Cath Lab Digest

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Index: Ostomy Wound Mange. 2008;54(8):44-48.

     Iliopsoas abscess is a life-threatening infection usually associated with urinary tract infections, Crohn’s disease, spinal tuberculosis, or a septic hip joint.^1-3 Secondary iliopsoas abscess tends to develop in spinal cord injury patients because hip joint infection sometimes occurs as a result of a deep ischial pressure ulcer. Rubayi et al^1,2 reviewed the records of 72 patients with iliopsoas abscess; nine were spinal cord injury patients. When iliopsoas abscess develops secondary to a pressure ulcer, it usually is caused by an ischial pressure ulcer because ischial infection can extend to the hip joint and iliopsoas muscles. Thus, iliopsoas abscess originating in a sacral pressure ulcer is considered unusual.^1,2

     To increase knowledge of this infrequent but challenging condition, a case study is presented of a 78-year-old bedridden, malnourished woman with iliopsoas abscess secondary to a sacral pressure ulcer that was successfully treated with computed tomography (CT)-guided aspiration, wound drains, and antibiotics. The guided aspiration is thought to have decreased risk for surgical and postsurgical complications and can be considered a viable option in fragile iliopsoas patients.

Case Report

     History. Ms. K was a 78-year-old woman who had been referred to an emergency unit of the National Hospital Organization Nagasaki Medical Center and subsequently referred to the Department of Plastic and Reconstructive Surgery for treatment of a high fever and a sacral pressure ulcer of 2 months’ duration. She had been bedridden at home due to senility; she had no other comorbidities other than her body was succumbing to old age and inactivity. She presented at a local clinic with a temperature of 39° C of 2 days’ duration and was admitted for 3 days. Before transfer to the hospital, computed tomographic (CT) examination in the clinic demonstrated an iliopsoas abscess.

     During the first examination in the hospital, Ms. K was found to be malnourished (body weight, 35 kg) and febrile (39.4° C). She had a sacral pressure ulcer with a subcutaneous cavity 20 cm in diameter (see Figure 1). She was taken to the emergency unit and provided treatment with high-dose intravenous antibiotics (clindamycin — 600 mg every 12 hours and cephazolin— 2 g every 12 hours) and immunoglobulin. A second CT scan was performed immediately after arrival in the authors’ unit that showed destroyed sacral bone and abscesses in the iliopsoas muscle and beneath the gluteal muscles (see Figure 2a, b). These abscesses seemed to be interconnected through fistulae. Hematological studies revealed a white blood cell (WBC) count of 11.6x109/L and a marked increase in C-reactive protein (CRP) level (11.2 mg/dL), indicating severe inflammation.

     Treatment. The infected right buttock skin was immediately incised and yellowish pus was aspirated (see Figure 3).