Iliopsoas Muscle Tear That Led To A Colectomy. - Page #4

Working Diagnosis:
Iliopsoas muscle tear with hematoma, Sartorius strain, and Rectus strain.

Patient was given crutches and allowed to weight-bear as tolerated based on pain. She was instructed to take anti-inflammatories, apply ice, and to refrain from ballistic activities for 1 month.

After 1 month of conservative treatment she felt almost completely better. Her exam showed logroll of the hip and firing of the rectus and iliopsoas musculature caused no significant pain. Hip flexion was about 10° off with moderate weakness of her core. She begin physical therapy for range of motion strength and core control. She completed her therapy without any problems and returned to running without any difficulties.

3 months later she presented with the same left hip/thigh pain without any inciting incident. Plain radiographs showed the development of a 28 cm gas collection from the lesser trochanter to above the pelvis. Stat labs showed elevation of WBC count of 15,440, neutrophil percentage of 76.2%, absolute neutrophil of 11,750, absolute monocytes of 900, CRP of 14.5, a high normal ESR of 27, and negative blood cultures. CT scan of the abdomen and pelvis without contrast showed a nonobstructive bowel gas pattern with a small strand of inflammatory change that extended from the sigmoid colon to the psoas which could represent a fistulous tract. She was admitted to the hospital, placed on intravenous Zosyn, and underwent incision and drainage of the fluid and for relief of the gas pattern. Cultures grew out E. coli and she was placed on long term antibiotics. Repeat CT scan showed resolution of the gas pattern and fluid collection. She recovered without any difficulties.

6 months later she experienced similar symptoms. CT scan showed recurrence of the gas pattern and fluid along her left psoas muscle tracking down into her groin. A colonoscopy showed a 3 cm erythematous mucosa segment in the sigmoid colon without any pus which was suspicious as being the reason that she had a colopsoas abscess that required drainage. She then underwent a sigmoid colectomy and primary anastomosis.

She is currently walking and working on CORE strengthening. Recommend a gradual return to running.

Editor's Comments:
This case illustrates a good example of a non-musculoskeletal cause of hip pain. With recurrence of pain without injury, the clinician here wisely pursued investigation of an intra-abdominal cause to this patient's pain. As well, with unusual abscesses, identification of the primary cause is necessary to fully treat the infection.

López VN, Ramos JM, Meseguer V. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine. 2009 Mar;88(2):120-130.
Dietrich A, Vaccarezza H, Vaccaro CA. Iliopsoas abscess: presentation, management, and outcomes. Surg Laparosc Endosc Percutan Tech. 2013 Feb;23(1):45-8.
Kryvonos V, Rodrigues C, Jácome J, Terrahe I, Mendonça P, Loureiro C. Primary psoas abscess, an unusual clinical presentation. European Journal of Internal Medicine. 2013 Oct 1;24:e215-e216 (suppl 1).
Shields D, Robinson P, Crowley TP. Iliopsoas abscess – a review and update on the literature. International Journal of Surgery. 2012 Jan 1;10(9):466-469.

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