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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 335-337

Iliopsoas gravity abscess secondary to a tuberculous empyema


1 Department of Respiratory Medicine, Katsushika Medical Center, The Jikei University School of Medicine, Tokyo, Japan
2 Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan

Date of Submission09-Jun-2021
Date of Acceptance10-Jul-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Kazuya Tone
Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-Ku, Tokyo
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_129_21

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  Abstract 


A 29-year-old Japanese man with a history of right-sided tuberculous pleurisy presented with fever and right flank pain. Computed tomography images revealed a right pleural effusion and an area of low attenuation in the right iliopsoas muscle. Percutaneous drainage of the iliopsoas lesion resulted in a bloody pyogenic discharge that tested positive for Mycobacterium tuberculosis by both acid-fast staining and polymerase chain reaction. Enhanced fluoroscopy revealed a perforation of the diaphragm between the thoracic region and the psoas muscle. The patient was diagnosed with an iliopsoas abscess secondary to tuberculous empyema.

Keywords: gravity abscess, iliopsoas abscess, tuberculosis, tuberculous empyema


How to cite this article:
Tone K, Hirano Y, Kuwano K. Iliopsoas gravity abscess secondary to a tuberculous empyema. Int J Mycobacteriol 2021;10:335-7

How to cite this URL:
Tone K, Hirano Y, Kuwano K. Iliopsoas gravity abscess secondary to a tuberculous empyema. Int J Mycobacteriol [serial online] 2021 [cited 2021 Dec 8];10:335-7. Available from: https://www.ijmyco.org/text.asp?2021/10/3/335/325493




  Introduction Top


Tuberculous iliopsoas abscess is a rare complication of tuberculous spondylodiscitis (Pott's disease).[1],[2] A gravity (or gravitation) abscess may result from a local source of infection and/or inflammation that breaks down tissue barriers and spreads to adjacent areas due to gravitational force. This type of abscess is diagnosed most typically as a result of spread from a tuberculous spinal lesion into the intra-abdominal space. We report here a case of an iliopsoas gravity abscess secondary to tuberculous empyema.


  Case Report Top


The patient was a 29-year-old Japanese man who presented with chief complaints of fever and right flank pain. His past medical history was notable for right tuberculous pleurisy; he underwent a directly observed treatment, short-course with isoniazid (INH; 5 mg/kg/day), rifampicin (RFP; 7.5 mg/kg/day), ethambutol (EB; 12.5 mg/kg/day), and pyrazinamide (PZA; 25 mg/kg/day) for 2 months followed by 4 months of INH and RFP at the same doses. Mycobacterium tuberculosis (MTB) isolated from the pleural effusion was susceptible to all of the aforementioned drugs, although it was resistant to streptomycin. A chest computed tomography (CT) scan performed after the completion of treatment revealed a small amount of residual pleural effusion and pleural thickening; these findings were compatible with previous tuberculous pleurisy [Figure 1]a. His overall condition and the state of the pleural effusion did not deteriorate for a period of 1 year. Eighteen months after completion of the initial round of treatment, the patient was referred to our hospital with the aforementioned chief complaints. He exhibited no respiratory symptoms. Blood tests revealed a normal leukocyte count with abnormally high levels of serum C-reactive protein. Liver and renal function tests were within normal limits, as were serum levels of glucose level and hemoglobin A1c. The serology test for human immunodeficiency virus was negative, and urine tests were all within normal limits. Contrast CT scans revealed increases in the right pleural effusion and pleural thickness [Figure 1]b accompanied by an area of low attenuation with rim enhancement within the right iliopsoas muscle that had not been detected in previous studies [Figure 1]c. T2-weighted magnetic resonance imaging revealed that the diaphragm was separated from its vertebral attachment, which permitted gravitational penetration of the pleural effusion into the right iliopsoas muscle [Figure 1]d; interestingly, no abnormalities of the spine were detected. Ultrasound-guided percutaneous drainage of the iliopsoas lesion was performed, which revealed a bloody pyogenic discharge that was removed from the catheter [Figure 1]e. Enhanced fluoroscopy revealed a fistula between the iliopsoas muscle and the thoracic region [Figure 1]f. Both polymerase chain reaction and Ziehl–Neelsen staining of the abscess were positive for MTB [Figure 1]g. The patient was diagnosed with an iliopsoas gravity abscess secondary to tuberculous empyema. We resumed antituberculosis therapy with INH (5 mg/kg/day), RFP (10 mg/kg/day), EB (12.5 mg/kg/day), and PZA (25 mg/kg/day). Given his prolonged state of pyrexia, levofloxacin (LVFX; 500 mg/day) was added to the aforementioned treatment regimen in consideration of the fact that MTB, considering the insufficient penetration of anti-MTB drugs to psoas muscle lesion. His pyrexia improved with the addition of LVFX. Mycobacteria were not isolated from the abscess; as such, drug susceptibility testing could not be performed. The patient underwent treatment for a full 9 months; the regimen included INH, RFP, EB, and PZA for 2 months followed by INH, RFP, EB, and LVFX for an additional 7 months, taking into account the fact that the standard protocol was insufficient to clear his disease on the earlier occasion. No relapse was observed at 2 years after completion of this treatment regimen.
Figure 1: (a) Chest computed tomography after the completion of the initial treatment for tuberculosis revealed a small amount of pleural effusion with pleural thickening which is compatible with a previous diagnosis of tuberculous pleurisy (arrow). (b) Chest contrast computed tomography documenting recurrence of tuberculosis revealed deterioration, with more pleural fluid and increased pleural thickening (arrow). (c) Abdominal contrast computed tomography at the recurrence of tuberculosis at the time of recurrence documenting a low attenuation area in iliopsoas muscle with rim enhancement (arrow). (d) T2-weighted magnetic resonance imaging revealing separation of the diaphragm from its site of attachment at the vertebrae; this resulted in penetration of the pleural effusion into the right iliopsoas muscle (circle). (e) Purulent, hemorrhagic fluid obtained from the right iliopsoas muscle. (f) Enhanced fluoroscopy of the right iliopsoas muscle revealed the presence of fistula between the psoas muscle and the thoracic region (arrow). (g) Ziehl–Neelsen staining fluid from the psoas abscess revealed a cluster of acid-fast bacilli

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  Discussion Top


The number of patients diagnosed with tuberculous iliopsoas abscesses is currently decreasing due to improvements in general nutrition condition and the use of effective antituberculosis drug regimens. However, this remains a severe and important complication of tuberculosis that can lead to unfavorable outcomes. Patients with iliopsoas abscesses typically report subacute or chronic symptoms, including back pain, pyrexia, or limping.[3] Those symptoms are nonspecific; as such, the diagnosis is often delayed if radiological and/or microbiological tests are not performed promptly.

In a series of 124 patients with iliopsoas abscesses, the most common origin of these lesions were infections in the skeleton (39.5%), followed by the gastrointestinal (19.4%) and urinary tract (13.7%).[4] Spinal lesions are not always detected in patients with tuberculous iliopsoas abscess. For example, Gupta et al.[5] reported that 7 of 27 patients diagnosed with tuberculous iliopsoas abscess had no spinal involvement.

In the present case, our radiological findings revealed that recurrent tuberculous pleurisy penetrated through the diaphragm to the iliopsoas muscle. The risk factors associated with recurrent tuberculosis include underweight body habitus at diagnosis, cavitation, and bilateral disease on chest radiography, white race, and residual culture-positive sputum samples after 8 weeks of treatment.[6] None of these factors applied to this case. Beginning in the 1970s, RFP at 10 mg/kg has been recommended for the treatment of tuberculosis; however, more recent studies suggest that this dose may not be optimal.[7] According to recent reports, a maximum dose of RFP at 35 mg/kg would be safe and well tolerated.[7],[8] As such, we considered the possibility that the RFP dose provided in the initial round of treatment might have been too low.

Although tuberculous pleurisy and empyema are well-known findings in patients diagnosed with tuberculosis,[9] the pleural lesions do not typically penetrate the diaphragm; this suggests that the diaphragm may ordinarily serve to provide protection against the spread of infection and inflammation into the abdominal cavity. However, as one limitation of this case report, we were not able to determine why this otherwise immunocompetent patient developed recurrent tuberculosis together with a very infrequent secondary complication.

In conclusion, clinicians should be aware that a thoracic extrapulmonary tuberculous lesion may generate an iliopsoas gravity abscess. Although a flank pain is not a major symptom associated with the diagnosis of tuberculosis, an iliopsoas abscess should be considered in the full-differential diagnosis of any patient with a history of tuberculosis who develops abdominal or flank pain.

Consent for publication

Written informed consent was obtained from the patient for the publication of this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, the anonymity of the patient is guaranteed.

Acknowledgment

We would like to thank Dr. Shinsuke Takenaga and Dr. Koichi Masuda for their support of iliopsoas abscess drainage treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khanna K, Sabharwal S. Spinal tuberculosis: A comprehensive review for the modern spine surgeon. Spine J 2019;19:1858-70.  Back to cited text no. 1
    
2.
Chaudhry LA, Zamzami M, Fakharudin SK. Paraplegia is not a diagnosis: Spinal tuberculosis deserves a place on the clinical radar screen: Awakening call to clinicians. Int J Mycobacteriol 2012;1:155-60.  Back to cited text no. 2
  [Full text]  
3.
Shields D, Robinson P, Crowley TP. Iliopsoas abscess--A review and update on the literature. Int J Surg 2012;10:466-9.  Back to cited text no. 3
    
4.
López VN, Ramos JM, Meseguer V, Pérez Arellano JL, Serrano R, Ordóñez MA, et al. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine (Baltimore) 2009;88:120-30.  Back to cited text no. 4
    
5.
Gupta S, Suri S, Gulati M, Singh P. Ilio-psoas abscesses: Percutaneous drainage under image guidance. Clin Radiol 1997;52:704-7.  Back to cited text no. 5
    
6.
Colangeli R, Jedrey H, Kim S, Connell R, Ma S, Chippada Venkata UD, et al. Bacterial factors that predict relapse after tuberculosis therapy. N Engl J Med 2018;379:823-33.  Back to cited text no. 6
    
7.
Boeree MJ, Diacon AH, Dawson R, Narunsky K, du Bois J, Venter A, et al. A dose-ranging trial to optimize the dose of rifampin in the treatment of tuberculosis. Am J Respir Crit Care Med 2015;191:1058-65.  Back to cited text no. 7
    
8.
Boeree MJ, Heinrich N, Aarnoutse R, Diacon AH, Dawson R, Rehal S, et al. High-dose rifampicin, moxifloxacin, and SQ109 for treating tuberculosis: A multi-arm, multi-stage randomised controlled trial. Lancet Infect Dis 2017;17:39-49.  Back to cited text no. 8
    
9.
Tufail M. A case report of tuberculous empyema: A tricky disease. Int J Mycobacteriol 2019;8:302-4.  Back to cited text no. 9
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