Pediatr Surg Int (2000) 16: 408410
ORIGINAL ARTICLE
D. Kadambari S. Jagdish
Primary pyogenic psoas abscess in children
Accepted: 22 July 1999
Abstract Primary pyogenic psoas abscess, although
quite a common condition, particularly in the tropics, is
often overlooked as a clinical entity, probably because a
psoas abscess has been traditionally associated with tu-
berculous spondylitis. The abscess is easily diagnosed by
ultrasonography (US). Treatment by open drainage and
antibiotics eective against Staphylococcus aureus results
in complete reversal of symptoms and signs. In our series
of 55 cases in the pediatric age group (012 years), pain
and exion at the hip were the most frequent clinical
features at presentation. US was diagnostic in all cases in
which it was performed. All except 1 patient showed
complete resolution with extraperitoneal drainage, an-
tibiotics, and skin traction. Although 4% of the cases
were associated with suppurative external-iliac lymph-
adenitis, the remaining ones arose de novo in the psoas
sheath, suggesting a primary pyomyositis of the psoas
muscle.
Key words Psoas abscess Pyogenic pediatric
Introduction
A diagnosis of psoas abscess has been almost synony-
mous with tuberculous spondylitis of the dorsolumbar
spine, where the ``cold'' pus tracks along the psoas
sheath and presents with swelling in the iliac fossa or
groin. Primary pyogenic abscess of the psoas sheath
(PPA) is a denite clinical entity recognised by the
classic clinical sign of exion at the hip due to spasm of
the psoas muscle. The origin of the pus may be
pyomyositis of the underlying psoas muscle or suppu-
rative external-iliac lymphadenitis spreading to the
psoas sheath. Secondary spread from infection of the
D. Kadambari (&) S. Jagdish
Department of Surgery,
Jawaharlal Institute of Postgraduate
Medical Education and Research,
Pondicherry, 605 006, India
Springer-Verlag 2000
genitourinary/gastrointestinal tract may also occur:
secondary PPA. We present the clinical features, mi-
crobiological prole, and management of a series of 55
consecutive cases of primary PPA treated in the pedi-
atric surgery unit of our hospital.
Materials and methods
Between January 1990 and December 1996, 55 children (35 male
and 20 female) in the 012-year age group were treated for psoas
abscess. The diagnosis at admission was psoas abscess in 46, ex-
ternal iliac lymphadenitis in 7, and acute appendicitis and per-
inephric abscess in 1 each. The presenting symptoms and signs in
order of frequency are listed in Tables 1 and 2. Ultrasonography
(US) was used to conrm the diagnosis in 36 cases; X-ray lms of
the dorsolumbar spine were taken in 7. Bone scans were not done in
any case. Needle aspiration was used to conrm the diagnosis in
only 1 case. All patients received systemic antibiotics and skin
traction to the leg. Extra-peritoneal drainage was performed in 43
patients. One patient was re-operated for a re-collection manifested
by persistent febrile spikes and unresolved psoas spasm.
Results
Pain, fever, and inability to use the aected limb with a
xed exion deformity at the hip were the commonest
clinical features. One child had recurrent symptoms 20
days following operative drainage of a psoas abscess.
The dorsolumbar spine was clinically normal in all pa-
tients. On US, a hypoechoic lesion in the psoas muscle
was read as an abscess cavity in 31 patients. In 5 others
thickening of the psoas muscle without liquefaction was
reported as an ``early abscess''. In 2 patients in whom an
X-ray lm was taken, the psoas shadow was obliterated;
the others were normal. Needle aspiration was done in
1 patient to conrm the diagnosis when acute arthritis of
the hip could not be clinically ruled out.
The abscess was surgically drained in 43 children and
a drain left in situ till drainage ceased usually the 3rd
or the 4th day. In 2 patients the pus was found to be
tracking from a group of suppurated external-iliac

Table 1 Distribution of cases according to symptoms
Symptom No. of cases Percent (n = 55)
Pain 41 74.55
Inability to use limb 44 80.00
Groin swelling 10 18.18
Table 2 Distribution of cases according to signs
Sign No. of
cases
Psoas spasm and deformity of hip 40
Swelling 28
External-iliac lymph node enlargement 14
lymph nodes the psoas muscle and sheath were not
involved. Twelve children responded to antibiotics and
skin traction alone. All 55 patients received systemic
cloxacillin with or without gentamycin for 5 to 7 days.
Skin traction applied pre-operatively was continued af-
ter surgery until the psoas spasm resolved. Cultures of
the pus were done in all operated cases; 38 grew
Staphylococcus aureus and 2 grew Acinetobactor an-
itratus. There was no growth from 3 samples. Following
operative drainage, the child's temperature returned to
normal by 24 to 48 h in all cases. At discharge, all
children had complete recovery of limb movements and
relief of psoas spasm.
Discussion
Pus in the psoas sheath is often thought to be a marker of
an underlying caries of the dorsolumbar spine, but acute
suppuration of non-tuberculous origin is almost as fre-
quent, if not more so. The PPA may be primary, or
rarely, secondary to an underlying pathology of kidney,
caecum, appendix, or terminal ileum on the right side
and iliac lymphadenitis [5]. The condition characteristi-
cally presents acutely with a painful, xed exion de-
formity of the hip, a tender mass in the iliac fossa, and
fever. The absence of swelling, however, does not rule out
suppuration. The limb is held in a characteristic exed,
externally rotated, and adducted or abducted position.
Extension and internal rotation stretches the psoas
muscle and causes pain the ``psoas sign'' [10]. Psoas
spasm was present in 70% of cases and was taken as
the sine qua non of a psoas abscess. The sign may also
be present with external-iliac lymphadenitis causing
reactive spasm of the psoas muscle. The abscess
commonly points anteriorly just above the outer as-
pect of the inguinal ligament. Initial features mimic
those of a primary disease of the hip, making dier-
entiation dicult. Typically, tenderness in the poste-
rior hip joint is absent when there is an abscess in the
psoas muscle, and a fully exed hip can be rotated
without pain [8].
409
Routine investigations show little more than le-
ucocytosis with neutrophilic preponderance. Radiologi-
cal features include a raised dome of the diaphragm on
chest radiograph and loss of denition or enlargement of
the psoas-muscle shadow on a plain abdominal lm. The
latter can also be seen in normal persons, and is there-
fore not a useful sign [1]: we could demonstrate this in
only 2 patients.
US is by far the best diagnostic investigation, and is
Percent usually accurate, inexpensive, and easy to perform. An
(n = 55) occasional small lesion/diuse phlegmon may be missed.
In our series, US conrmed the diagnosis in all 36 pa-
72.73 tients in whom it was done. Of the 5 in whom the di-
50.91
25.45
agnosis was a ``nonliquied'' abscess, 2 responded to
non-operative treatment alone, 2 required drainage at a
later date, and 1 proved to have suppuration of the ex-
ternal-iliac lymph nodes requiring drainage. Computed
tomography (CT) with contrast enhancement is recom-
mended as the standard diagnostic study, although its
value in children may be reduced owing to less fat in the
interfascial planes. We did not use CT in any of our
patients. Where available, radionuclide scanning with
gallium 67 is also useful for localisation as well as fol-
low-up of residual collections [3].
Early surgical drainage with appropriate systemic
antibiotic coverage is the ideal treatment, usually fol-
lowed by immediate defervescence and relief of pain. In
our series, 43 patients underwent extraperitoneal surgical
drainage. One child required re-exploration for a residual
collection that manifested with persistent pain, fever, and
psoas spasm. A blocked drainage tube after the rst
surgery with resultant early removal was probably the
cause. Systemic antibiotics eective against Staph. aureus
were usually started pre-operatively and continued for 3
7 days post-operatively. In the 12 children who re-
sponded to non-operative treatment, there was probably
a phase of ``psoas myositis'' before actual pus formation.
US or CT-guided percutaneous catheter drainage has
been recommended, but the rate of catheter blockage is
too high to justify its use as a routine procedure [9].
The aetiology of primary PPA remains speculative.
Suppurative lymphadenitis [6, 7] and trauma with for-
mation of a haematoma that becomes infected by ha-
ematogenous seeding [2] are two of the proposed causes.
Lam and Hodgson [4], in a series of 24 cases, noted 4
patients with antecedent/concomitant staphylococcal
infection elsewhere in the body. In our series 7 patients
gave a history of trauma, some of them too remote in the
past to be of any signicance. One child, a 9-month-old
male who was being treated for multiple subcutaneous
abscesses, was incidentally found to have a psoas abscess
on US examination of the abdomen. We did not nd
evidence of other foci of Staph. aureus infection in the
remaining cases. Nine of the children had palpable,
tender external-iliac lymph nodes, and in 2 of them the
pus arose from these suppurated lymph nodes.
In conclusion, primary PPA is more common than is
generally thought, and a high index of suspicion is
needed to make an accurate early diagnosis. US is a
410
simple, noninvasive investigation with a high positive
predictive value. Surgical drainage results in complete
relief of symptoms and hip deformity. Staph. aureus is
the commonest isolated organism. Although the exact
pathogenesis is unclear, local pyomyositis with suppu-
ration, haematogenous seeding from a distant septic
focus, and spread of pus from adjacent suppurative ex-
ternal-iliac lymphadenitis are strong possibilities.
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