Extensive retroperitoneal abscess in a patient on steroids

Abstract

A 60 year-old Hispanic woman visiting from Puerto Rico was admitted with abdominal pain, low-grade fever and significant weight loss for one month. Comorbid conditions included diabetes, psoriasis, hypertension and depression. She had partial colectomy performed elsewhere for unclear indications, several years ago. Medications included insulin, prednisone, fluoxetine and captopril. On examination, she was febrile (102 F), inspection of the skin revealed psoriatic lesions.She had a heart rate of 98 beats per minute and a blood pressure of 160/90. Abdomen examination revealed fullness in the right lower quadrant and in the right flank, with associated tenderness. Bowel sounds were present. Labs: Hb: 11.0 g/dl Hct: 34.7 WBC: 15.6 BUN: 9 mg/dl Creatinine:0. 8mg/dl LFT: normalIgA: 539 mg/dl (80–450) IgM: 163 mg/dl (40–240) IgG: 2661 mg/dl (600–1600)C4 complement: 16.0 mg/dl (N=16–45) C3 complement: 78 mg/dl (N=62–212) CT scan: Fluid collections in the right psoas muscle extending inferiorly into the right iliacus muscle and into the groin involving the right gluteal muscles. MRI of the spine did not show any evidence of spinal tuberculosis.The PPD test was negative and chest X ray was normal. Hospital course: open surgical drainage of the psoas abscess yielded 400cc of white pus. She underwent a second drainage procedure 10 days later due to persistent fever. The fluid culture revealed Klebsiella sensitive to Ceftriaxone, Gentamicin and Ciprofloxacin. AFB and fungal culture was negative. At discharge, she was afebrile and asymptomatic. Retroperitoneal abdominal abscesses often develop in the immunocompromised patient and pose a diagnostic challenge due to atypical symptoms. Conditions like diabetes mellitus, chronic alcoholism and malnutrition may promote the development and progression of such abscesses. Our patient's immunosupression from diabetes mellitus was probably aggravated by chronic steroid use. Percutaneous catheter drainage guided by ultrasonography or CT is successful in selected patients. Nevertheless, surgical drainage with concomitant antimicrobial therapy remains the gold standard for treatment.