Psoas abscess by Candida spp. in an immunocompetent patient

Valero Soriano, María; González Valverde, Francisco Miguel; Albarracín Marín-Blázquez, Antonio

doi:10.1016/j.medcle.2021.08.001

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However, its incidence is increasing due to the availability of imaging techniques and predisposing factors such as population aging, diabetes, immunosuppression, or the use of parenteral drugs. Its etiology is bacterial in most cases, with a fungal origin being exceptional and characterized by more larvate manifestations and a more complex treatment.We hereby present the case of a 43-year-old woman with a surgical history of a tubal ligation in 2012 and an appendectomy in 2016 (pathological diagnosis of chronic, non-specific serositis and culture with isolates of Peptostreptococcus sp.), but no other relevant medical history, who consulted us for a 15-day episode of lumbar pain radiating toward her groin and hip, associated with a maximum fever spike of 39 °C and diarrhea without pathological products on the last day. During a previous visit to the Emergency Department, her condition was diagnosed as mechanical lumbar pain and, subsequently, as a urinary tract infection (UTI). Because of this, she was treated with antibiotics and anti-inflammatories, despite which she achieved no improvement.Physical examination revealed pain and abdominal defense in her right hemiabdomen and a mass in her lumbar region. Blood and urine cultures were negative for isolates. A blood test revealed a leukocyte count of 19.3 × 103/μl (78.20% neutrophils) and a platelet count of 550.0 × 103/μl. An abdominal ultrasound and computed tomography (CT) scan showed a multilocular collection in the right retroperitoneal space affecting the iliopsoas muscle and extending toward the posterolateral abdominal wall, measuring 14 × 10 × 8 cm (craniocaudal × anteroposterior × transversal), and with peripheral contrast enhancement and some air bubbles within it, thus being suggestive of an abscess without a clear origin. Adequate passage of the oral contrast medium toward the colon was achieved, without contrast leaks up to the area of the collection.After establishing the diagnosis of a psoas abscess, a surgical intervention was carried out to dissect the mass through a right lumbar incision, observing purulent material within it (culture positive for Candida spp.), owing to which the cavity was drained, debrided, and flushed. During a second stage of the procedure, the patient’s abdominal cavity was examined, detecting signs of inflammation in the ileocecal junction, which otherwise had a normal appearance, without signs of an inflammatory bowel disease or neoplasms (biopsy findings compatible with fibroadipose tissue containing granulation tissue with signs of acute and chronic inflammation). No appendicular stump or communication with the gastrointestinal tract was observed. Examination of the remaining abdominal cavity, including the bowel loops, stomach, colon, and liver, revealed no lesions.The diagnostic studies were subsequently expanded with a serology test (negative for the hepatitis C virus [HCV], the hepatitis B virus [HBV], and the human immunodeficiency virus [HIV]), a Mantoux test (negative), and a follow-up abdominal CT scan that revealed a small, persistent, 1.3 × 2 cm collection located adjacent to the psoas muscle and the right quadratus lumborum muscle. An electrocardiogram and both transthoracic and transesophageal echocardiograms revealed normal findings. A colonoscopy and other ancillary tests also yielded normal results. The patient was discharged after three weeks of treatment with fluconazole (400 mg/24 h) and is currently asymptomatic. We have been unable to identify the cause of the infectious conditions affecting the adjacent organs that would justify her symptoms.Psoas abscess is categorized into primary, of hematogenous or lymphatic etiology and usually caused by Staphylococcus aureus, and secondary, caused by intraabdominal infectious-inflammatory processes that may be of digestive (inflammatory bowel disease, diverticulitis, or neoplasm), vertebral, or genitourinary etiology, most frequently due to Escherichia coli.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> However, a significant percentage of cases are caused by polymicrobial infections, especially those of gastrointestinal etiology. A psoas abscess can occasionally also be the primary manifestation of Crohn’s disease.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Only a few cases of primary psoas abscess caused by Candida sp. have been described in the literature, with Candida sp. being detected in up to 12% of intraabdominal infections.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The most common clinical manifestations are lumbar, flank, inguinal, or leg pain, usually insidious, whereas the classic triad of fever and both abdominal and lumbar pain is present in only 30% of cases.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Imaging studies are crucial to reach the diagnosis, with an abdominopelvic CT scan being the standard test of choice, although the definitive diagnosis is reached through the culture of the abscess drainage fluid or, occasionally, a blood culture.Treatment of this ailment is based on antibiotic therapy and surgical or imaging-guided percutaneous drainage.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In case of a positive culture for Candida sp., antifungal treatment should be continued up to 15 days after a first negative culture, and subsequent follow-up imaging tests should be performed.Primary psoas abscesses caused by Candida sp. in immunocompetent individuals are truly exceptional. Based on the consulted literature, most of these abscesses are secondary to intraabdominal processes and of bacterial etiology, whereas those of fungal etiology tend to appear in people with the aforementioned predisposing factors. Therefore, although Candida sp. is not a frequent etiology of psoas abscess, we believe that it should be considered.FundingThis study has not received any funding.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Valero Soriano M, González Valverde FM, Albarracín Marín-Blázquez A. Absceso de psoas por Candida spp. en un paciente inmunocompetente. Med Clin (Barc). 2021;157:259–260." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnóstico microbiológico de las infecciones intraabdominales" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.E. García Sánchez" 1 => "M.I. García García" 2 => "F. García Garrote" 3 => "I. Sánchez Romero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2012.01.023" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin." "fecha" => "2013" "volumen" => "31" "paginaInicial" => "230" "paginaFinal" => "239" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22409953" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Iliopsoas abscess—a review and update on the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Shields" 1 => "P. Robinson" 2 => "T.P. Crowley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijsu.2012.08.016" "Revista" => array:6 [ "tituloSerie" => "Int J Surg." "fecha" => "2012" "volumen" => "10" "paginaInicial" => "466" "paginaFinal" => "469" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22960467" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of psoas abscess caused by Candida albicans" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Fukuhara" 1 => "K. Nishimura" 2 => "K. Yoshimura" 3 => "A Okuyama" 4 => "M Yamato" 5 => "D Kawamori" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Hinyokika Kiyo." "fecha" => "2003" "volumen" => "49" "paginaInicial" => "141" "paginaFinal" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12728526" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retrospective review of clinical presentations, microbiology, and outcomes of patients with psoas abscess" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O.F. Wong" 1 => "P.L. Ho" 2 => "S.K. Lam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.12809/hkmj133793" "Revista" => array:6 [ "tituloSerie" => "Hong Kong Med J." 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"fecha" => "2006" "volumen" => "24" "paginaInicial" => "313" "paginaFinal" => "318" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16762257" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000005/v1_202109171210/S2387020621003971/v1_202109171210/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000005/v1_202109171210/S2387020621003971/v1_202109171210/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621003971?idApp=UINPBA00004N"]

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Vol. 157. Issue 5.

Pages 259-260 (September 2021)

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