Working Diagnosis:
Paraspinal Muscle Abscess

Treatment:
The patient was admitted to the hospital and initially started on broad spectrum intravenous antibiotics consisting of Vancomycin, piperacillin-tazobactam, and levofloxacin. She underwent CT-guided percutaneous drainage of her left flank abscess with pigtail catheter placement and also had a thoracostomy tube placed for drainage of a suspected pleural empyema.

Outcome:
Antibiotics were deescalated to Vancomycin after abscess and pleural fluid cultures became positive for MRSA after two days. The pigtail catheter and thoracostomy tube were eventually removed. The patient’s hospital course was complicated by development of an additional pleural empyema. She subsequently underwent thoracotomy and total decortication of the left lung. When thoracotomy tubes were removed, the patient developed a small left sided pneumothorax which spontaneously resolved. The patient was discharged on hospital day 15 in stable condition on pain medications, iron supplementation, and seven additional days of trimethoprim/sulfamethoxazole. Upon hospital discharge, the patient had a minor gait disturbance and deconditioning.

The patient followed up with cardiothoracic surgery and her primary care physician two weeks after hospital discharge. The incisions overlying the thoracostomy and abscess sites were essentially healed. She subsequently underwent gait, locomotion, and balance training with physical therapy three times weekly as well as aerobic capacity and endurance training. She was initially restricted to lifting no more than five pounds for six weeks. The patient’s pain, gait disturbance, and deconditioning eventually resolved and she returned to her normal baseline activity.

Editor's Comments:
This patient appears to have suffered a series of unfortunate events. Her case highlights the possibility of hematogenous spread of infection - this patient had a buttock abcess prior to development of her lung and paraspinal abcess.

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