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Primary Retroperitoneal Abscess Extending to the Calf

Primary Retroperitoneal Abscess Extending to the Calf A 77-year-old man with diabetes mellitus presented with a 2-month history of lumbago radiating to the right lower limb as well as high fever spikes. Physical examination revealed a distended abdomen with right lower quadrant tenderness. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess. The patient began receiving intravenous antibiotics, but fever and abdominal pain persisted and a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh and right calf. The patient underwent surgical exploration: a right lateral abdominal incision was performed, and the pus collection in retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 incision on the upper calf, resulting in the drainage of pus. The patient made a slow but steady recovery.A 77-year-old man with diabetes mellitus presented to our department with a 2-month history of severe lumbago radiating to the right lower limb, high fever spikes, and general malaise. He had been treated with nonsteroidal anti-inflammatory drugs for suspected lumbar disk herniation. The control of his plasma glucose level had been poor for the preceding several weeks, despite increased insulin administration. His medical history was also remarkable for hypertension and a left hemicolectomy for sigmoid cancer 5 years previously. On admission, he was alert and oriented, his temperature was 38.2°C, his blood pressure was 142/82 mm Hg, and his pulse rate was 100 beats/min. Physical examination revealed a slightly distended abdomen with right lower quadrant tenderness. The laboratory data on admission showed a white blood cell count of 18.7 × 103/μL with 74% neutrophils, a fasting plasma glucose level of 225 mg/dL (12.49 mmol/L), and a hemoglobin level of 8.9 g/dL. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess (Figure, A). Ultrasound-guided drainage of the abscess was initially attempted; more than 300 mL of pus was aspirated, and on culture, it grew a polymicrobic flora including coliforms, anaerobes, and gas-forming organisms. A colonoscopy showed a normal-looking large-bowel remnant with no evidence of diverticuli or tumor recurrence. Intensive treatment was initiated with intravenous piperacillin and tazobactam (8 g per 24 hours) as well as metronidazole (2 g per 24 hours) for infection, with a drip infusion of insulin to control the high blood glucose level. Despite this therapy, fever and abdominal pain persisted, and the patient’s mental state began to deteriorate. Also, a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh, and a smaller, similar swelling appeared on the medial aspect of his right calf. Another computed tomographic scan showed a persistent collection of pus in his retroperitoneal space as well as a fluid collection in his right lower limb. The patient underwent surgical exploration: a right lateral incision was performed, and the pus collection in the retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 on the upper calf (Figure, B), resulting in the drainage of large amounts of pus that had the same characteristics of that retrieved from the retroperitoneal space. It became clear that the pus was tracking along the musculofascial planes from the retroperitoneum down into the thigh and lower leg. This time, cultural analysis revealed the presence of group D streptococcus (enterococcus), and the patient began receiving intravenous teicoplanin (400 mg per 24 hours) based on the antibiogram. The patient made a slow but steady recovery, and within a few days, his general condition improved, the fever subsided, and his diabetes mellitus came under control. The wounds in his thigh and calf gradually healed, and the patient was able to begin a program of physical rehabilitation. When last seen in the clinic, he was generally well and afebrile; his abdominal, thigh, and calf wounds were nearly healed, and he could walk with crutches.Figure.Patient’s computed tomographic scan showing the large right retroperitoneal cavity (arrow) containing an air-fluid level consistent with a gas-producing abscess (A), and his incisions on the medial aspect of the right thigh and an incision on the upper calf, resulting in the drainage of large amounts of pus (B).Retroperitoneal abscess is a relatively rare, but potentially lethal, infection if it is not treated promptly. Its onset may be insidious, and diagnosis may be difficult. This could lead to delayed treatment, considerably increasing the morbidity and mortality associated with this disease. In more than 80% of cases, the retroperitoneal abscess is secondary to a digestive, renal, or vertebral focus or is derived from the iliopsoas muscles.Up to 14% of retroperitoneal abscesses are considered primary because no other associated condition can be found. Recently, they have been described as a late complication originating from a “lost” stone following laparoscopic cholecystectomy.Diabetes mellitus, trauma, and immunodeficiency are predisposing factors. The diagnosis should be suspected clinically in all cases of persistent fever of unknown origin, and it should be confirmed by either ultrasound or computed tomographic imaging, although magnetic resonance imaging can give additional useful information when a spinal focus of infection must be ruled out.A retroperitoneal abscess may result in or even initially present as a collection of pus in the medial aspect of the thigh,but tracking down below the knee, as in our case, is extremely rare and, to our knowledge, has not been described before.A retroperitoneal abscess can be treated with intravenous antibiotics alone but only if the abscess is small (<3 cm) and the patient’s general condition is good. However, drainage is required in most cases. Ultrasound-guided or computed tomography–guided percutaneous drainage is the initial procedure of choice, and it has a high success rate (>80%), although the insertion of more than 1 catheter is sometimes necessary. Surgical exploration should be reserved for cases that are not responding adequately to percutaneous drainage or when malignancy in either the urinary tract or the bowel is suspected. Collections tracking along the psoas fascia into the lower limb, as in our case, should be drained by separate multiple incisions and debridement.Correspondence:Massimiliano Solazzo, MD, Department of Surgery, Manerbio Hospital, 25025 Manerbio, Brescia, Italy (solazzom@hotmail.com).Accepted for Publication:February 14, 2005.REFERENCESCCapitan ManjonATejido SanchezJDPiedra LaraRetroperitoneal abscesses: analysis of a series of 66 cases.Scand J Urol Nephrol20033713914412745723EKocMSuherSUOztugutCEnsariMKarakurtNOzlemRetroperitoneal abscess as a late complication following laparoscopic cholecystectomy.Med Sci Monit200410CS27CS2915173674SNegusPSSidhuMRI of retroperitoneal collections: a comparison with CT.Br J Radiol20007390791211026872NSEl-MasryNATheodorouRetroperitoneal perforation of the appendix presenting as right thigh abscess.Int Surg200287616412222917 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Primary Retroperitoneal Abscess Extending to the Calf

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Publisher
American Medical Association
Copyright
Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/archsurg.140.12.1230
pmid
16365248
Publisher site
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Abstract

A 77-year-old man with diabetes mellitus presented with a 2-month history of lumbago radiating to the right lower limb as well as high fever spikes. Physical examination revealed a distended abdomen with right lower quadrant tenderness. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess. The patient began receiving intravenous antibiotics, but fever and abdominal pain persisted and a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh and right calf. The patient underwent surgical exploration: a right lateral abdominal incision was performed, and the pus collection in retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 incision on the upper calf, resulting in the drainage of pus. The patient made a slow but steady recovery.A 77-year-old man with diabetes mellitus presented to our department with a 2-month history of severe lumbago radiating to the right lower limb, high fever spikes, and general malaise. He had been treated with nonsteroidal anti-inflammatory drugs for suspected lumbar disk herniation. The control of his plasma glucose level had been poor for the preceding several weeks, despite increased insulin administration. His medical history was also remarkable for hypertension and a left hemicolectomy for sigmoid cancer 5 years previously. On admission, he was alert and oriented, his temperature was 38.2°C, his blood pressure was 142/82 mm Hg, and his pulse rate was 100 beats/min. Physical examination revealed a slightly distended abdomen with right lower quadrant tenderness. The laboratory data on admission showed a white blood cell count of 18.7 × 103/μL with 74% neutrophils, a fasting plasma glucose level of 225 mg/dL (12.49 mmol/L), and a hemoglobin level of 8.9 g/dL. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess (Figure, A). Ultrasound-guided drainage of the abscess was initially attempted; more than 300 mL of pus was aspirated, and on culture, it grew a polymicrobic flora including coliforms, anaerobes, and gas-forming organisms. A colonoscopy showed a normal-looking large-bowel remnant with no evidence of diverticuli or tumor recurrence. Intensive treatment was initiated with intravenous piperacillin and tazobactam (8 g per 24 hours) as well as metronidazole (2 g per 24 hours) for infection, with a drip infusion of insulin to control the high blood glucose level. Despite this therapy, fever and abdominal pain persisted, and the patient’s mental state began to deteriorate. Also, a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh, and a smaller, similar swelling appeared on the medial aspect of his right calf. Another computed tomographic scan showed a persistent collection of pus in his retroperitoneal space as well as a fluid collection in his right lower limb. The patient underwent surgical exploration: a right lateral incision was performed, and the pus collection in the retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 on the upper calf (Figure, B), resulting in the drainage of large amounts of pus that had the same characteristics of that retrieved from the retroperitoneal space. It became clear that the pus was tracking along the musculofascial planes from the retroperitoneum down into the thigh and lower leg. This time, cultural analysis revealed the presence of group D streptococcus (enterococcus), and the patient began receiving intravenous teicoplanin (400 mg per 24 hours) based on the antibiogram. The patient made a slow but steady recovery, and within a few days, his general condition improved, the fever subsided, and his diabetes mellitus came under control. The wounds in his thigh and calf gradually healed, and the patient was able to begin a program of physical rehabilitation. When last seen in the clinic, he was generally well and afebrile; his abdominal, thigh, and calf wounds were nearly healed, and he could walk with crutches.Figure.Patient’s computed tomographic scan showing the large right retroperitoneal cavity (arrow) containing an air-fluid level consistent with a gas-producing abscess (A), and his incisions on the medial aspect of the right thigh and an incision on the upper calf, resulting in the drainage of large amounts of pus (B).Retroperitoneal abscess is a relatively rare, but potentially lethal, infection if it is not treated promptly. Its onset may be insidious, and diagnosis may be difficult. This could lead to delayed treatment, considerably increasing the morbidity and mortality associated with this disease. In more than 80% of cases, the retroperitoneal abscess is secondary to a digestive, renal, or vertebral focus or is derived from the iliopsoas muscles.Up to 14% of retroperitoneal abscesses are considered primary because no other associated condition can be found. Recently, they have been described as a late complication originating from a “lost” stone following laparoscopic cholecystectomy.Diabetes mellitus, trauma, and immunodeficiency are predisposing factors. The diagnosis should be suspected clinically in all cases of persistent fever of unknown origin, and it should be confirmed by either ultrasound or computed tomographic imaging, although magnetic resonance imaging can give additional useful information when a spinal focus of infection must be ruled out.A retroperitoneal abscess may result in or even initially present as a collection of pus in the medial aspect of the thigh,but tracking down below the knee, as in our case, is extremely rare and, to our knowledge, has not been described before.A retroperitoneal abscess can be treated with intravenous antibiotics alone but only if the abscess is small (<3 cm) and the patient’s general condition is good. However, drainage is required in most cases. Ultrasound-guided or computed tomography–guided percutaneous drainage is the initial procedure of choice, and it has a high success rate (>80%), although the insertion of more than 1 catheter is sometimes necessary. Surgical exploration should be reserved for cases that are not responding adequately to percutaneous drainage or when malignancy in either the urinary tract or the bowel is suspected. Collections tracking along the psoas fascia into the lower limb, as in our case, should be drained by separate multiple incisions and debridement.Correspondence:Massimiliano Solazzo, MD, Department of Surgery, Manerbio Hospital, 25025 Manerbio, Brescia, Italy (solazzom@hotmail.com).Accepted for Publication:February 14, 2005.REFERENCESCCapitan ManjonATejido SanchezJDPiedra LaraRetroperitoneal abscesses: analysis of a series of 66 cases.Scand J Urol Nephrol20033713914412745723EKocMSuherSUOztugutCEnsariMKarakurtNOzlemRetroperitoneal abscess as a late complication following laparoscopic cholecystectomy.Med Sci Monit200410CS27CS2915173674SNegusPSSidhuMRI of retroperitoneal collections: a comparison with CT.Br J Radiol20007390791211026872NSEl-MasryNATheodorouRetroperitoneal perforation of the appendix presenting as right thigh abscess.Int Surg200287616412222917

Journal

JAMA SurgeryAmerican Medical Association

Published: Dec 1, 2005

References

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