Psoas Abscess: A Primer for the Internist

, Department of Internal Medicine, Lincoln Health Center and Durham Regional Hospital, Durham, NC

South Med J. 2001;94(1) 

In This Article

Case Report

A 51-year-old man without a history of urologic disease went to his primary care physician after 4 days of right flank pain associated with urinary frequency. He denied dysuria, fever, chills, nausea, or vomiting. Physical examination revealed a temperature of 97.8°F and blood pressure of 127/67 mm Hg. There was mild tenderness in the right flank but no pulsatile abdominal mass, bruit, or significant abdominal tenderness. Prostate examination was unremarkable. White blood cell count was 9,400/mm3. Urinalysis showed 5 to 10 WBCs. A 10-day course of trimethoprim/sulfamethoxazole was started for presumed urinary tract infection, and the patient was told to return upon completion of the treatment.

A week after initiating antibiotic therapy, he went to an urgent care clinic because of right hip pain and nausea. He had lost about 4 pounds. Findings on radiography of the hip were negative. No definite diagnosis was made. He was given ibuprofen and discharged home. Three days later, the patient returned to his primary care physician for follow-up. By then, he had severe right hip pain with radiation to the anterior thigh. Temperature was 98.7°F, and total weight loss was 7 pounds. He had physical signs of psoas inflammation in addition to tenderness in the right lower quadrant. Computed tomography of the abdomen and pelvis showed a large right psoas abscess (Figure). The WBC was 7,800/mm3. Liver enzyme, creatinine, and BUN values were normal. The ESR was 87 mm/hr. Broad spectrum antibiotic therapy was started, and percutaneous drainage of the psoas abscess yielded 210 mL of purulent material, which grew E coli and Streptococcus viridans. Urine culture from the initial presentation to his primary care physician also grew E coli. Colonoscopy and upper GI series with small bowel follow-through did not reveal any gastrointestinal disease. Multiple blood cultures were negative, and results of echocardiography were normal. Test for HIV was positive. The patient recovered fully from the abscess after drainage and antibiotic treatment. He is currently receiving care for HIV infection.

Figure 1.

Large right psoas abscess

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