Left Iliopsoas Research Articles

A Cross-sectional Study on Association of Iliopsoas Muscle Length with Lumbar Lordosis Among Desk Job Workers

Background: Prolonged hours of sitting in sustained posture is a common job requirement of desk job workers. Potential risk of iliopsoas muscle shortening leading to lumbar hyperlordosis, which in turn may cause low-back pain was identified. Thus, this study determined association between iliopsoas muscle length and lumbar lordosis in desk job workers. Methods and Material: This cross-sectional study was conducted on forty-six desk job workers working for 5 hrs/day for at least 5 years. Workers were assessed for iliopsoas muscle length using Modified Thomas test and flexi-ruler was used to measure lumbar lordosis. Pearson’s correlation was operated for association of iliopsoas length with lumbar lordosis. Results: Lumbar lordosis demonstrated moderate positive correlation with both right (r = 0.628) and left Iliopsoas muscle length (r = 0.647). Conclusion: This study concluded workers with higher degree of lumbar lordosis presented with shorter iliopsoas length. Timely intervention to maintain the length of this muscle will ensure low incidence of low-back pain among desk job workers thereby safeguarding their spine due to cumulative trauma.

Advanced osteoarthritis of the hip as reason for extensive asymmetric leg edema: a rare case report and review of the literature.

An enlarged iliopectineal bursa (IB) can cause pressure on iliofemoral veins. Clinical presentation can manifest as asymmetrical lower extremity edema. This case report demonstrates extensive asymmetrical leg edema caused by femoral vein compression based on iliopectineal bursitis (IB-itis) associated with advanced osteoarthritis (OA) of the left hip joint with an outline of relevant current literature. A female patient presented with left hip pain and edema in the leg. X-ray showed severe OA of the left hip. Computed Tomography (CT) concluded a cystic abnormality at the left iliopsoas muscle associated with the joint consistent with IB-itis, associated with a degenerative left hip joint. Hybrid total hip replacement was performed. At three-month follow-up her left leg showed no longer signs of extensive edema and she walked without the use of walking aids. IB-itis is mostly associated with rheumatoid arthritis (RA). There are no reports which only describe OA as cause of IB-itis. Extensive asymmetrical leg edema can be caused by venous compression of the femoral vein by an IB-itis. If the latter is the consequence of advanced hip OA, a total hip replacement can yield excellent clinical outcomes both functionally and with regard to the edema.

Multidisciplinary Approaches: Cingulotomy in an Adult With Refractory Neuropathic Cancer-Related Pain.

Background: Oral medications, intravenous medications, and invasive interventions are effective means of neuropathic pain control. In patients with pain refractory to more conventional approaches, cingulum bundle ablation is an alternative treatment modality not routinely considered by providers. Case Description: A 42-year-old woman with history of cervical cancer in remission presented with intractable left lower extremity pain. Workup revealed radiation-induced left iliopsoas osteosarcoma complicated by deep venous occlusion and thrombosis. Her pain remained intractable to pharmacologic therapies and more invasive pain control interventions. A multidisciplinary decision was made to pursue bilateral subcortical cingulum bundle radiofrequency ablation. After a technically successful surgery, the patient exhibited improved pain control as evidenced by a decline in her numerical rating scale of pain and analgesic medication requirements. Conclusion: Cancer-related neuropathic pain often requires treatment with multiple modalities involving multidisciplinary teams. In select refractory cases, cingulum bundle ablation may be an effective alternative treatment modality.

Application of oblique lateral interbody fusion in the treatment of lumbar intervertebral disc degeneration in patients with Modic change and endplate sclerosis

To explore the feasibility and clinical effect of Stand-alone oblique lateral interbody fusion (OLIF) in the treatment of lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis. A retrospective analysis was performed on 16 cases with lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis admitted to three medical centers from January 2015 to December 2018. There were 6 males and 10 females, the age ranged from 45 to 67 years old with an average of (55.48±8.07) years old, the medical history ranged from 36 to 240 months with an average of (82.40±47.68) months. The lesion sites included L2,3 in 2 cases, L3,4 in 5 cases, and L4,5 in 9 cases. All patients presented with chronic low back pain with lower limb neurological symptoms in 3 cases. All patients were treated by Stand-alone oblique lateral lumbar interbody fusion. Clinical and radiological findings and complications were observed. There was no vascular injury, endplate injury and vertebral fracture during the operation. The mean incision length, operation time, and intraoperative blood loss were(4.06±0.42) cm, (45.12±5.43) min, (33.40±7.29) ml, respectively. The mean visual analogue scale (VAS) of the incision pain was (1.14±0.47) at 72 hours after operation. There was no incision skin necrosis, poor incision healing or infection in patients. Sympathetic chain injury occurred in 1 case, anterolateral pain and numbness of the left thigh in 2 cases, and weakness of the left iliopsoas muscle in 1 case, all of which were transient injuries with a complication rate of 25%(4/16). All 16 patients were followed up from 12 to 36 months with an average of (20.80±5.46) months. The intervertebral space height was significantly recovered after operation, with slight lost during the follow-up. Coronal and sagittal balance of the lumbar spine showed good improvement at the final follow-up. There was no obvious subsidence or displacement of the cage, and the interbody fusion was obtained. At the final follow-up, Japanese Orthopaedic Association(JOA) score and Oswestry disability index(ODI) were significantly improved. As long as the selection of case is strict enough and the preoperative examination is sufficients, the use of Stand-alone OLIF in the treatment of lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis has a good results, with obvious clinical advantages and is a better surgical choice.

Single Leg Posture of a Professional Soccer Player with Iliopsoas Injury and the Relationship Between Trunk and Pelvis Posture and Torque of the Hip Flexor

BACKGROUND: The purpose of this study was to provide data on postural characteristics and the low torque of the hip flexor observed after an iliopsoas injury in a professional soccer player. CASE PRESENTATION: The patient was a male professional soccer player. He was diagnosed with an injury to the left iliopsoas. After completing rehabilitation, he complained of decreased performance that he described as “not being able to take one more step.” OUTCOME: In terms of single-leg standing posture, different phenomena were observed between the right and left legs in the posture angles of the trunk and pelvis. The low torque was observed in the left hip flexor. DISCUSSION: We hypothesized that the low torque of the left hip flexor affected the left leg support and soccer performance. JOSPT Cases 2022;2(4):234–239. doi:10.2519/josptcases.2022.11053

Fatal Aortoduodenal Fistula after FEVAR

An 84 year old man underwent a fenestrated endovascular abdominal aortic aneurysm repair (FEVAR) six years previously with no abnormal findings during computed tomography angiography (CTA) follow up. He presented with malaise, haematemesis, abdominal pain, and anaemia, and became haemodynamically unstable due to massive haematemesis. Upper gastrointestinal endoscopy was normal. CTA showed air bubbles surrounding the endograft within the aneurysm sac adjacent to the third part of the duodenum suggesting an aortoduodenal fistula (A, arrow), an abscess in left iliopsoas muscle (B, asterisk), and subcutaneous abdominal emphysema (B, arrow). The patient was not fit for surgery and was offered palliative care.Image 1

S1954 An Unusual Location of Pseudoaneurysm in the Setting of Acute Severe Pancreatitis

Introduction: Acute pancreatitis (AP) is one of the most common gastroenterological causes of hospital admissions. The mortality rate of AP is around 10% despite medical advancements. Around 4-17% of cases of acute pancreatitis are complicated by the formation of pseudoaneurysms. The most commonly involved arteries are splenic artery (60-65%), gastroduodenal (20-25%), pancreaticoduodenal (10-15%), hepatic (5-10%) and left gastric arteries (2-5%). We present a case of superior mesenteric artery (SMA) pseudoaneurysm secondary to acute severe pancreatitis. Case Description/Methods: A 33-year-old male patient with a past medical history of alcohol abuse presented to the hospital for abdominal pain after an alcohol binge. He was found to have significant acute kidney injury, metabolic acidosis, and leukocytosis to 24 K/uL. CT showed acute pancreatitis and a large peripancreatic collection consistent with hemorrhage with posterolateral extension into the left iliopsoas space. He was found to have staphylococcus aureus bacteremia thus he was initially treated with fluid resuscitation and cefazolin. Several days into the admission he had an episode of hemodynamic instability with a CT showing a 7 mm pseudoaneurysm seen within the collection with active contrast extravasation. His hemoglobin dropped 2g during this episode requiring pRBC transfusion. He underwent IR coil embolization of the middle colic branch of the SMA (Figure). During a subsequent admission, he had worsening abdominal pain and distension with radiographic evidence of enlarging collections so a drain was placed into the peripancreatic collection by IR with improvement in symptoms. Discussion: Pseudoaneurysm formation is an uncommon but life-threatening complication of pancreatitis. Pancreatic enzymes released in the setting of pancreatic inflammation leak into vessel walls causing destruction. The majority develop in the splenic artery given the proximity to the pancreas. Those in the SMA account for just 5% of cases. CT angiography is the best diagnostic modality for assessing pseudoaneurysm arterial bleeding. Treatment in the past was primarily surgical but with endovascular advancements, embolization with coils or glue is now first line. However, many patients may still require surgery if embolization fails or if hemodynamically unstable. Despite the rarity of pseudoaneurysm formation, it is important to have knowledge of the appropriate diagnostic workup and treatment given the potentially high mortality rate.Figure 1.: IR coil embolization of the middle colic branch of the SMA

Rare Case of Hip Pain Due to Iliopsoas Tendon Rupture; A Case Report and Review of the Literature

ObjectiveHip pain is common in patients of advanced age and has a very broad differential. Of the potential aetiologies, iliopsoas tendon ruptures are rare. Consequently, there is a paucity of literature on iliopsoas rupture in the older adult population, and its rarity can lead to a delay in its diagnosis. When iliopsoas ruptures do occur, they are typically secondary to trauma; however, they can occur spontaneously. Iliopsoas injuries can be disabling, but they respond well to conservative management. We report here a case of a 70-year-old woman who presented to an unaffiliated emergency department with left anterior hip pain 2 weeks after a fall from standing height.ResultsInitial X-ray and computed tomography were negative for fracture, and the patient was discharged with home health physical therapy. Her symptoms persisted. At a subsequent emergency department visit several weeks later, magnetic resonance imaging revealed a complete left iliopsoas tendon rupture with retraction. She was treated conservatively and made a complete recovery after physical therapy.DiscussionThis paper reviews the literature related to iliopsoas injuries, highlights the importance of iliopsoas tendon injuries among the differential for acute hip pain, and provides management recommendations for this rare, but probably underdiagnosed, injury. This treatable condition warrants further attention, as delay in diagnosis can prolong morbidity.LAY ABSTRACTHip pain is common in the elderly population and has many causes. Of the potential sources of hip pain, a complete tear of the iliopsoas, or hip flexor, tendon is rare. When iliopsoas tears do occur, it is typically after trauma, such as a fall. However, tears can happen spontaneously. Diagnosis is best made using magnetic resonance imaging (MRI), but can be made with ultrasound. These injuries can be disabling, but respond well to conservative management consisting of rest and pain management principles, followed by physical therapy active rehabilitation. This paper reviews the literature on iliopsoas tears, provides management recommendations for this rare, but probably underdiagnosed, injury, and reports a case of a 70-year-old woman who experienced a complete iliopsoas tear after a fall from standing height. The diagnosis was missed on initial evaluation, and was subsequently made using MRI. The patient made a full recovery after conservative management.

A case report of minimally invasive percutaneous ultrasound guided tuberculous iliopsoas abscess drainage in an immunocompromised patient.

Introduction and importanceIliopsoas abscess is a collection of pus that presents with nonspecific features with often delays in diagnosis however cause significant morbidity and mortality with Mycobacterium tuberculosis to be considered as causative agent in at risk individuals in tuberculous endemic regions. Management involves drainage and initiation of adequate antibiotics with radiological guided percutaneous approach considered the appropriate initial approach.Case presentation50-year-old immunosuppressed presenting with left iliopsoas abscess who underwent ultrasound guided drainage and placement of pigtail catheter successfully without the need for open surgical drainage. Our experience of interventional radiology for diagnosis of causative agent and treatment in a sub-Saharan Africa.Clinical discussionWe concur with the recommendation to analyse fluid for tuberculosis in at risk individuals with minimally invasive procedures via interventional radiology as an adequate first line diagnostic and treatment option of psoas abscess. Ultrasound guided catheter placement and drainage successfully drained the abscess by day 10 similarly seen as the average duration in a case series from India.ConclusionThe importance of the role of interventional radiology in treatment for complex abdominal pathologies in sub-Saharan Africa with its ability to diagnose and treat via minimally invasive procedures at highest precision and lowest risks and complications while maintaining a high level of suspicion for tuberculosis as the underlying etiology is highlighted.

S2455 To Start or Not to Start: Early Initiation of Vedolizumab Post-Operatively in Crohn’s Disease

Introduction: Crohn’s disease can often be complicated by intra-abdominal abscesses. Mild cases are managed with percutaneous drainage and antibiotics while severe cases require surgical management. While resumption of biologic therapy is often delayed post operatively due to concerns for infections and poor wound healing, early resumption in high-risk patients has been associated with lower rates of early disease recurrence. Early initiation of post-operative Vedolizumab, a newer anti-integrin biologic, has not been well documented in the literature. Case description/methods: A 28-year-old man with a 7-year history of Crohn’s disease currently managed with vedolizumab and budesonide, presented with one-week history of worsening left lower abdomen and groin pain. Work-up revealed body mass index of 16, hemoglobin 3.6 g/dL, and CT imaging showing a multi-loculated abscess involving the left iliopsoas muscle with tract formation towards the descending colon. He was started on piperacillin-tazobactam and underwent percutaneous drainage of abscess. Repeat CT demonstrated re-accumulation of abscess despite drainage and antibiotics. A subtotal colectomy was performed with ileostomy formation and I&D of the abscess. The patient was continued on antibiotics, and he received his first dose of vedolizumab inpatient on post-operative day 7 given his severe presentation. At his 1 and 3 month follow up in clinic he was noted to have pink and healthy ileostomy stump, well healing incisions, and no signs of infection. He was also tolerating his diet well with more formed stools from his ostomy and a 20-pound weight gain since discharge. Discussion: Crohn’s patients have a high lifetime risk of requiring surgical management of disease. There is a 90% risk for post-operative endoscopic recurrence (PER) at 12 months in these patients. While resumption of biologic therapy has been shown to reduce rates of PER at 6 and 12 months, early initiation of therapy, especially in patients with ileostomy formation, has been controversial given concerns for infections and poor wound healing. Outcomes of early resumption with Vedolizumab in particular, has not been well reported. We present the case of a high-risk patient with active infection who restarted therapy within 7 days of resection with good surgical outcomes and no clinical recurrence at 3 month follow up. Early initiation of Vedolizumab may prove to be a viable strategy in preventing early PER and repeat surgery.

Development of Psoas Hematoma After Lumbar Sympathetic Block in a Patient on Anticoagulants

BACKGROUND: Lumbar sympathetic blocks (LSB) play an important role in the therapeutic management of patients who suffer from neuropathic pain conditions such as complex regional pain syndrome (CRPS). LSB is a generally safe and well-tolerated procedure, however rare complications may occur. While case reports of iliopsoas hematomas related to bleeding disorders, surgical interventions, and trauma are well reported in the literature, similar complications after LSB have not been reported. CASE REPORT: Development of an 18 x 6.1-cm hematoma in the left iliopsoas muscle after a fluoroscopically-guided LSB in an anticoagulated patient despite following recommended periprocedural anticoagulation management guidelines resulted in pain, impaired mobility, and likely femoral neuropathy. CONCLUSION: Pain management physicians should be aware that hematomas are a possible complication of LSB and should weigh the risks and benefits of holding anticoagulation therapy in patients undergoing such procedures. KEY WORDS: Anticoagulation, complex regional pain syndrome, hematoma, lumbar sympathetic block, lumbar sympathetic block complications

PERDARAHAN ILIOPSOAS PADA PASIEN COVID-19 DALAM TERAPI ANTIKOAGULAN

Background: Giving anticoagulants to Covid-19 patients is included in one of the standard protocols for Covid-19 therapy. The focus on anticoagulation to prevent thrombotic events often creates a “double-edged sword” with the risk of bleeding, which is also potentially fatal. We present a rare but fatal case of iliopsoas hemorrhage.Case: A Covid-19 patient, 70 years old male, received anticoagulant therapy with unfractionated heparin instead of enoxaparine (LMWH) due to high D-dimer. As the D-dimer value improves, massive and continuous left iliopsoas hemorrhage appears which causes hemodynamic disturbances. Fluid resuscitation, vasopressors, and transfusions were administered following a CT scan of the abdomen. Follow-up CT angiography could not locate the source of the bleeding. Surgery or percutaneous intervention cannot be performed. The patient eventually died.Conclusion: The incidence of bleeding on anticoagulant therapy is low, especially iliopsoas bleeding. Given the massive anticoagulant therapy in almost all Covid-19 patients, as well as the pathogenesis of Covid-19 that interferes with vascular conditions and the coagulation system, the incidence of bleeding risk may increase. This needs to be a concern and anticipation of comprehensive management.

Schwannomatosis in pelvic region topography with neuro-muscular complications: A case report

Introduction: Schwannomatosis is a rare type of neurofibromatosis, usually affects people between ages 25 and 30 years old. Schwannomatosis causes tumors to develop on the cranial, spinal, and peripheral nerves. The most common symptoms are: chronic pain, which can occur anywhere in the body and can be disabling, numbness or weakness in various parts of the body, and muscle paresis. Two genes are known to cause schwannomatosis. Mutations of the genes SMARCB1 and LZTR1, which suppress tumors, are associated with this type of neurofibromatosis. We report the case of a patient victimized by schwannomas in the pelvic region and, as a consequence, neuromuscular injuries. Case Report: Patient under investigation of lesions in the lumbosacral plexus and clinical picture marked by pain in the iliopsoas muscle in the left pelvic region and ipsilateral involvement of the obturator nerve (mild paresis in the adduction of the thigh and allodynia in the anterolateral region). A positron emission tomography-computed tomography (PET-CT) study was carried out to assess the nodular findings. Elongated and nodular lesions were observed, with attenuation of soft tissues, located laterally to the left iliopsoas muscle. In the biopsy of one of the nodules, the result was compatible with schwannomas. Immunohistochemical assay confirmed the schwannomas to be positive for Sox10. Conclusion: The patient, in this case, will be surgically approached due to the topography of the lesion, which currently causes refractory pain and impaired mobility.

Large-scale analysis of iliopsoas muscle volumes in the UK Biobank

Psoas muscle measurements are frequently used as markers of sarcopenia and predictors of health. Manually measured cross-sectional areas are most commonly used, but there is a lack of consistency regarding the position of the measurement and manual annotations are not practical for large population studies. We have developed a fully automated method to measure iliopsoas muscle volume (comprised of the psoas and iliacus muscles) using a convolutional neural network. Magnetic resonance images were obtained from the UK Biobank for 5000 participants, balanced for age, gender and BMI. Ninety manual annotations were available for model training and validation. The model showed excellent performance against out-of-sample data (average dice score coefficient of 0.9046 ± 0.0058 for six-fold cross-validation). Iliopsoas muscle volumes were successfully measured in all 5000 participants. Iliopsoas volume was greater in male compared with female subjects. There was a small but significant asymmetry between left and right iliopsoas muscle volumes. We also found that iliopsoas volume was significantly related to height, BMI and age, and that there was an acceleration in muscle volume decrease in men with age. Our method provides a robust technique for measuring iliopsoas muscle volume that can be applied to large cohorts.

Spontaneous Pan-Vertebral Epidural Abscesses Caused by Streptococcus Intermedius in an Immunocompetent Patient

Spinal epidural abscess (SEA) is a rarely reported condition. Here, we present a unique case of a 54-year-old immunocompetent man who developed worsening lower back pain of 2 weeks duration. A full spine magnetic resonance imaging (MRI) was performed with contrast. This showed extensive epidural abscess extending from C2 to S2, more extensive around L5-S2, with left paraspinal, left iliopsoas and right psoas abscess confirming the diagnosis of spinal epidural abscess of the spine. Blood cultures grew Streptococcus intermedius, an anaerobic commensal bacterium of the normal flora of the mouth and upper airways. The patient was treated conservatively with intravenous Ceftriaxone 2g and oral Rifampicin 600mg. He was discharged on those medication for 10 weeks. There was remarkable improvement in his symptoms as he retained his baseline strength in his lower extremity and has regained function to the extent that he is independent with his activities of daily living. A high index of clinical suspicion and a low threshold of appropriate imaging, magnetic resonance imaging (MRI) being the gold standard, are important for accurate diagnosis. Though our patient was treated Medically, Prompt medical and surgical treatment may avert complications, and although the patient presented made a complete recovery, patients may be left with neurological deficits.

A wearable lower extremity support for laparoscopic surgeons: A pilot study.

Surgeons have increased physical stress during laparoscopic surgery due to operative site constraints. We developed a wearable device to reduce the physical stress on surgeons' lower extremities. The device mechanically facilitates maintaining a near-upright posture. The surgeon's knees are gently bent by a knee-joint locking mechanism, and fixing and releasing are performed independently on each side. The subjects were one female and two male surgeons, who wore the device during laparoscopic inguinal hernia repair or high anterior resection. Surface electromyogram (EMG) was conducted for both iliopsoas muscles. Control values were determined with the subject not wearing the device. Participants completed a post-procedure questionnaire. With the device, EMG activity had a tendency to decrease in the left iliopsoas muscle (P = .055), but it changed little on the right (P = .406). The post-procedure questionnaire showed an overall positive impression, although subjects reported some difficulty walking. This device decreases EMG activity and may improve a surgeon's work environment.

Xp11.2 translocation renal cell carcinoma with TFE3 gene fusion in the elderly: case report and literature review

A 68-year-old man was followed up with chronic kidney disease. Follow-up CT incidentally detected a tumor at the left kidney and multiple small nodular shadows in the lungs bilaterally. The patient underwent needle biopsy and was diagnosed with Xp11.2 translocation renal cell carcinoma (RCC) pathologically. Hence, laparoscopic nephrectomy was performed. Fluorescence in situ hybridization analysis revealed a break-apart of the transcription factor E3 (TFE3) genes in the left tumor. After 2months postoperatively, nivolumab and ipilimumab were administered thrice intravenously, considering the intermediate risk by the IMDC risk classification. However, pleural effusion occurred but was removed adequately. Lung metastasis decreased, but new metastasis occurred at the left iliopsoas muscle. Target therapy was performed with axitinib. Unfortunately, he died 6months later postoperatively. These tumors commonly occur in children than in adults, and very rare in elderly patients. Xp11.2 translocation RCC in the elderly has a poorer prognosis than that in children. To date, no effective treatment for Xp11.2 translocation RCC has been established.

HIP INJURY- CROSS COUNTRY

HISTORY 18-year-old high school female cross-country runner presented with one week of left anterior hip pain. Denied a specific injury. Pain started during a late season meet causing her to finish at a slower pace. Pain progressively worsened requiring crutches to ambulate, despite no further activity. Max mileage was 40 miles/week, had tapered to 20 miles/week prior to injury. History of stress fracture 4 years prior. Initial x-ray of left hip revealed open epiphyseal plates, no other osseous abnormalities. Inquiring about menstrual history, she had yet to reach menarche. Per the patient’s mother, she had been trialed on growth hormone and is currently on estradiol patches. She has a known eating disorder for which she is not actively receiving help, despite multiple hospitalizations. PMHX Primary amenorrhea, followed by endocrinology. Lab work revealed low estradiol, LH, FSH with high alkaline phosphatase. Normal labs were thyroid studies, BMP, LFT, vitamin D and prolactin. Genetics showed 46XX. Multiple XR for bone age showed that of an 11-year-old. Cardiac work up showed sinus bradycardia on EKG and normal echo. Brain/pituitary MRI revealed normal pituitary and mild enlargement of ventricles, sulci, cerebellar folia. PHYSICAL EXAMINATION Patient stands 55 inches tall, weighing 61 pounds with a BMI of 14. She appears much younger than stated age. Hair is full, though fine. Breast tissue is not appreciated. On left hip exam, there is TTP along flexor tendon, lateral hip, and piriformis. She has pain with external rotation, weakness and pain with hip flexion, abduction, and adduction against resistance. She is unable to do a single leg hop due to groin pain. She is neurovascularly intact. DIFFERENTIAL DIAGNOSIS 1. Femoral neck stress fracture 2. Primary amenorrhea 3. Hip flexor strain 4. Relative Energy Deficiency in Sports syndrome 5. ASIS avulsion fracture TESTS/RESULTS MRI left hip 1. Partial thickness tear at attachment of left iliopsoas tendon to lesser trochanter with intramuscular hematoma 2. Minimal partial thickness tear of the left common hamstring origin FINAL DIAGNOSIS 1. Partial tear of left iliopsoas tendon and hamstring 2. RED-S TREATMENT/OUTCOMES 1. Shut down from all activities 2. Weightbearing as tolerated 3. Referral to gynecology for transvaginal ultrasound 4. Referral to Eating Recovery Center

Abscess of the Iliopsoas Muscle Discovered in Premature Newborn: about a Case in Dakar

The abscess of the Iliopsoas muscle is an unusual situation in the new born. Its diagnosis is difficult due to its nonspecific symptomatology. We report the case of a 19-day-old, premature and male infant. He presented with an abscess of the left iliopsoas muscle diagnosed by the ultrasound and CT scan pair. The treatment started was an evacuated needle puncture guided by ultrasound and antibiotic therapy targeting staphylococcus aureus. The evolution was favorable

SAT-LB302 From Urolithiasis to Genetic Testing: An Unusual Presentation of MEN-4 Syndrome

Background:Germline mutations in the CDKN1B gene are responsible for Multiple Endocrine Neoplasia Type 4 (MEN 4) syndrome (Alrezk et al. 2017). Around 20 cases have been reported to date. Here, we report on a new MEN4 family which possibly extends the phenotypic spectrum attributable to germline mutations in CDKN1B. Clinical Case: A 56-year-old female presented with urolithiasis & was found to have hypercalcemia (serum calcium of 2.76 mmol/l ref. 2.12-2.62 mmol/l). Workup was in keeping with primary hyperparathyroidism (PHPT) (PTH 28.7 pmol/l ref. 1.50-9.30 pmol/l; phosphorus 0.89 mmol/l ref. 0.80-1.45 mmol/l). Sestamibi & US of the neck revealed no clear parathyroid adenoma. Two incidental thyroid nodules were benign on FNA cytology.The patient underwent neck exploration & a single enlarged parathyroid gland was removed. Pathology showed an enlarged hypercellular gland. Her calcium & PTH normalized after surgery but recurrence was documented a year later. Her family history was significant for PHPT in two brothers & a history of kidney stones in a third brother. Multi-gene panel testing (CASR, CDC73, CDKN1B, MEN1, RET, Invitae Corp.) revealed a pathogenic variant (PV) in CDKN1B (c.215delG). The patient underwent a 2 ½ parathyroidectomy with subsequent normalization of her calcium & PTH. Further work-up showed a 4.5mm non-secreting pituitary adenoma. Plasma metanephrines & NE were intermittently elevated. Serum gastrin was also mildly elevated 83 pmol/l (<53 pmol/l). A Ga68-DOTATATE PET scan was negative. Her 23-year-old daughter tested positive for the familial PV. She is asymptomatic & has normal calcium & PTH; pituitary function is normal except for an elevated IGF-1 at 63.9 nmol/l (ref 13.3- 42.6 nmol/l) with borderline growth hormone during OGTT (0.40 ug/l). Her pituitary MRI was normal. One brother with history of prostate cancer, PHPT & partial parathyroidectomy has tested positive for the familial CDKN1B variant. A second brother was also found to carry the familial variant & was clinically asymptomatic.Endocrinological workup has revealed he has PHPT, elevated chromogranin A at 196.2 ng/ml (ref <=82), calcitonin at 25 ng/l (normal <=9 ng/l), IFG1 (35.3 nmol/L ref. 13-21) but normal plasma metanephrines. An MRI of the sella shows an 8mm hypoenhancing lesion. On CT, a retroperitoneal hyperenhancing 4cm mass adjacent to the left ilio-psoas was seen, in keeping with a paraganglioma; additionally, he has a congenital left atrophic kidney & ureter. Two additional brothers; one with history of non-Hodgkin’s lymphoma, PHPT & partial parathyroidectomy & a second brother, also with prostate cancer & recurrent renal stones, have yet to be tested. Conclusions: A new MEN4 family is described here which expands the spectrum of clinical manifestations of this syndrome. Of great interest in our cases is the presence of paraganglioma, urological malformation, & pre-clinical GH/IGF1 elevation.