Tuberculous psoas abscess in obstetrics

Abstract

We read with interest the article by Kumar et al. [1] regarding psoas abscess in obstetrics. Although rare, psoas abscess have been reported during pregnancy. Their subtle symptomatology evades detection clinically. We will like to share our experience of a case of psoas abscess diagnosed during an exploratory laparotomy for ruptured ectopic pregnancy. A para 1, 22-year-old woman presented with 2 months of amenorrhea and pain in abdomen. The pain had worsened in past 3 days and was now associated with vomiting and giddiness. Patient had severe palor, tachycardia and hypotension. On palpation of abdomen, Wndings were a Wxed dull to percussion mass felt in left lumbar region with mild tenderness and rigidity in right iliac fossa. Digital vaginal examination revealed an anteverted normal size uterus associated with cervical motion tenderness and a cystic mass about 4 £ 5 cm was palpable in right fornix extending to pouch of Douglas. The left lumbar abdominal mass was also tipped through left fornix. Blood chemistry revealed hemoglobin of 6 g%. Complete blood count, liver and kidney functions were normal. Urine pregnancy test was positive. On ultrasound evaluation, right adnexa revealed a ruptured ectopic gestational sac with Xuid in pouch of Douglas. Uterus was normal in size and endometrial cavity was empty. Left ovary was normally visualized. The left abdominal mass was suspected to be a psoas abscess extending into the hemipelvis. It was cystic with thick wall and few septations. Patient was taken for urgent laparotomy and right-sided salpingectomy for ruptured ectopic pregnancy. The left retroperitoneal cystic Xuctuant swelling measured approximately 10 £ 15 cm. It was suspected to be tuberculous psoas abscess in view of straw colored Xuid obtained on aspiration peroperatively. Fluid cytology revealed exudative nature with predominance of lymphocytes. The Gram stain and aerobic culture revealed no organisms. The aspirated Xuid investigated by PCR (polymerase chain reaction) tested positive for Mycobacterium. The radiographs of the spine, pelvis with both hips were normal. Computed tomography (CT) of spine and abdomen other than presence of left psoas abscess was also normal. The abscess was drained percutaneously under CT (Fig. 1) guidance postoperatively under cover of multidrug antitubercular chemotherapy. Serial ultrasound has shown remarkable response to the therapy. Psoas abscess is a rare manifestation in pregnancy. Only four cases of psoas abscess diagnosed during ongoing pregnancy have been reported in indexed English literature till date (Table 1) [1, 2]. Other reported cases have either been postabortal or post partum [2–5]. Kumar et al. describes the only other case of tubercular psoas abscess detected during pregnancy [1]. Our case is the Wrst report of psoas abscess diagnosed with ectopic pregnancy. Patient gave no history of previous tuberculosis or exposure on retrospective questioning. The psoas abscess seemed tubercular in view of straw colored Xuid obtained on aspiration peroperatively. There was a risk of tubercular Xare-up with the contamination of abdominal cavity. The percutaneous drainage under CT guidance was done under cover of antitubercular drugs a few weeks later. Wherever possible, percutaneous drainage is the preferred method of abscess drainage as it is much less invasive than open surgical technique. It is technically demanding and requires help of a trained radiologist. R. Agarwal · A. Suneja · S. Raina Department of Obstetrics and Gynaecology, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, Delhi, India