The Case
A 63-year-old man arrives leaning forward, one hand pressed into his left flank and the other gripping a cane. For two weeks he has had night sweats, fatigue, and a deep ache that runs from his back toward the groin; today he can barely climb the three steps to his apartment. His abdomen is soft, but extending the left hip makes him wince. The source remains hidden somewhere behind the abdominal organs, and the next scan has not yet been ordered.
Before You Read
- What constellation should make a psoas process enter the differential despite a benign abdomen?
- Which imaging test confirms the diagnosis and identifies a drainable collection?
- How should antibiotics and drainage be coordinated?
Why It Matters
Psoas abscess is often indolent and diagnosed late, after bacteremia, sepsis, hip destruction, or spinal infection has developed. The physical examination may be subtle, so the diagnosis depends on pattern recognition and timely imaging.
When to Think of It
Fever or unexplained inflammatory illness plus flank, back, hip, groin, or thigh pain; limp, pain with hip extension, abdominal pain, weight loss, or inability to ambulate. Risk rises with diabetes, IV drug use, immunosuppression, recent bacteremia, spinal infection, urinary infection, GI disease, or recent instrumentation.
Sick or Not Sick
The critical call is stable localized infection versus sepsis, neurologic compromise, or rapidly progressive deep infection. Hypotension, altered mentation, rising lactate, neurologic deficits, or severe pain require immediate resuscitation, broad antibiotics, and urgent source-control consultation.
The First Fifteen Minutes
- Establish IV access, obtain CBC, CMP, lactate, urinalysis, blood cultures ×2, and inflammatory markers; perform neurologic and hip examination. If hypotensive or hypoperfused, give balanced crystalloid 30 mL/kg IV, because it restores circulating volume.
- Once cultures are obtained—or immediately if unstable—give vancomycin 15–20 mg/kg IV over 1–2 hours plus ceftriaxone 2 g IV; this covers MRSA and common streptococci/gram-negative organisms. Dose and interval for vancomycin require renal/pharmacy guidance.
- If GI, pelvic, urinary instrumentation, or polymicrobial infection is plausible, use piperacillin-tazobactam 4.5 g IV over 30 minutes every 6 hours instead of ceftriaxone, because it adds anaerobic and broader gram-negative coverage. Adjust for renal function and check local protocol.
- If persistent MAP <65 mm Hg after fluids, start norepinephrine 0.05–0.1 mcg/kg/min IV infusion, titrating to MAP ≥65, because alpha-adrenergic vasoconstriction restores perfusion; central access is preferred, but carefully monitored peripheral initiation should not be delayed.
- For severe pain, give fentanyl 25–50 mcg IV every 5 minutes as needed, titrated cautiously, because analgesia reduces suffering without requiring large hemodynamically destabilizing doses.
Definitive Care & Disposition
Obtain contrast-enhanced CT abdomen/pelvis, which usually identifies the collection, extent, and adjacent source; MRI is preferred when spinal epidural infection or vertebral osteomyelitis is suspected. Arrange image-guided percutaneous drainage with cultures; surgical drainage is needed for multiloculated, inaccessible, recurrent, or source-related disease. Treat for approximately 2–6 weeks, tailored to cultures and source control; duration varies and should be guided by infectious disease. Admit all confirmed cases; ICU care is appropriate for shock, organ dysfunction, or neurologic compromise.
How This One Kills
The lethal miss is treating “back strain” or “
pyelonephritis” without imaging, allowing an enlarging abscess to seed the bloodstream or extend into the spine, hip, or retroperitoneum.
The Atypical Presentation
Older or immunocompromised patients may have no fever, focal abdominal tenderness, or leukocytosis. They may present with weeks of weakness, falls, anorexia, or new difficulty walking. Persistent unilateral hip or back pain plus elevated inflammatory markers, bacteremia, or unexplained sepsis should trigger CT even when the abdomen is benign.
Back to Our Patient
The 63-year-old man has a classic indolent deep-infection pattern: constitutional symptoms, flank-to-groin pain, limp, and pain with hip extension, without peritoneal findings. He is initially stable, so blood cultures and laboratory studies are obtained, contrast CT reveals a left psoas collection, and he receives prompt vancomycin plus ceftriaxone while interventional radiology is contacted. He is admitted for image-guided drainage and culture-directed prolonged antibiotics; any hypotension, lactate elevation, or neurologic deficit would escalate him to immediate sepsis resuscitation and ICU-level care.
Patient Presentation to Attending
“This is a 63-year-old man with two weeks of night sweats, fatigue, and progressive left flank and groin pain, now associated with a limp and inability to climb stairs. He has diabetes but no recent trauma; he denies dysuria, hematuria, bowel symptoms, or radicular weakness. He is febrile, tachycardic, and normotensive, with a soft abdomen, left flank discomfort, and pain when the left hip is extended, but no focal neurologic deficit. Labs show leukocytosis, elevated CRP, and lactate of 2.1; blood cultures are pending. I am concerned for a psoas abscess, possibly from hematogenous or urinary spread, and plan contrast CT abdomen/pelvis, prompt vancomycin plus ceftriaxone after cultures, and early drainage consultation.”
Study Directive
- Sketch the psoas compartment and list hematogenous, gastrointestinal, urinary, and spinal sources.
- Review a CT example and identify the psoas muscle, abscess, spine, kidney, and hip.
- Memorize your institution’s sepsis antibiotic pathways and vancomycin dosing workflow.
- Practice a one-minute presentation that explicitly requests source-control consultation.