A case of primary psoas abscess presenting as buttock abscess
© Springer-Verlag 2009
Received: 29 January 2009
Accepted: 23 October 2009
Published: 20 November 2009
Buttock abscess is a rare clinical manifestation from unusual extrapelvic extension of psoas abscess. A 48-year-old woman presented with painful swelling of the buttock with a sense of local heat. Magnetic resonance imaging revealed a large subfascial abscess over the glutei muscles and was traced into the intraabdominal cavity over the iliac wing to the psoas muscle. Both the psoas abscess and the buttock abscess were evacuated via separate approaches. Empirical antibiotic therapy was delivered for 3 weeks. After 6 months, no evidence of recurrence was found. Psoas abscess could be included in the differential diagnosis of buttock abscess.
Abscess of the psoas muscle is rare [1, 2]. Clinical presentation includes back pain with limited function, fever, and leukocytosis . Prompt diagnosis continues to rely upon retaining a high degree of suspicion, as the signs and symptoms may be diffuse, chronic, and nonspecific [4–7]. Because the psoas musculature extends from the lowest thoracic and five lumbar vertebrae to the lesser trochanter of the femur, differentiation from the pathologies around the hip joint is emphasized [8–14]. The muscle itself sometimes acts as a conduit for the spread of suppuration, and propagations to the hip joint [8, 15–17], the thigh , and even the calf  have been reported. However, only a few cases of unusual spread of psoas abscess to the flank [3, 19] or buttock  have been described. It would not be so easy for a clinician to suspect the presence of the psoas abscess if the initial manifestation were a flank or buttock mass.
We present a case of psoas abscess, the initial clinical presentation of which was painful swelling of the buttock with local erythema and a sense of heat. Recognition of the psoas abscess as well as the apparent manifestation and evacuation of the whole lesion via combined anterior retroperitoneal approach and direct incision over the buttock led to complete eradication of the pathology.
The psoas abscess is rare [1, 2], and those presenting as extrapelvic extension are even more rare. The psoas abscess that extends over the iliac wing and presents as a flank or buttock abscess is a much rarer clinical feature, with only a few case reports in the medical literature [3, 9, 19–22]. Although the worldwide incidence was considered to be only 12 cases per year [1, 2], it is more frequently diagnosed and reported with the advent of computed tomography (CT) and MR imaging [2, 23]. The psoas abscess is considered primary if the cause is hematogenous seeding from a distant site and secondary if there is a contiguous infectious source from vertebrae, pancreas, kidney, ureter, appendix, bowel, or hip joint [1, 2, 24]. Our case was primary psoas abscess, which extends to the adjacent retroperitoneum and buttock through the abdominal wall. The susceptibility of the psoas muscle as primary type is attributed to its rich blood supply and proximity to overlying retroperitoneal lymphatic channels [25, 26].
The most common causative organism of the psoas abscess is Staphylococcus aureus in primary type and enteric organisms in secondary type [2, 4, 24], whereas tuberculous spinal infection was the most common etiology half a century ago . Fungal infection also should be excluded [4, 23, 28]. In addition to the origin of infection, appendicitis, pancreatitis, pyelonephritis, and Crohn’s disease occasionally cause psoas abscess [25, 27]. The pathogenic organism could not be identified in our case. Because the negative result of the microbiological test cannot warrant the absence of pathogen, broad-spectrum antibiotics were empirically delivered.
This is not the first case in the medical literature in which the psoas abscess presented as a flank or buttock mass. Mycobacterial [3, 19] or pyogenic  infection of the psoas muscle has been reported to propagate to the retroperitoneum or flank/buttock through the abdominal wall. Psoas abscess and cellulitis of the right gluteal region resulting from retroperitoneal perforation of cecum carcinoma has also been reported . Psoas, piriformis, and gluteal abscess, as well as right iliac vein thrombosis, have been documented .
We document a rare clinical manifestation of buttock abscess from unusual extrapelvic extension of a psoas abscess. Psoas abscess could be included in the differential diagnosis of buttock abscess.
Conflict of interest statement
The authors declare that they have no conflict of interest related to the publication of this manuscript.
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