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Pyogenic psoas abscess: Worldwide variations in etiology

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Abstract

Pyogenic abscess of the psoas muscle results from primary suppuration or direct extension of intraabdominal infection. The etiology varies with the country of origin. Our experience with 9 cases prompted a review of 367 cases from the world literature. A total of 286 primary abscesses occurred mainly in developing nations (200 cases), although 74 were reported from the United States. Younger patients predominated in developing nations (81.4% <20 years old), while only 47.8% from the United States were younger than 20 years. PureStaphylococcus aureus was commonly cultured (88.4%); simple incision and drainage cured 97.3% of patients with primary psoas abscess. Of 7 (2.5%) patients who died, 6 were from the United States; therapy was inadequate or delayed in all 7 patients. Ninety secondary abscesses appeared almost exclusively in reports from Europe, the United States, and Canada. Crohn's disease was the most common etiology followed by appendicitis and colon inflammation or cancer; mixed enteric infections predominated (55.7%). Although rare during the first decade, distribution was otherwise relatively even across all age groups. Simple drainage succeeded in only 49% of cases. Higher mortality accompanied secondary abscess (17 cases, 18.9%). The etiology of pyogenic psoas abscess guides the selection of proper medical and surgical therapy. While primary abscess is the likely etiology in developing nations and secondary abscess in Europe, either may occur in the United States. Early diagnosis and proper therapy are necessary to reduce mortality.

Résumé

L'abcès purulent du muscle psoas résulte d'une suppuration primitive ou de l'extension directe d'une infection intra-abdominale. Son étiologie varie avec le pays d'origine du patient. A partir de leur expérience sur 9 cas, les auteurs procèdent à une revue de 367 cas décrits dans la littérature mondiale. Un total de 286 abcès primaires est observé principalement dans les pays en voie de développement (200 cas), alors que 74 cas sont rapportés des Etats-Unis. Les patients jeunes prédominent dans les pays en voie de développement (81.4% ont moins de 20 ans), alors que dans seulement 47.8% des cas observés aux Etats-Unis, les sujets ont moins de 20 ans. Le staphylocoque seul est couramment mis en évidence lors des cultures (88.4%). Dans 97.3% des cas d'abcès primitif du psoas, une incision simple avec drainage permet la guérison. Parmi les 7 patients décédés (2.5%), 6 d'entres eux étaient originaires des EtatsUnis; la thérapeutique étant soit inadaptée soit retardée chez ces 7 patients. Quatre-vingt-dix abcès secondaires sont observés pratiquement exclusivement dans les cas originaires d'Europe, des Etats-Unis et du Canada. La maladie de Crohn est l'étiologie la plus commune suivie par l'appendicite et par l'inflammation ou le cancer coliques; les infections entériques mixtes prédominent (55.7%). Bien que rares durant la première décade, leur distribution était relativement fréquente dans tout les groupes d'age. Un simple drainage permet la guérison dans seulement 49.0% des cas. Les abcès secondaires se sont accompagnés d'une mortalité plus importante (17 cas; 18.9%). L'étiologie de l'abcès purulent du psoas oriente le choix de la thérapeutique chirurgicale et médicale la plus adaptée. Alors que l'abcès primitif a vraisemblablement pour étiologie les nations en voie de développement et l'abcès secondaire l'Europe, l'un comme l'autre peuvent s'observer aux Etats-Unis. Le diagnostic précoce et une thérapeutique adaptée sont nécessaires pour en réduire la mortalité.

Resumen

El absceso piogénico del músculo psoas resulta de supuración primaria o de la extensión directa de una infección intraabdominal. La etiología varía según el país de origen. Nuestra experiencia con 9 casos promovió una revisión de 367 casos emanados de la literatura mundial. La mayoría del total de 286 abscesos primarios se presentó primordialmente en naciones en vía de desarrollo (200 casos), aunque 74 fueron informados en los Estados Unidos. Los pacientes jóvenes predominaron en las naciones en vía de desarrollo (81.4% en menores de 20 años), mientras sólo 47.8% de los pacientes de los Estados Unidos eran menores de 20 años. PuroStaphylococcus aureus fue frecuentemente cultivado (88.4%); el procedimiento de simple incisión y drenaje curó a 97.3% de los pacientes con absceso primario del psoas. De 7 pacientes (2.5%) que murieron, 6 provenian de los Estados Unidos; la terapia apareció inadecuada o tardía en todos los 7 pacientes. Noventa abscesos secundarios se presentaron en forma casi exclusiva en reportes de Europa, los Estados Unidos y Canadá. La enfermedad de Crohn apareció como la etiología más común, seguida de apendicitis e inflamación o cáncer del colon; se observó predominancia de las infecciones entéricas mixtas (55.7%). Aunque rara en las primeras décadas de la vida, la entidad por lo demás aparece igualmente distribuida a través de los diferentes grupos etáreos. El procedimiento quirúrgico de elección es el drenaje de emergencia a través de una incisión extraperitoneal sobre la parte baja del abdomen. El drenaje simple fue exitoso en sólo el 49% de los casos. La aspiración guiada por tomografía computadorizada fue exitosa en un número limitado de pacientes, y puede significar una alternativa, especialmente en el paciente tóxico. Una mayor mortalidad apareció asociada con los casos de absceso secundario (17 casos, 18.9%). La etiología del absceso piogénico del psoas determina la debida selección de la terapia médica y quirúrgica. En tanto que el absceso primario representa la etiologiá más probable en las naciones en vía de desarrollo y el absceso secundario en Europa, ambos tipos pueden ocurrir en los Estados Unidos. Un diagnóstico precoz y una forma adecuada de terapia son factores imprescindibles en la reducción de la mortalidad.

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Ricci, M.A., Rose, F.B. & Meyer, K.K. Pyogenic psoas abscess: Worldwide variations in etiology. World J. Surg. 10, 834–842 (1986). https://doi.org/10.1007/BF01655254

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