Psoas abscess in patients with an infected aortic aneurysm

Article Outline

• Abstract
• Methods
  • Patients
  • Medical treatment
  • Surgical treatment
  • Data collection
  • Statistical analysis
• Results
  • Patients
  • Microbiology
  • Medical treatment
  • Surgical treatment
  • Psoas abscess
• Discussion
  • Infected aneurysm
  • Psoas abscess
  • Limitations
• Conclusions
• Author contributions
• References
• Copyright

Background

Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. Infected aortic aneurysms could be complicated by psoas abscess.

Methods

A retrospective chart review was conducted to examine the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with an infected aortic aneurysm.

Results

Between 1996 and 2007, 40 patients (32 men) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). In 38 patients a blood or tissue culture had a positive result. The most common responsible pathogen was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One patient underwent endovascular repair but died. In-situ graft replacement was done in 32 patients. Persistent or recurrent infection occurred in seven (22%) of 32 operated on patients. The mortality rate was 86%, and the overall aneurysm-related mortality rate of in situ graft replacement was 22% (7/32). In eight (20%) of the 40 patients, aortic infection was complicated by psoas abscess. Infection complicated by psoas abscess was present in seven of 32 operated patients. It was associated with higher incidence of emergency operation, hospital mortality, prosthetic graft infection, and aneurysm-related mortality than infection without abscess.

Conclusion

Psoas abscess was common in patients with infected infrarenal aortic aneurysm. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.

Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. The clinical triad of fever, flank pain, and limited hip movement is present in only 30% of patients.¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹ Psoas abscess can be primary (hematogenous) or secondary to an infection from contiguous sources of bowel, kidney, or spine.¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹ The incidence of psoas abscess is unknown but has probably increased in recent years.² Infected aortic aneurysms can be complicated by psoas abscess.¹⁰ The incidence and clinical significance of psoas abscess in patients with infected aortic aneurysm are unclear, and only sporadic cases have been reported in the English literature.¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷ The purpose of this retrospective study was to examine the incidence, clinical presentations, microbiologic characteristics, and outcome of psoas abscess in patients with infected aortic aneurysm.

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Methods 

This study took place in the National Taiwan University Hospital (Taipei, Taiwan), a 2000-bed tertiary care hospital. It serves an urban population of 2 million people as both first-line and tertiary facilities. It serves also as a referral center for other hospitals in the country (population, 22 million).

Patients 

From February 1996 to February 2007, patients with infrarenal abdominal aortic infection complicated by psoas abscess were diagnosed by reviewing medical records in our institution. The diagnosis of infected aortic aneurysm was made by a combination of clinical evidence of infection and characteristic imaging findings on computed tomography (CT) or magnetic resonance imaging.¹⁸, ¹⁹ The confirmed diagnosis of psoas abscess was made by documentation of abscess in the psoas muscle by surgery or appropriate clinical findings consistent with CT findings of psoas abscess.²⁰, ²¹ The imaging features of psoas abscess included rim enhancement of the abscess wall, inappropriate gas production, soft-tissue mass with central necrosis, and asymmetric ipsilateral enlargement of the psoas muscle.²⁰, ²¹

Medical treatment 

As described previously,¹⁸, ¹⁹ intravenous antibiotic was given once the diagnosis of infected aortic aneurysm was confirmed. For patients with infection caused by Salmonella spp, intravenous ceftriaxone (1000 to 2000 grams every 12 hours) was used. For patients with non-Salmonella infections, the antibiotic used was tailored to culture results and sensitivity test.

In patients with good response to antibiotic treatment (no fever, no localized pain and declining white cell count), surgical intervention was considered after the infection was controlled. The imaging study was repeated if patients had a new symptom or sign suggesting an increase of aortic pseudoaneurysm size (shock, a new localized pain or a new palpable mass) or after complete antibiotic treatment. Early or emergency surgical intervention, which was defined as operation before the infection was controlled, was performed only in the situations of uncontrolled infection (persistent fever or septic shock) or evidences of impending aortic rupture, including persistent pain, shock or enlarging pseudoaneurysm formation on the repeated imaging study.

Surgical treatment 

As described previously,¹⁸, ¹⁹ surgical management consisted of wide débridement of necrotic tissue, copious saline irrigation, and in situ graft replacement using a Dacron graft. Grafts were not soaked in rifampin or another antibiotic before implantation. We did not perform extra-anatomic reconstruction with axillobifemoral bypass in patients with infrarenal infections. Homograft was not used because of unavailability.

Antibiotics were administered intravenously in the hospital for at least 6 to 8 weeks and until the clinical and laboratory indicators of fever, white cell count, and C-reactive protein were normalized. Antibiotic therapy continued orally after discharge, with the duration of at least 6 months by surgeon’s preference.

Data collection 

The medical records of patients with infected aneurysm of the infrarenal abdominal aorta and its major branches were reviewed, and patient data were recorded. These demographics included age and gender; underlying disease, including included diabetes mellitus, chronic liver disease, chronic renal insufficiency, hemodialysis, malignancy, heart disease, intravenous drug abuse, and immunodeficiency; the type of operation; and clinical outcome, including postoperative complication, prosthetic graft infection and death. Chronic renal insufficiency was defined as serum creatinine level ≥2.0 mg/dL. Immunodeficiency was defined as having human immunodeficiency virus infection, steroid therapy, chemotherapy for malignancy and autoimmune diseases, or immunosuppressive therapy for organ transplantation. Medical records and imaging findings were carefully reviewed for the presence of psoas abscess.

Statistical analysis 

Data of patients with psoas muscle abscess who underwent operation were compared with data of patients without abscess by using the χ² test, the Fisher exact test, and the Mann-Whitney test.

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Results 

Patients 

Between 1996 and 2007, 40 patients (32 men, 8 women) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). Major medical comorbidities were present in 32 patients (80%) and included hypertension in 18, diabetes mellitus in 8, coronary artery disease in 6, chronic renal insufficiency in 5, prior or present malignancy in 3, and 1 patient each with end-stage renal disease requiring hemodialysis, liver cirrhosis, human immunodeficiency virus (HIV) infection, and Evan syndrome (autoimmune hemolytic anemia and thrombocytopenia). At presentation, 36 (90%) of the 40 patients were febrile and 36 (90%) had localized back or abdominal pain. Two patients had massive gastrointestinal bleeding and shock because of complicated aortoenteric fistula.

The site of infection was the infrarenal abdominal aorta in 34 patients, the right iliac artery in four, and the left iliac artery in two. Imaging studies showed pseudoaneurysm in 38 patients (95%) with a maximal diameter of 2.2 to 12 cm. Eight (20%) of the 40 patients had psoas abscess: one was on the right side, five were on the left side, and two were bilateral.

Microbiology 

A positive result on blood or tissue culture was found in 38 of the 40 patients. The diagnosis of infected aneurysm in two patients with negative culture results was made solely by clinical and imaging evidence. The most common responsible microorganism was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One of three infections caused by S aureus was methicillin-resistant. As summarized in Table I, Salmonella spp accounted for four (50%) of eight patients with infected aneurysm complicated by psoas abscess.

Table I. Demographics of patients presenting with infected aortic aneurysm and psoas muscle abscess

CAD, Coronary artery disease; ESRD, end-stage renal disease; HIV, human immunodeficiency virus.

Medical treatment 

Seven patients declined operation because of old age or severe medical comorbidities. One patient refused medical treatment and was lost to follow-up after discharge. Of the six patients treated with medical treatment alone, the first three died of aneurysm rupture at 1, 4, and 17 days after the diagnosis of aortic infection. The fourth patient, a 35-year-old man with drug abuse and HIV infection, died of persistent sepsis and aneurysm rupture 6 months after the diagnosis of aortic infection. The last two patients received intravenous antibiotic therapy for 4 weeks and were discharged in stable condition; however, both were lost at outpatient follow-up. Overall, the hospital mortality rate of medical treatment alone was 67% (4/6), and all in-hospital deaths were from aneurysm rupture.

Surgical treatment 

Open surgical procedures were done in 32 patients, and one patient had an endovascular intervention. The median duration of preoperative antibiotic use was 14 days (range, 0 to 48 days). An emergency operation was performed in nine patients (27%) because of septic or hypovolemic shock (n = 5), persistent pain (n = 2), and large (8-cm) pseudoaneurysm (n = 2). An 88-year-old man with a history of hypertension had aortic infection caused by K pneumoniae. He underwent emergency implantation of a Zenith (Cook, Bloomington, Ind) stent graft, followed by the use of intravenous ceftriaxone. However, he died of persistent infection and massive gastrointestinal bleeding 14 days after the procedure.

In situ graft replacement was done in 32 patients. The operations were performed through midline laparotomy or retroperitoneal approach. During the procedure, the infected aorta was widely resected and the remaining noninfected aortic wall was irrigated with copious warm saline. Psoas abscess was débrided and irrigated if it was present. Four of these patients (13%) died in the hospital because of early prosthetic graft infection (n = 3) and intraoperative bleeding (n = 1). There was no perioperative intestinal ischemia, perioperative limb loss, or acute renal failure requiring dialysis.

Two patients with aortoenteric fistula underwent emergency in situ graft replacement because of hypovolemic shock. The first, a 79-year-old woman with infection caused by S choleraesuis, died of intraoperative bleeding. The second, a 60-year-old man with infection caused by E coli, died of persistent abdominal sepsis 22 days after the operation. Two patients with bilateral psoas abscess lesions underwent emergency operations. They died of early prosthetic graft infection at 10 and 37 days after the operation.

The median duration of follow-up was 22 months (range, 2 to 96). Late prosthetic graft infection occurred after discharge in four patients:

The Figure summarizes the treatment and outcome of all patients. In summary, the hospital mortality rate was 67% in patients treated with medical treatment alone, 100% in one patient treated with endografting, and 13% in patients treated with combined medical treatment and in situ graft replacement. Seven (22%) of 32 operated on patients presented with persistent or recurrent infection (3 early; 4 late). The mortality rate of graft infection was 86% (6/7). The overall aneurysm-related mortality rate of combined medical treatment and in situ graft replacement was 22% (7/32). Table II summarizes the seven aneurysm-related mortalities in 32 patients who had operations.

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• Fig 1. 

  Flow chart shows treatment and outcome in patients presenting with infected infrarenal abdominal aortic aneurysm.

Table II. Patient demographics of seven aneurysm-related mortalities

CAD, Coronary artery disease.

Psoas abscess 

Psoas abscess was present in seven of the 32 patients who underwent in situ graft replacement. Data were compared between seven operated on patients with infected aneurysm complicated by psoas abscess and 25 operated on patients without abscess (Table III). Infection complicated by psoas abscess was associated with higher incidence of emergency operation (71% vs 12%, P = .005 by Fisher exact test), hospital mortality (43% vs 4%, P = .025 by Fisher exact test), prosthetic graft infection (57% vs 12%, P = .026 by Fisher exact test) and aneurysm-related mortality (57% vs 12%, P = .026 by Fisher exact test) than infection without abscess.

Table III. Comparison of clinical data of infected aortic aneurysm between operated patients with psoas abscess and patients without abscess

Variables	With abscess, n (%)	Without abscess, n (%)	P
	7	25
Male	6(86)	20(80)	.999
Median age, years(range)	72(59-83)	69(54-85)	.5679
Chronic renal insufficiency	2(29)	3(12)	.296
Liver cirrhosis	0(0)	1(4)	.999
Diabetes mellitus	1(14)	7(28)	.646
Coronary artery disease	2(29)	4(16)	.590
Malignancy	1(14)	2(8)	.536
Salmonella infection	4(57)	21(84)	.157
Site of infection
Infrarenal abdominal aorta	6(86)	22(88)	.999
Iliac artery	1(14)	3(12)
Emergency operation	5(71)	3(12)	.005
Hospital mortality	3(43)	1(4)	.025
Prosthetic graft infection	4(57)	3(12)	.026
Aneurysm-related mortality	4(57)	3(12)	.026

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Discussion 

Infected aneurysm 

Infected aortic aneurysm is common in Taiwan and Hong Kong. Salmonella spp was the most common responsible microorganism. With surgical intervention and prolonged intravenous antibiotic therapy, in situ graft replacement provided a good outcome.¹⁸, ¹⁹, ²² This is an update adding new 21 patients to our 19 previously reported patients.¹⁹ Here, we report the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with infected aortic aneurysm.

Infected aortic aneurysm is a rare but life-threatening condition. In Western countries, the most common responsible microorganisms are S aureus and Streptococcus spp, followed by Salmonella spp.²³, ²⁴, ²⁵ The standard treatment of infected aortic aneurysm is surgery consisting of wide débridement and resection of the infected aorta and the surrounding tissue, followed by arterial reconstruction using in situ graft replacement or extra-anatomic bypass. Surgical repair by in situ graft replacement or extra-anatomic reconstruction is still controversial, however.

Extra-anatomic bypass has the problem of inferior graft patency, limb loss, and the necessity of a future reconstruction. One study reported a high incidence of complications with extra-anatomic bypass, including a 20% stump disruption, a 20% to 29% amputation rate, and a 20% risk of reinfection.²⁶ Recently, more and more studies¹⁸, ¹⁹, ²³, ²⁴, ²⁵, ²⁷ showed that in situ graft replacement was successful if prompt confirmation of infection was obtained, all possibly infected tissue was resected, and antibiotic therapy tailored to sensitivity data was administered for a prolonged period. The reported in-hospital mortality rates of in situ graft replacement were 16% to 44%.²³, ²⁴, ²⁵ The autogenous femoral vein was used in infected aortic aneurysm because of its proven durability and resistance to infection.²⁷

Psoas abscess 

Infected aortic aneurysms can be complicated by blood stream infection, vertebral osteomyelitis, enteric fistula, and rarely, psoas abscess. The association of a psoas abscess and infected aortic aneurysm is extremely rare. The incidence of psoas abscess in patients with infected aortic aneurysm was 4%.²⁸ The total number of previously reported patients with aortic infection complicated by psoas abscess in the English literature was about a dozen.¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷ Salmonella spp were the most common responsible pathogens.¹⁰ The prognosis of infected aneurysm was poor, especially in the case of rupture of the aneurysm. Early abscess drainage and arterial reconstruction before aortic rupture were mandatory.¹⁰

In this study, the overall hospital mortality rate and aneurysm-related mortality rate of in situ graft replacement in patients with infrarenal abdominal aortic infection was similar to that in our previous reports.¹⁷, ¹⁸ The hospital mortality rate in patients with aortic infection complicated by psoas abscess was significantly higher than in patients with infected aneurysm and no abscess. The overall aneurysm-related mortality rate of 43% in our patients with aortic infection complicated by psoas abscess was slightly lower than the mortality rate of 60% in previously reported cases.¹⁰

The presence of psoas abscess was associated with an aggressive clinical behavior because emergency operation was usually required in >70% of our patients with infected aneurysm complicated by psoas abscess, and the incidence of prosthetic graft infection was high after operation. A psoas abscess should be a relative contraindication to in situ graft replacement. Because of high rates of prosthetic graft infection and aneurysm-related mortality associated with in situ graft replacement, extra-anatomic bypass might be considered as a method of choice in those patients with infrarenal abdominal aortic infection complicated by psoas abscess.¹⁰, ¹²

A Gram stain in the operating room might aid the surgeon in decision-making if infected aortic tissue is identified over the aortic stump. However, the prevalence of stump disruption and the risk of reinfection necessitate further investigation.

The feasibility and effectiveness of endovascular stent graft repair of infected aortic aneurysms are still unclear.¹³, ²⁹, ³⁰ Although endovascular repair appears to be a promising therapeutic modality, this technique should be considered on an individual basis in the presence of severe infection. The reported aneurysm-related mortality rate is about 37% because of persistent infection.²⁹, ³⁰ Failure of treatment should be expected in a significant number of cases during follow-up, particularly in patients having signs of severe sepsis and requiring emergency operation. In our group, we added a case of octogenarian who died of persistent graft infection after emergency implantation of a stent graft.

Limitations 

The major limitation of our study is its retrospective nature and the small number of cases. However, to our knowledge, this is the first study, and among the largest series, to assess the incidence and clinical significance of psoas abscess in patients with primary infected aortic aneurysms.

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Conclusions 

Psoas abscess was common in patients with infrarenal infected aortic aneurysm in this study. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.

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Author contributions 

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