Thigh Abscess Research Articles

Complex Multimodal Management of Acute Pain in a Patient with Invasive Thigh Abscess

Complex Multimodal Management of Acute Pain in a Patient with Invasive Thigh Abscess

Thigh Abscess Formation Due to Severe Sacral Pressure Ulcer Dissemination: A Case Report

Patients with chronic and non-healing pressure ulcers are susceptible to recurrent infections, often leading to complications, such as abscesses. However, to the best of our knowledge, no cases of abscesses disseminating from a pressure sore to the thigh have yet been reported in the literature. We report the case of a 53-year-old man with a severe pressure ulcer in the sacral area and an abscess extending to the thigh. The presence of an abscess in an area devoid of pressure ulcers was suspected. Prior to surgical intervention, a comprehensive evaluation was undertaken, culminating in debridement and subsequent reconstruction, yielding excellent results. Abscesses are often difficult to evaluate with physical examination alone. Therefore, the possibility of extensive abscess formation and dissemination should be considered in patients with severe pressure ulcers.

An unusual presentation of penetrating bladder injury with vesicocutaneous fistula: a case report

BackgroundBlunt trauma to the urinary bladder is common with penetrating injury being a rare occasion. Most common entry pint for penetrating injuries includes buttock, abdomen and perineum with thigh being rare. There are a number of complications that may develop as a result of penetrating injury with vesicocutanous fistula being a rare occurrence that usually presents with typical sign and symptoms.Case presentationWe present a rare case of penetrating bladder injury through medial upper thigh as an entry point that had complicated into vesicocutaneous fistula with atypical presentation of long-standing pus discharge that had been managed by incision and drainage several times with no success. MRI demonstrated a presence of fistula tract and a foreign body (piece of wood) in-situ confirmed the diagnosis.ConclusionFistulas are a rare complication of bladder injuries and can cause negative impact on the quality of life of patients. Delayed urinary tract fistulations and secondary thigh abscesses are uncommon therefore a high index of suspicion is needed for early diagnosis. This case emphasizes the importance of radiological tests in aiding the diagnosis and ultimately proper management.

Bilateral Thigh Abscess Due to Rectal Fistula: A Rare Case Report With Silent Clinical Presentation

A 53-year-old male patient who underwent a rectal cancer operation nine years ago was evaluated with complaints of pain and swelling in the lateral thigh. Radiological imaging revealed abscess foci in the right thigh muscles. Surgical drainage and debridement were performed but developed recurrence. Contrast-enhanced abdominal tomography was performed due to a positive medical history and it was seen that an enterocutaneous fistula was formed from the anastomosis site of previous cancer surgery to both sides of the thigh. Bilateral thigh abscesses were drained and radical debridement was performed in the same session with surgery for the fistula. Pathological examination of the surgical specimens showed no evidence of cancer and the patient was discharged on the 14th postoperative day with complete resolution of the infection. Hip abscesses are rare, delays in the diagnosis and treatment of the underlying cause in cases of abscess secondary to abdominal or pelvic pathologies lead to an increase in mortality. Therefore, it should be kept in mind that thigh abscesses may be another side of the coin besides being seen as an isolated infection.

SJLA_2024_A16: Unusual Complications of Open Preperitoneal Tension-Free Inguinal Hernia Repair

Background: The purpose of this study is to report two patients referred to our hospital after developing unusual complications attributed to prior open preperitoneal tension-free inguinal hernia repair. Methods: Case # 1 A 75-year-old male developed a left proximal thigh abscess requiring incision and drainage 5 years after open prosthetic, preperitoneal inguinal hernia repair with single-layer mesh. A pelvic computed tomography (CT) scan demonstrated an abscess in the left inguinal preperitoneal space as well as diverticulosis but no diverticulitis. A colonoscopy was negative for any additional findings. The patient underwent groin exploration, debridement of the inguinal canal and sinus tract, and mesh resection followed by JP drain placement. The inguinal defect was repaired utilizing the should ice technique. Intraoperative cultures revealed penicillin-resistant Staphylococcus aureus. The drain was removed on postoperative day nine, and his recovery remains uneventful without hernia recurrence or infectious complications at 11-month follow-up. Case # 2 An 82-year-old man developed progressive left lower extremity edema and disabling claudication 1 month after open prosthetic inguinal hernia repair with a bilayer disc mesh. Venous duplex imaging revealed compression of the left common femoral and external iliac veins. A CT angiogram demonstrated left external iliac and common femoral artery thrombosis and a 5.2 cm fluid collection consistent with hematoma. An inferior vena cava filter was placed. The common femoral artery was controlled after initial exploration revealed a common femoral artery pseudoaneurysm. The mesh was densely adherent to the external iliac vein and was thus not resected. The common femoral artery pseudoaneurysm was repaired and the profunda femoris artery over sewn. An external iliac to superficial femoral artery 8 mm Polytetrafluoroethylene bypass graft was placed. The patient was discharged on systemic anticoagulation without claudication on postoperative day thirteen. Results: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Discussion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Conclusion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available.

P19 A case of pyrexia of unknown origin - wrong way round!

P19 A case of pyrexia of unknown origin - wrong way round!

Thigh and iliopsoas abscess as a rare presentation of perforated mucinous appendix carcinoma. A case report.

Classic presentation of appendicular neoplasms in early stage includes appendicitis-like symptoms. For mucinous adenocarcinoma, it presents at an average age of 60 years, this is why when they present these symptoms a high index of suspicion must be maintained. Only one case has been reported of an appendiceal neoplasm with a thigh abscess. We present a 65-year-old with a preoperative diagnosis of an appendiceal phlegmon with and iliopsoas and thigh abscess. Percutaneous drainage and thigh drainage were initially performed. Due to persisting fever and increased abdominal symptoms, 48 h postoperative hours, on multidisciplinary discussion, exploratory laparoscopy was decided, finding the iliac abscess and a perforated appendix. Right hemicolectomy was performed, revealing a mucinous appendicular carcinoma. Conservative management of a mass or appendiceal abscess has a high success rate and low complication rate during the initial period but despite this, some patients must undergo emergency surgery. Right hemicolectomy was performed because of the large inflammatory compromise and adhesions of the appendix and caecum and a more conservative approach could not be performed due to the deformation of anatomic structures. This has been a complex case, not only for its different approaches but also because of its singularity of presentation, this is why it has to be taken into account the group age that it has to be dealt with, clinical presentation, anamnesis, etc. There are no guidelines for the management of this disease but it is unquestionable that multidisciplinary management leads to better outcomes. • Only one case has been reported of an appendiceal neoplasm with a thigh abscess. • The classic presentation of appendicular neoplasms includes appendicitis-like symptoms. • We performed a right hemicolectomy and thigh abscess drainage. • No guidelines exist but multidisciplinary management leads to better outcomes.

Femoral artery aneurysm with large hematoma from Pasteurella: case report and literature review

BackgroundPasteurella multocida is a well-known gram-negative facultative anaerobe well known for its ability to cause soft tissue infections following animal bite or scratch. Here we present a case with mycotic aneurysm of the superficial femoral artery due to P. multocida infection.Case presentationA 62 year old male patient presented with worsening right leg pain and swelling. On examination, he was found to have profound swelling and erythema of the right medial thigh and tenderness to palpation. Computerized tomography showed findings suggestive of right femoral pseudoaneurysm with a large right medial thigh hematoma. Blood cultures grew P. multocida. Patient underwent emergent open resection of the mycotic aneurysm and vascular bypass surgery. Intraoperatively, the site was noted to be grossly infected with multiple pockets of pus which were drained and pus cultures grew P. multocida. The diagnosis of P. multocida bacteremia with right femoral mycotic aneurysm and thigh abscess was made. Patient received 6 weeks of intravenous ceftriaxone and recovered.ConclusionOur case is the first report on infection of peripheral vessel with Pasteurella and highlights the importance of prompt surgical intervention and effective antibiotic treatment

Mycobacterium avium pelvic abscess with vaginocutaneous fistula after transobturatory sling surgery

This study presents a rare case of abscess associated with vaginocutaneous fistula due to atypical mycobacterial infection after sling surgery, which was successfully treated. Abscesses and fistulas are rare postoperative complications in treatment of stress urinary incontinence by transobturatory sling surgery, due to its high rate of positive outcomes in the treatment of urinary incontinence in women. These complications are considered to be related to the composition of the mesh and bacterial infection. We report a case of a 50-year-old patient who developed, in the 7th postoperative year of perineoplasty with sling placement, pelvic abscess and cutaneous fistula in the left thigh. Microbiological examination of the lesion revealed infection by Mycobacterium avium. Antibiotic therapy plus abscess drainage surgery and surgical correction of the fistulous pathway were the treatment of choice. During the surgery, a vaginal opening of the cutaneous fistula was evidenced, originating from the sling mesh, which was removed and later proved to be colonized by M. avium. The patient became asymptomatic after 1 year of postoperative follow-up.

825. Immunosuppressive Agent Use in Patients with Comorbid HIV and Inflammatory Bowel Disease

Abstract Background Epidemiologic data from HIV/AIDS registries and inflammatory bowel disease (IBD) centers have identified comorbid IBD to be a challenge in the long-term care of patients with HIV, but data on management are sparse. At a multisite tertiary center, we examined medical management, disease control, and complications of patients with comorbid HIV and IBD. Methods We reviewed 126 charts between April 2017 and December 2020 for subjects 18+ years with HIV-1 infection and Crohn’s disease (CD) or ulcerative colitis (UC). Participants received HIV and/or IBD care at Jefferson. We documented CD4 count, HIV viral load, IBD regimen, and the Harvey-Bradshaw Index (HBI) for CD and the Mayo Score for UC (DAI). Results Twelve patients met criteria for inclusion, n=6 with CD and n=6 with UC. They were all prescribed antiretroviral therapy (ART), with median CD4 722 and 83% virally suppressed (Table 1). 67% had ever been prescribed immunosuppressive IBD regimens while known to be HIV+. Eight patients had CD4s > 200 with low HBI or DAI. Patient #s 4, 8 and 10 were managed with only mesalamine. Patient #s 5 and 12 had received immunomodulators, with #5 controlled on azathioprine for years but stopped following admission for septic shock due to a thigh abscess, and #12 newly trialed methotrexate in the setting of IBD-related arthritis. Patient #s 2, 6, and 7 were treated with adalimumab: #2 newly for IBD-related arthritis, while #6 and #7 had been maintained long-term for luminal disease, but #7 was a new HIV diagnosis recently initiated on ART. Two patients were AIDS-defined with low HBI: #1 on mesalamine only, as infliximab was discontinued on HIV diagnosis with CD4 36, and #9 who was not on an IBD regimen. Two patients CD4 200+ had inconsistent viral suppression and moderate HBI/DAI: #3, who had responded to vedolizumab prescribed briefly during viral suppression but stopped due to poor follow-up and ART non-adherence, and #11, whose only documented IBD regimen since HIV diagnosis was chronic prednisone. Table 1. Cohort Background and Currently Prescribed Regimens These data observe the cohort’s current regimens and longitudinal control. They do not include windows of prior medication trials that were not maintained, which are detailed in the text. Conclusion This small case series suggests that comorbid IBD and HIV patients may be managed successfully with immunosuppressive therapy when indicated. More information is needed regarding whether immunomodulators and biologics may affect CD4 and viral loads and conversely how poor control of HIV affects IBD activity. Disclosures All Authors: No reported disclosures

Thigh Abscess Secondary to Intra-abdominal Pathologic Conditions: Three Cases Progressing to Necrotizing Fasciitis

Necrotizing fasciitis results in progressive destruction of the fascia and overlying tissue. Mortality primarily depends upon the timing of medical care and the extent of infection. This article presents a case series of thigh abscesses originating from intra-abdominal pathologic conditions and progressing to necrotizing fasciitis due to delayed diagnosis. The data concerning 3 patients with thigh abscess originating from an intra-abdominal pathologic condition and progressing to necrotizing fasciitis are presented. All patients had undergone previous colorectal surgery for malignancy and were admitted to the hospital with pain concentrated in the lower back and spreading down to the buttock, sacrum and coccyx, and leg. Patients had received symptomatic therapy, including nonsteroidal anti-inflammatory drugs, and 1 patient had undergone diskectomy for a herniated disk in the lumbar region. All 3 patients subsequently developed thigh abscesses (initially treated by percutaneous and/or surgical drainage) and received antibiotic therapy. One patient underwent percutaneous drainage, and 2 patients underwent abdominal surgery to address the abdominal abscess. During the course of treatment, thigh abscesses progressed to necrotizing fasciitis, which was treated by surgical debridement with or without negative pressure wound therapy. All patients died of overwhelming sepsis. Thigh abscess may spontaneously arise from surrounding soft tissues, or it may be a sign of intraperitoneal, retroperitoneal, or pelvic pathologic conditions. Deep, vague pain in the back or hip area that spreads downward to the buttock and leg may be an early symptom of these pathologic conditions. Clinical suspicion may be effective in reducing mortality by enabling early surgical intervention, especially in the patient with a previous history of abdominal surgery, radiotherapy, or inflammatory or malignant disease.

脆弱性恥骨骨折後に生じた化膿性恥骨骨髄炎および左大腿内転筋膿瘍から敗血症性ショックに至った1例(A case of septic shock caused by suppurative pubic osteomyelitis and muscle abscess in left thigh following fragility pubic fracture)

要旨開放性外傷や手術歴がない成人の恥骨骨髄炎は稀である。脆弱性左恥骨骨折の保存的加療中であった患者が，左恥骨骨髄炎と多発筋肉内膿瘍を発症し，敗血症性ショックとなった症例を経験した。脆弱性骨折の頻度が高い超高齢社会では，本症例と同様に脆弱骨折部分に感染を合併する症例の頻度が高くなる可能性が示唆されるため報告する。症例は76歳の女性。約4週間前に脆弱性左恥骨骨折と診断され保存療法が行われていた。搬送1時間前に突然の全身痛と呼吸困難感を訴え救急搬送された。画像検査で左恥骨融解像と恥骨に接する複数の筋肉内に膿瘍を認め，左恥骨骨髄炎および多発筋肉内膿瘍による敗血症性ショックと診断し得た。長期間の抗菌薬投与と外科的処置を行い，第85病日に転院となった。本症例は恥骨骨髄炎が原発巣であり，恥骨に付着する筋肉へ感染が波及して多発筋肉内膿瘍を形成したと推察した。骨髄炎の原因は，恥骨骨折周囲での血腫形成に，長期臥床に伴う褥瘡形成による菌血症が重なり，血腫感染を起こしたことが考えられた。脆弱性骨盤骨折は，保存療法により感染を伴わずに治癒する場合がほとんどだが，今回のように免疫不全となる既往歴がなくても骨折部分の骨髄炎を発症し，敗血症に至ることがある。骨髄炎はその頻度の少なさや非特異的な症状から診断が遅れる場合が多く，先行する骨折部位が骨髄炎を発症しうることを考慮して診療にあたる必要がある。

Paraganglioma

Introduction: Paragangliomas are rare neuroendocrine tumors arising from extra-adrenal medullary neural crest derivatives. The terms pheochromocytoma and paraganglioma are often used interchangeably because morphologically and functionally these entities are almost the same. However, paragangliomas that arise in the adrenal medulla are called pheochromocytomas and those outside the adrenal gland are called paragangliomas. Paragangliomas are often discovered incidentally during imaging studies performed for other reasons. We report a case of a patient who had incidental finding of retroperitoneal paraganglioma on imaging done for evaluation of thigh and gluteal cellulitis. Clinical Case: A 24-year-old female presented with chief complaints of episodic headaches, multiple skin abscesses, fever and malaise. She has a history of Type 1DM and had been non-compliant on insulin. Vitals on presentation was significant for tachycardia with heart rate of 124, blood pressure of 119/81, respiratory rate of 16. Initial labs were consistent with DKA. CT abdomen and pelvis done for further evaluation of gluteal and thigh abscess showed incidental finding of a 3.4 cm retroperitoneal/para-aortic well-circumscribed rim-enhancing mass with central hypoenhancing component, suspicious for neoplasm such as paraganglioma. Biochemical testing was performed. 24-hour urine catecholamine levels obtained showed elevated urine norepinephrine level of 1008μg/day (reference range 15-100μg/day), urine dopamine 410μg/day (reference range 65- 400μg/day), urine epinephrine less than 2μg/day (reference range 0-20μg/day). Total urine catecholamines was elevated 1008μg/day (reference range 15-100μg/day). These results confirmed diagnosis of paraganglioma. Treatment options were discussed with the patient including surgery for removal of paraganglioma which she has currently declined. Conclusion: Diagnosis of a paraganglioma can usually be made using biochemical and radiographic testing. All patients with paraganglioma should be tested for hypersecretion of catecholamines in a 24-hour urine or serum collection, even if they do not present with a clinical picture of catecholamine hypersecretion. Importantly these extra-adrenal tumors do not have the enzymatic capacity to form epinephrine from norepinephrine as was exemplified by our case. For catecholamine-secreting tumors, biochemical diagnosis should be followed by radiological evaluation (typically either CT or MRI of the abdomen and pelvis) to locate the tumor. Treatment options are dependent on location of tumor, size, presence of symptoms and if there is metastatic disease present.

Cutaneous thigh abscess secondary to melioidosis: a rare cause for a common presentation

Melioidosis is a notifiable disease caused by Burkholderia pseudomallei . It is associated with a mortality rate of up to 50% and over the last decade, has only been reported...

Post-vaccination Tubercular Cold Abscess of Thigh of An Infant

We report a case of post immunization tubercular soft tissue cold abscess on a lateral part of the right thigh in an eight-month-old male baby following third dose of intramuscular Hepatitis B vaccination. The baby presented with gradual onset of fever for 10 days after hepatitis B vaccination this was followed by an erythematous, painless, firm small swelling on the anterolateral part of the right thigh which grew gradually to a size of 2 × 2.5 cm size. The baby was treated with empirical antibiotics (Amoxicillin) following which fever subsided but there was no improvement in swelling so the baby was advised for various laboratory investigations. The aspirate from the abscess was subjected to Acid fast staining using microscopy (Ziehl-Neelsen staining) that revealed Acid Fast Bacilli (2+). In addition (Cartridge Based Nucleic Acid Amplification Test) confirmed the presence of M. tuberculosis complex sensitive to Rifampicin. J Microbiol Infect Dis 2020; 10(4): 234-236.

LATE DIAGNOSIS OF ANTI-MDA5 ANTIBODY-POSITIVE RAPIDLY PROGRESSIVE INTERSTITIAL LUNG DISEASE WITH CUTANEOUS MANIFESTATIONS

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody is associated with rapidly progressive interstitial lung disease (RP-ILD). This can be seen in patients with clinically amyopathic dermatomyositis or more typical dermatomyositis. Not only is MDA5-positive RP-ILD a rare cause of ILD, but the ILD often results in significant morbidity and mortality. Although there are several proposed treatment regimens, patients often succumb to the illness despite initiation of therapy. As such, early diagnosis and treatment in these patients is of paramount importance. CASE PRESENTATION: Herein we report a case of 37-year-old male diagnosed with anti-MDA5-associated RP-ILD late in his clinical course. He presented in October 2019. He initially presented with marked unintentional weight loss, preceding episodes of antimicrobial-refractory pneumonia, and an upper thigh abscess prior to his transfer to our hospital. He had a complicated hospital course with profound multi-organ system failure. Given an unclear underlying diagnosis, empiric antimicrobials and corticosteroids were started and intensified, without improvement. Furthermore, his secondary acute respiratory distress syndrome did not respond to standard evidence-based strategies. In the setting of chest imaging suggestive of underlying ILD with profound pneumomediastium and concomitant Gottron papules, rheumatologic work-up revealed a unifying diagnosis very late in his hospital course. Despite mechanical ventilation, venovenous extracorporeal membrane oxygenation (VV-ECMO), high-dose steroids, intravenous immunoglobulin, and tacrolimus, the patient had little clinical response to his disease which ultimately proved fatal. DISCUSSION: To the best of our knowledge, this is one of the first cases where VV-ECMO was used to treat anti-MDA5 positive RP-ILD. Unfortunately, this case demonstrates the futility of supporting patients with anti-MDA5 positive RP-ILD with VV-ECMO, particularly when that support is initiated late in their clinical course. His hospital and pre-hospital course highlight the barriers of a healthcare system that ultimately could not save him. Moreover, this case illustrates the importance of early diagnosis and expedited trials of therapy. In the future, early diagnosis of anti-MDA5 positive RP-ILD may support the utility of VV-ECMO as a bridge to lung transplant. CONCLUSIONS: In a case such as this one, where the diagnosis eludes while irreversible lung disease progresses, ECMO is a therapeutic modality best avoided. We would further recommend, should ECMO be utilized in such cases, where the diagnosis has yet to be made, it is important that all parties involved are clear on the overall treatment plan to include when extracorporeal support will be withdrawn. Reference #1: Gonzalez-Moreno et al. Rapidly progressive interstitial lung disease due to anti-MDA5 antibodies without skin involvement: a case report and literature review. Rheumatology International 2018. 38:1293-1296. Reference #2: LeClair et al. Successful lung transplantation in a case of rapidly progressive interstitial lung disease associated with antimelanoma differentiation-associated gene 5 antibodies. Journal of Rheumatology 2018. 45:581-583. Reference #3: So et al. Rituximab for refractory rapidly progressive interstitial lung disease related to anti-MDA5 antibody-positive amyopathic dermatomyositis. Clinical Rheumatology 2018. 37:1983-1989. DISCLOSURES: No relevant relationships by Erika Anderson, source=Web Response No relevant relationships by Cyrus Askin, source=Web Response No relevant relationships by Carl Kay, source=Web Response No relevant relationships by Whittney Warren, source=Web Response

Aggregatibacter actinomycetemcomitans Causing Empyema Necessitans and Pyomyositis in an Immunocompetent Patient

Empyema necessitans is a relatively rare clinical entity in which the empyema extends through the parietal pleura into the adjacent soft tissue and musculature of the chest wall. It usually occurs due to inadequate treatment of a primary lung infection. Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans is a facultative anaerobic gram-negative coccobacillus that is part of the normal oral flora. Infections due to this organism usually result from aspiration in conjunction with dental disease or trauma to the oral mucosa resulting in pneumonia or empyema. It often coinfects with Actinomyces and is known to cause empyema necessitans. Cases of monomicrobial empyema necessitans due to Aggregatibacter actinomycetemcomitans in adults have rarely been reported with four such publications found on review of the literature. We present a patient with severe periodontitis who developed empyema necessitans due to Aggregatibacter actinomycetemcomitans likely from aspiration complicated by pyomyositis of the right triceps brachii and a left posterior thigh abscess.

Perforated retroperitoneal appendicitis presented with right thigh abscess: case report and literature review

The typical clinical presentation of acute appendicitis is initial diffuse abdominal pain that shifts to right iliac fossa, nausea, vomiting supported with elevated white blood cell count [3]. It is reported that there are atypical presentation of acute appendicitis approximately 20%-30%. Retroperitoneal perforated appendix can cause retroperitoneal and psoas abscess. After abscess formation, inflammation and pus may extend to pelvis and extra-abdominal compartments through certain routes and tissue plains. Reported routes in literature such as deep to inguinal ligament (through psoas sheath, femoral sheath and femoral canal), fibro-osseus canals (through sacrosciatic notch and Obturator foramen). We report a 67 years old patient with initial presentation of right thigh abscess and psoas abscess caused by perforated retroperitoneal appendicitis. He was managed with vertical drainage of the thigh abscess and laparoscopic appendectomy with psoas abscess drainage. There are several reports that diagnostic modalities such as CT of the abdomen and pelvis or MRI could direct the management to surgical or non-surgical plans. The early surgical intervention to the intra-abdomen pathology with sufficient drainage of the psoas and thigh abscess is the definite treatment. It is suggested that in unexplained thigh or groin pain/soft tissue infection with fever and leukocytosis a gastrointestinal pathology should not be overlooked.

A tricky trochanter

A 24-year-old previously well female presented with a discharging thigh abscess after travel to Ghana. She reported malaise but was otherwise systemically well. Further history revealed 2 years of intermittent left thigh pain, which had been attributed to a large trochanteric bursa identified on ultrasound in 2017. On examination she was afebrile with a deep, undermined ulcer discharging pus in the left antero-lateral thigh. Femoral X-ray was unremarkable. She underwent surgical debridement and intra-operatively infection was found to track to the greater trochanter. Tissue specimens grew Gemella morbillorum, Klebsiella pneumoniae, Enterobacter cloacae, Streptococcus anginosus and mixed anaerobes. She responded well to 4 weeks of ciprofloxacin, metronidazole and amoxicillin. Histological examination of the ulcer edge revealed non-necrotising granulomata (Ziehl-Neelsen stain negative).Mycobacterium tuberculosis(MTB) was subsequently isolated on mycobacterial culture from the same site. MRI demonstrated osteomyelitis of the greater trochanter with a 2cm intramedullary abscess and an adjacent soft tissue collection. Macroscopically caseous material was found on further debridement and tissue samples were AAFB smear negative but MTB complex was detected by PCR and culture of intra-medullary bone. This case demonstrates that bacteria and mycobacteria may be co-pathogens, and that M. tuberculosis bone infection may present with no systemic symptoms. It is a reminder of the importance of cross-sectional imaging and mycobacterial culture in deep soft tissue infections with a long or unusual history.

Application of Negative Pressure Manual Dressing Change Combined with Mupirocin Ointment in the Treatment of a Case of a Patient with Cirrhosis Complicated with Deep Thigh Abscess

Objective: To explore the treatment and nursing characteristics for pressure injury on the inside of the thigh caused by forced posture in patients with cirrhosis and diabetes mellitus. Methods: A patient with cirrhosis and diabetes mellitus complicated with abscess of right inner thigh pressure injury was selected as the study object, who was admitted to Xuzhou Medical University Hospital on June 29, 2019. The analysis of the clinical diagnosis, treatment and nursing process were applied to explore the prognosis of the patient with cirrhosis and diabetes mellitus complicated with deep abscess of the thigh. Results: The traditional treatment including incision and drainage was not allowed, as the general treatment was not effective for the patients with cirrhosis and diabetes mellitus complicated with deep abscess in the inner thigh. After 8 days of negative pressure manual dressing change combined with mupirocin ointment treatment, the local skin condition returned to normal. Conclusion: After literature search, it was found that the above-mentioned cirrhosis combined with diabetes and deep abscess cases in the inner thigh were rare clinically. When the traditional treatment of incision and drainage is limited, negative pressure manual dressing change combined with antibiotics is an effective method, which is worthy of clinical application and promotion.