal failure,
immunosuppresion or malnutrition. Low

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socioeconomic status males under 20 years

of age are more succeptible although psoas
abscess can occur in any age group. The
predominant organism in primary psoas abscess is
Staphylococcus aureus followed by Escherichia
coli and Streptococcus. Secondary abscess is
caused by a mixed flora of enteric bacteria,
commonly E.coli and Bacteroides.
Historically, psoas abscess was most
commonly seen in patients with spinal
tuberculosis also known as Potts disease.
Today, it is associated with infections of the
bowel, kidney and spine. Though in developing
countries, Mycobacterium tuberculosis is the
most frequent cause of secondary abscess. The
typical triad of fever, flank pain, and limitation
of hip movement is present only in 30% of cases.
Other symptoms include malaise, anorexia,
lower back pain, a palpable mass, or pyrexia of
unknown origin.8,9
Laboratory tests such as raised leucocytes
count and inflammatory markers are useful in
the evaluation of suspected psoas abscess, but
none are universal findings. As in most clinical
scenarios, diagnosis is aided (confirmed) by
appropriate radiological investigations. CT
scanning has proved superior to ultra sound
scanning and is considered the radiological
investigation of choice.1,10 USG of the abdomen
may demonstrate a hypoechoic mass suggestive
of PA, but cannot identify the cause of the
abscess. CT scan of the abdomen with contrast
is the most efficient and accurate imaging study
in diagnosing a psoas abscess as in our case.
CT scanning is now used as the first line of
investigation. CT scan of the abdomen not only
helps in diagnosis, but also in identification
of the etiology, for therapeutic purposes, and
postoperative follow-up.11
Abscess can be drained radiologically
or surgically. Percutaneous drainage may be
difficult in some patients because of the location
of the abscess, but whenever possible it should
be employed. Even in patients with complex,
multiloculated abscesses, percutaneous drainage
should be attempted and open surgical drainage
should be reserved if percutaneous drainage
fails.4 We have done extraperitoneal drainage
which is a safe and effective method for these

Giant primary psoas abscess: Masquerading peritonitis

abscesses. We are agreed with the author that

with open drainage is a better option than
percutaneous drainage because debridement and
biopsy of adjacent tissues can be done with open
process, which may help in shortening recovery
time.4 The prognosis of PPA is better compared to
secondary abscess.4 With appropriate treatment
the prognosis is generally good. Primary psoas
abscess has a better prognosis, the mortality rate
being only 2.4%.
CONCLUSION

Ultrasound, CT, and MRI helped to make a

definitive diagnosis. Psoas muscle abscess is a
rare condition with vague clinical presentation,
which presents a diagnostic challenge requiring a
high index of suspicion. The role of CT scan was
very important in this case. If patients are treated
with USG basis then incision site could have
been different, thus CT has helped us to remain
in retroperitoneal space only. The patient was
treated successfully with open surgical drainage
and antibiotic therapy.
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