Scand J Urol Nephrol26: 305-306, 1992
SEPTIC ARTHRITIS OF THE HIP COMPLICATING SALMONELLA PSOAS ABSCESS Case Report Samson Liu, Hing Leung, Chris Kadow and Jack M. Obrien From the Department of Urology, East Birmingham Hospital, Birmingham, England
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Auckland on 10/29/14 For personal use only.
(Submitted June 4, 1991. Accepted for publication June 26, 1991)
Key words: psoas abscess, salmonella, septic arthritis.
CASE REPORT A 50 years old male Caucasian was admitted to hospital with a one week history of fever, rigors and left flank pain. Previously, he had radiotherapy followed by total cystectomy and uretero-sigmoidostomy as urinary diversion for a poorly differentiated transitional cell carcinoma of the bladder. He has regular follow-up for 10 years and remained well until this admission. He was pyrexial37.8"C on admission, with a tachycardia of I30 per minute, clinically dehydrated and was tender in the left loin. A provisional diagnosis of acute pyelonephritis was made. Subsequent investigations showed a raised leucocyte count, normal serum electrolytes and multiple sterile urine and blood cultures. Plain X ray and ultrasound scan of the abdomen demonstrated a large fluid collection posterior to the left kidney. He was treated with intravenous fluid and parenteral antibiotics. The retroperitoneal collection was drained percutaneously under ultrasound guidance and a drainage tube was left in situ. The pus drained was sent for culture and sensitivity. In order to determine the origin of the sepsis, other radiological investigations including sinogram, IVU and barium enema were performed but these showed no communication between the abscess cavity and the urinary tract nor the large bowel. Culture of the pus revealed Salmonella newport infection, while other cultures were negative. Guided by the sensitivity result and the advice by the infectious disease physicians, parenteral chloramphenicol treatment was commenced. Over the next two weeks, his condition showed no real improvement and the drainage from the loin persisted. In order to improve drainage, the drainage track was dilated under local anaesthetic and a wide bore tube inserted. Repeat sinogram showed tracking of contrast medium along the psoas fascia from the left flank to the left hip area (Fig. 1). This was confirmed by a gallium scan (Fig. 2) which showed increased uptake over the same area, while the thoracolumbar
spine appeared normal. Three weeks after his initial percutaneous drainage, his condition deteriorated with acute left hip pain and painful weight bearing, indicating septic arthritis of the hip complicating or causing the initial psoas abscess. The left hip was explored by the orthopaedic surgeons. At operation, the femoral head and neck were necrotic within a pus filled joint cavity. Girdlestone arthroplasty was performed with excision of the necrotic bones and drainage of the septic hip. He made a good post-operative recovery and the drainage from both his loin and hip wounds improved markedly. He was discharged home after a prolonged course of antibiotic over a few weeks and was able to partially support himself on crutches. His subsequent home convalescence, physiotherapy and general rehabilitation and orthopaedic follow-up were uneventful.
DISCUSSION Salmonella infection is generally recognized to affect primarily the gastrointestinal tract, but infection at other sites may occur (2). The common strains isolated in extra-intestinal infection are S. typhimurium, S. choleraesuis, S. paratyphi and S. newport (6). The non-gastrointestinal infection is said to be more common in the elderly, in immunosuppressed patients and in sickle cell positive individuals (4, 5 ) , and is unusual in a 50 year old man who is well otherwise as in our case patient. The source of the infection was thought to be blood borne from a subclinical salmonella gastroenteritis, and not related to the previous history of bladder cancer which had been well controlled for over 10 years. However, in view of his uretero-sigmoidostomy (which provides a communication between the gastrointestinal and the urinary tract) and the well recognized complication of periScand J Urol Nephrol26
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Auckland on 10/29/14 For personal use only.
306
S. Liu et al.
3 i - 2 W 8 6 AG-53 5 x 4 13-20ji72 Fig. 2. Gallium scan showing increase uptake over the left retro-peritoneal area down to left sacroiliac and hip region. Fig. I. Sinogram (lateral view) showing the retroperitoneal abscess cavity extending from left renal area down to sacroiliac level.
nephric or psoas abscess from urinary tract infection, we extensively investigated both the urinary and the gastrointestinal tract for the source of infection. Once the infection has entered the psoas sheath, it may spread along its entire length and the classical ‘cold abscess’ of tuberculosis is an example which tracts underneath the inguinal ligament into the thigh (1). Rarely, the infection may penetrate into the hip joint through the psoas muscle and sheath causing septic arthritis. Pyogenic psoas abscess with involvement of the hip joint is not a recognized complication of salmonella infection. Despite appropriate parenteral antibiotic and adequate percutaneous drainage of his abscess (3), the patient did not improve and progressed to develop acute septic arthritis of his hip which resulted in the subsequent Girdlestone arthroplasty. On retrospect, it seemed possible that he might have silent primary septic arthritis of his hip leading to the secondary development of
Scand J Urol NiJphrol-76
retro-peritoneal sepsis initially, but the clinical course of his illness seemed to favour the opposite; that is, the hip infection developed secondary to the retroperitoneal sepsis. Furthermore, whether an interventional open exploration and drainage of his abscess would have prevented his hip sepsis or not, remains controversial. REFERENCES 1. Aird I. Kidney and ureter. In: Aird I , ed. A com-
2. 3. 4.
5.
6.
panion in surgical studies. Edinburgh and London: E & S Livingstone Ltd.. 1957: 1072-1 138. Cohen JI, Barlett JA, Corey GR. Extra-intestinal manifestations of salmonella infections. In: Medicine (Baltimore) 1987; 66: 349-388. Kaneti J, Hertzanu Y. Renal abscess owing to salmonella septicaemia: percutaneous drainage. J Urol 1987; 138: 395-396. Thuluvath PJ, McKendrick MW. Salmonella and complication relating to age-Sheffield experience. Q J Med 1988; 67: 487-496. Van der Laar MA, Meenhorst PL, Van Soesergen RM. Polyarticular salmonella bacterial arthritis in a patient with systemic lupus erythematosus. J Rheumatol 1989; 16: 23 1-234. Wilkins EG, Roberts C. Extraintestinal salmonellosis. Epidemiol Infect 1988: 100: 361-368.
SEPTIC ARTHRITIS OF THE HIP COMPLICATING SALMONELLA PSOAS ABSCESS Case Report Samson Liu, Hing Leung, Chris Kadow and Jack M. Obrien From the Department of Urology, East Birmingham Hospital, Birmingham, England
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Auckland on 10/29/14 For personal use only.
(Submitted June 4, 1991. Accepted for publication June 26, 1991)
Key words: psoas abscess, salmonella, septic arthritis.
CASE REPORT A 50 years old male Caucasian was admitted to hospital with a one week history of fever, rigors and left flank pain. Previously, he had radiotherapy followed by total cystectomy and uretero-sigmoidostomy as urinary diversion for a poorly differentiated transitional cell carcinoma of the bladder. He has regular follow-up for 10 years and remained well until this admission. He was pyrexial37.8"C on admission, with a tachycardia of I30 per minute, clinically dehydrated and was tender in the left loin. A provisional diagnosis of acute pyelonephritis was made. Subsequent investigations showed a raised leucocyte count, normal serum electrolytes and multiple sterile urine and blood cultures. Plain X ray and ultrasound scan of the abdomen demonstrated a large fluid collection posterior to the left kidney. He was treated with intravenous fluid and parenteral antibiotics. The retroperitoneal collection was drained percutaneously under ultrasound guidance and a drainage tube was left in situ. The pus drained was sent for culture and sensitivity. In order to determine the origin of the sepsis, other radiological investigations including sinogram, IVU and barium enema were performed but these showed no communication between the abscess cavity and the urinary tract nor the large bowel. Culture of the pus revealed Salmonella newport infection, while other cultures were negative. Guided by the sensitivity result and the advice by the infectious disease physicians, parenteral chloramphenicol treatment was commenced. Over the next two weeks, his condition showed no real improvement and the drainage from the loin persisted. In order to improve drainage, the drainage track was dilated under local anaesthetic and a wide bore tube inserted. Repeat sinogram showed tracking of contrast medium along the psoas fascia from the left flank to the left hip area (Fig. 1). This was confirmed by a gallium scan (Fig. 2) which showed increased uptake over the same area, while the thoracolumbar
spine appeared normal. Three weeks after his initial percutaneous drainage, his condition deteriorated with acute left hip pain and painful weight bearing, indicating septic arthritis of the hip complicating or causing the initial psoas abscess. The left hip was explored by the orthopaedic surgeons. At operation, the femoral head and neck were necrotic within a pus filled joint cavity. Girdlestone arthroplasty was performed with excision of the necrotic bones and drainage of the septic hip. He made a good post-operative recovery and the drainage from both his loin and hip wounds improved markedly. He was discharged home after a prolonged course of antibiotic over a few weeks and was able to partially support himself on crutches. His subsequent home convalescence, physiotherapy and general rehabilitation and orthopaedic follow-up were uneventful.
DISCUSSION Salmonella infection is generally recognized to affect primarily the gastrointestinal tract, but infection at other sites may occur (2). The common strains isolated in extra-intestinal infection are S. typhimurium, S. choleraesuis, S. paratyphi and S. newport (6). The non-gastrointestinal infection is said to be more common in the elderly, in immunosuppressed patients and in sickle cell positive individuals (4, 5 ) , and is unusual in a 50 year old man who is well otherwise as in our case patient. The source of the infection was thought to be blood borne from a subclinical salmonella gastroenteritis, and not related to the previous history of bladder cancer which had been well controlled for over 10 years. However, in view of his uretero-sigmoidostomy (which provides a communication between the gastrointestinal and the urinary tract) and the well recognized complication of periScand J Urol Nephrol26
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Auckland on 10/29/14 For personal use only.
306
S. Liu et al.
3 i - 2 W 8 6 AG-53 5 x 4 13-20ji72 Fig. 2. Gallium scan showing increase uptake over the left retro-peritoneal area down to left sacroiliac and hip region. Fig. I. Sinogram (lateral view) showing the retroperitoneal abscess cavity extending from left renal area down to sacroiliac level.
nephric or psoas abscess from urinary tract infection, we extensively investigated both the urinary and the gastrointestinal tract for the source of infection. Once the infection has entered the psoas sheath, it may spread along its entire length and the classical ‘cold abscess’ of tuberculosis is an example which tracts underneath the inguinal ligament into the thigh (1). Rarely, the infection may penetrate into the hip joint through the psoas muscle and sheath causing septic arthritis. Pyogenic psoas abscess with involvement of the hip joint is not a recognized complication of salmonella infection. Despite appropriate parenteral antibiotic and adequate percutaneous drainage of his abscess (3), the patient did not improve and progressed to develop acute septic arthritis of his hip which resulted in the subsequent Girdlestone arthroplasty. On retrospect, it seemed possible that he might have silent primary septic arthritis of his hip leading to the secondary development of
Scand J Urol NiJphrol-76
retro-peritoneal sepsis initially, but the clinical course of his illness seemed to favour the opposite; that is, the hip infection developed secondary to the retroperitoneal sepsis. Furthermore, whether an interventional open exploration and drainage of his abscess would have prevented his hip sepsis or not, remains controversial. REFERENCES 1. Aird I. Kidney and ureter. In: Aird I , ed. A com-
2. 3. 4.
5.
6.
panion in surgical studies. Edinburgh and London: E & S Livingstone Ltd.. 1957: 1072-1 138. Cohen JI, Barlett JA, Corey GR. Extra-intestinal manifestations of salmonella infections. In: Medicine (Baltimore) 1987; 66: 349-388. Kaneti J, Hertzanu Y. Renal abscess owing to salmonella septicaemia: percutaneous drainage. J Urol 1987; 138: 395-396. Thuluvath PJ, McKendrick MW. Salmonella and complication relating to age-Sheffield experience. Q J Med 1988; 67: 487-496. Van der Laar MA, Meenhorst PL, Van Soesergen RM. Polyarticular salmonella bacterial arthritis in a patient with systemic lupus erythematosus. J Rheumatol 1989; 16: 23 1-234. Wilkins EG, Roberts C. Extraintestinal salmonellosis. Epidemiol Infect 1988: 100: 361-368.
