Spontaneous psoas abscess: presenting with phlegmasia cerulea dolens

Abstract

Figure 1 Coronal multiplanar reconstructed CT: thrombosed left external iliac vein (short arrow) and left psoas collection (long arrow)Phlegmasia cerulea dolens (PCD) is a severe form of proximal venous thrombosis that often threatens viability of the lower extremity. We report a case of PCD as a complication of spontaneous psoas abscess in a diabetic patient. The underlying processes described in the literature include malignancy, protein C deficiency, antithrombin III deficiency and thrombocytopenia.1,2 Venous congestion with massive fluid sequestration can lead to circulatory collapse and shock. Early investigations with Doppler ultrasound and computed tomography (CT) have been advocated in the literature.3 Treatments used include thrombectomy, thrombolysis and anticoagulation with heparin. A combination of different treatment modalities is often employed for a successful outcome.Spontaneous psoas abscess is a rare condition and predisposing conditions include intravenous drug use, diabetes mellitus and bleeding diatheses such as haemophilia A.4 CT with contrast enhancement is the most useful diagnostic imaging modality. Percutaneous drainage under CT or ultrasound guidance is the preferred initial therapeutic approach, followed by surgery. 5 Case historyA 45-year-old man with type 2 diabetes presented with a 7-day history of increasing left groin pain associated with swelling and purple discolouration of the left lower extremity. The patient was admitted under a physician with a working diagnosis of deep vein thrombosis of the left leg and treated with a heparin infusion. A Doppler ultrasound scan confirmed iliac vein thrombosis. The patient was in septic shock with tachycardia and hypotension. Inflammatory markers were raised with C-reactive protein levels at 423 and a white cell count of 34,000. Chest radiograph and urine analysis, performed as part of a septic screen, were negative. The patient was initially treated with aggressive fluid resuscitation, anticoagulation and empirical antibiotics. A CT scan of the abdomen revealed left external iliac vein thrombosis and left psoas swelling but no obvious collection (Fig 1). Phlegmasia cerulea dolens (PCD) is a limb-threatening venous disorder involving massive proximal venous thrombosis. The clinical manifestations are of oedema, cyanosis and pain of lower extremity. Patients presenting with PCD have an underlying pathological condition that predisposes to the thrombotic process. We report a diabetic patient who presented with PCD and septicaemia due to a spontaneous psoas abscess. Anticoagulation with heparin and treatment of the underlying psoas abscess led to complete resolution of symptoms. An understanding of the underlying pathological process responsible is vital to early recognition and successful outcome in this rare limb-and life-threatening venous disorder.

Clinical case report: discitis osteomyelitis complicated by inferior vena cava venous thrombosis and septic pulmonary emboli

“…Few cases of psoas abscess resulting in iliofemoral venous thrombosis have been reported [4], [5], [6], [7], [8]. We report a rare case of paraspinal abscess causing IVC thrombus, and the first as a result of viridans infection.…”

“…Psoas and paravertebral abscesses, as a complication of osteomyelitis, are frequently associated with Pott’s disease; however, pyogenic vertebral osteomyelitis can also result in formation of these abscesses [3]. Such intra-abdominal collections can in rare occasions cause compression of adjacent venous structures and result in deep vein thrombosis [4], [5], [6], [7], [8].…”

Rare etiological causes of iliofemoral deep venous thrombosis: Reports of 2 cases

“… 7 Another psoas abscess in a patient with signs of Phlegmasia Cerulea Dolens also underwent percutaneous drainage. 8 …”

Rare Etiological Causes of Iliofemoral Deep Venous Thrombosis: Reports of 2 Cases

“…7 Another psoas abscess in a patient with signs of Phlegmasia Cerulea Dolens also underwent percutaneous drainage. 8 The primary factors causing DVT in malignancy patients are mass effect, paraneoplastic effects, and chemotherapy. Upper extremity DVT only comprises 2% of all DVT patients.…”