Hemodialysis International 2015; 19:330–351
Case Reports
Iliopsoas abscess as a complication of tunneled jugular vein catheterization in a hemodialysis patient Po-Jen HSIAO,1 Ming-Hsien TSAI,2 Jyh-Gang LEU,2 Yu-Wei FANG2 1
Department of Nephrology, Hong Yi Hospital, Chaiyi, Taiwan; 2Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Abstract Iliopsoas abscess is a rare complication in hemodialysis patients that is mainly due to adjacent catheterization, local acupuncture, discitis, and bacteremia. Herein, we report a 47-year-old woman undergoing regular hemodialysis via a catheter in the internal jugular vein who presented with low back pain and dyspnea. A heart murmur suggested the presence of catheter-related endocarditis, and this was confirmed by an echocardiogram and a blood culture of methicillin-resistant Staphylococcus aureus. A computed tomography indicated a pulmonary embolism and an incidental finding of iliopsoas abscess. Following surgical intervention and intravenous daptomycin, the patient experienced full recovery and a return to usual activities. This case indicates that an iliopsoas abscess can be related to a jugular vein catheter, which is apparently facilitated by infective endocarditis. The possibility of iliopsoas abscess should be considered when a hemodialysis patient presents with severe low back pain, even when there is no history of adjacent mechanical intervention. Key words: Iliopsoas abscess, tunneled dialysis catheter, infective endocarditis, methicillinresistant Staphylococcus aureus (MRSA), hemodialysis
INTRODUCTION Hemodialysis (HD) patients are immunocompromised and susceptible to systemic infection, and infection is the most common cause of hospitalization and the second most common cause of mortality in these patients.1 Patients with HD catheters have an elevated risk for catheter-related bacteremia,2 and Staphylococcus aureus is Correspondence to: Y-W. Fang, MD, Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95, Wen-Chang Rd, Shih-Lin, Taipei 111, Taiwan. E-mail: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible the content and writing this paper.
one of the main pathogens responsible for the higher mortality in such patients.3 Iliopsoas abscess is a somewhat rare condition in these patients. The causes of this abscess include osteomyelitis, discitis, enterocolitis, bacteremia, or adjacent acupuncture and cannulation.4–7 Iliopsoas abscess due to remote cannulation is easily neglected in HD patients because of anatomic irrelevance and the limited number of case reports in the literature. We present a patient undergoing HD who developed an iliopsoas abscess with infective endocarditis that originated from an infection of the tunneled jugular vein catheterization.
CASE REPORT A 47-year-old woman with end-stage renal disease (ESRD) had received automated peritoneal dialysis (PD) for 3
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12197
330
Case Reports
Figure 1 (A) Echocardiogram, showing tricuspid valve vegetation (white arrow), and axial enhanced computed tomography (CT). (B) Axial enhanced CT showing multiple bilateral pulmonary emboli (black arrow) in the periphery. (C) Multi-septated low-density area (6.5 × 3.8 cm) along the right iliopsoas muscle (white arrow).
years. Six months prior to the episode reported in this study, she exhibited refractory Pseudomonas aeruginosa peritonitis and the Tenckhoff catheter was removed. Since then, she has been receiving HD through a tunneled catheter in the right internal jugular vein. She presented to the emergency department with severe lower back pain and progressive shortness of breath. A physical examination indicated bilateral pretibial pitting edema, pale conjunctiva, and icteric sclera. A grade 3 systolic murmur over the left parasternal border was also noted during auscultation. Her vital signs were as follows: Blood pressure, 76/49 mmHg; body temperature, 36.8°C; pulse rate, 108 beats per minute; and respiration rate, 20 breaths per minute. Laboratory investigations indicated marked leukocytosis (white blood cell count, 44 × 103/ μL, reference range: 3.8–10 × 103/μL), anemia (hemoglobin, 7.9 g/dL, reference range: 11–16 g/dL), and jaundice (direct bilirubin, 2.2 mg/dL, reference range: 0.3–1.2 mg/ dL). She also had elevated blood urea nitrogen (53 mg/dL, reference range: 7–20 mg/dL), creatinine (6.3 mg/dL, reference range: 0.6–1.3 mg/dL), serum glutamic oxaloacetic transaminase (50 U/L, reference range: 12–38 U/L), erythrocyte sedimentation rate (>140 mm/h, reference range: 0–20 mm/h), and C-reactive protein (24.4 mg/dL, reference range: 0.2–3.0 mg/L). Since severe sepsis was suspected, so transthoracic echocardiography and enhanced computed tomography were conducted. The findings indicated a large vegetation over the tricuspid valve (Figure 1A), pulmonary emboli, and a multi-septated abscess (6.5 × 3.8 cm) on the right iliopsoas muscle that extended into the right periarticular portion of the hip bone (Figure 1B and C). This abscess
Hemodialysis International 2015; 19:330–351
was treated through open drainage, and the tunneled jugular vein catheter was removed. A new noncuffed double lumen was inserted via left femoral vein. Cultures of pus from the abscess, blood, and catheter-tip samples were all positive for methicillin-resistant Staphylococcus aureus (MRSA). We diagnosed this condition as iliopsoas abscess with concurrent infective endocarditis due to catheter-related MRSA infection, and administered intravenous daptomycin (350 mg every 3 days) accordingly. Her fever and low back pain gradually resolved after 2 weeks treatment. The patient was discharged after 6 weeks antibiotic treatment.
DISCUSSION Iliopsoas abscess is an uncommon condition that presents with pus formation in the iliopsoas compartment. The relative obscurity of this condition, coupled with vague clinical characteristics, complicates its diagnosis and treatment. One of the most common manifestations of this condition is local irritation, such as flank pain or pain in a lower limb. Other symptoms include fever, anorexia, weight loss, and general malaise.8 The incidence of iliopsoas abscess has been increasing in recent years. It is more evident in patients who are elderly and immunocompromised, such as those with malignancies, HIV infection, ESRD, and multi-systemic diseases.9 A secondary iliopsoas abscess can develop by direct invasion from a contiguous structure or via the bloodstream from a distant site. Early diagnosis and intervention, including broad-spectrum antibiotics and surgical drainage, can reduce the morbidity and mortality associated with this condition.
331
Case Reports
In 1987, Tillman et al. reported that four maintenance dialysis patients developed iliopsoas abscesses, two of these patients were on HD and had discitis and the other two patients were on PD and had unknown etiologies.6 After this report, there have been several additional case reports of this condition. The primary infection sources were reported as femoral vein catheterization with local anatomical changes in the lumbar veins,10,11 adjacent acupuncture,5 discitis,6,7 enterocolitis,4,7 systemic amyloidosis,12 arteriovenous shunt infection, endocarditis, and diverticulitis.7 Remote catheter infection (as in the present case) as the cause of iliopsoas abscess is apparently rare, and only one recent paper reported iliopsoas abscess as a complication of internal jugular vein catheter infection; however, the causal relationship was uncertain because the culture results of catheter tip and abscess were inconsistent.13 Moreover, the pathogens causing this abscess in hemodialysis patients were mostly MRSA,7,10,11,13 and most patients had better outcomes after surgical intervention and medical treatment. Because no MRSA endocarditis sign was noted before vascular access insertion and catheter was thought to be vulnerable for MRSA infection, a hypothesis was that the primary source of infection in our case was the tunneled jugular catheter, and she developed MRSA endocarditis, and ultimately, a right iliopsoas abscess. Septicemia is a common complication of prolonged catheter placement, but the development of psoas muscle abscess is rare. In the general population, very few cases of iliopsoas abscess are caused by MRSA infection,9 although the incidence of MRSA infection in dialysis patients in the United States is 100-fold higher than that in the general population.14 The major risk factors for MRSA in HD patients are frequent hospital visits and prolonged blood stream access with central venous catheters.15 The longterm usage of tunneled jugular vein catheters is common in maintenance HD patients when arteriovenous shunt creation is difficult. Thus, MRSA infection is a critical issue in such patients. In conclusion, a 47-year-old female undergoing maintenance HD presented with an iliopsoas abscess as a complication of an infected remote jugular vein catheter and MRSA endocarditis. Thus, iliopsoas abscess is a possible focus of infection even without contiguous catheter insertion in HD patients who present with severe low back pain. In addition, the possibility of concurrent endocarditis should be considered. Manuscript received March 2014; revised May 2014.
332
REFERENCES 1 Lukowsky LR, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh K. Patterns and predictors of early mortality in incident hemodialysis patients: New insights. Am J Nephrol. 2012; 35:548–558. 2 Katneni R, Hedayati SS. Central venous catheter-related bacteremia in chronic hemodialysis patients: Epidemiology and evidence-based management. Nat Clin Pract Nephrol. 2007; 3:256–266. 3 Inrig JK, Reed SD, Szczech LA, et al. Relationship between clinical outcomes and vascular access type among hemodialysis patients with Staphylococcus aureus bacteremia. Clin J Am Soc Nephrol. 2006; 1:518–524. 4 Kato A, Takahashi T, Watanabe T, Furuhashi M, Maruyama Y, Hishida A. Psoas abscess with osteomyelitis in a patient undergoing long-term hemodialysis. Am J Nephrol. 2001; 21:410–412. 5 Kim JW, Kim YS. Psoas abscess formation after acupuncture in a hemodialysis patient. Hemodial Int. 2010; 14:343–344. 6 Tillman BF, Gibson RL, Stone WJ. Psoas abscess in chronic dialysis patients. J Urol. 1987; 137:489–490. 7 Sato M, Iwasa Y, Otsubo S, et al. Psoas abscess in hemodialysis patients. Int Urol Nephrol. 2010; 42:1113–1116. 8 Mallick IH, Thoufeeq MH, Rajendran TP. Iliopsoas abscesses. Postgrad Med J. 2004; 80:459–462. 9 Navarro López V, Ramos JM, Meseguer V, et al. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine (Baltimore). 2009; 88:120–130. 10 Kikuchi S1, Muro K, Yoh K, et al. Two cases of psoas abscess with discitis by methicillin-resistant Staphylococcus aureus as a complication of femoral-vein catheterization for haemodialysis. Nephrol Dial Transplant. 1999; 14:1279–1281. 11 Lin CJ, Lin HC, Wu CJ, Chen HH, Chen YC. Psoas muscle abscess as a complication of femoral vein catheterization in a hemodialysis patient. South Med J. 2008; 101:566–567. 12 Dovas S, Liakopoulos V, Simopoulou T, et al. Psoas abscess in a dialysis patient with dialysis-related amyloidosis. Int Urol Nephrol. 2008; 40:543–546. 13 Peddi S, Ram R, Boreddy VD, Avssn S, Chennu KK, Vishnubotla SK. Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter. Hemodial Int. 2014; 18:192–194. 14 Centers for Disease Control and Prevention. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients—United States, 2005. MMWR Morb Mortal Wkly Rep. 2007; 56:197–199. 15 Nguyen DB1, Lessa FC, Belflower R, et al. Invasive methicillin-resistant Staphylococcus aureus infections among chronic dialysis patients in the United States, 2005–2011. Clin Infect Dis. 2013; 57:1393–1400.
Hemodialysis International 2015; 19:330–351
Case Reports
Iliopsoas abscess as a complication of tunneled jugular vein catheterization in a hemodialysis patient Po-Jen HSIAO,1 Ming-Hsien TSAI,2 Jyh-Gang LEU,2 Yu-Wei FANG2 1
Department of Nephrology, Hong Yi Hospital, Chaiyi, Taiwan; 2Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Abstract Iliopsoas abscess is a rare complication in hemodialysis patients that is mainly due to adjacent catheterization, local acupuncture, discitis, and bacteremia. Herein, we report a 47-year-old woman undergoing regular hemodialysis via a catheter in the internal jugular vein who presented with low back pain and dyspnea. A heart murmur suggested the presence of catheter-related endocarditis, and this was confirmed by an echocardiogram and a blood culture of methicillin-resistant Staphylococcus aureus. A computed tomography indicated a pulmonary embolism and an incidental finding of iliopsoas abscess. Following surgical intervention and intravenous daptomycin, the patient experienced full recovery and a return to usual activities. This case indicates that an iliopsoas abscess can be related to a jugular vein catheter, which is apparently facilitated by infective endocarditis. The possibility of iliopsoas abscess should be considered when a hemodialysis patient presents with severe low back pain, even when there is no history of adjacent mechanical intervention. Key words: Iliopsoas abscess, tunneled dialysis catheter, infective endocarditis, methicillinresistant Staphylococcus aureus (MRSA), hemodialysis
INTRODUCTION Hemodialysis (HD) patients are immunocompromised and susceptible to systemic infection, and infection is the most common cause of hospitalization and the second most common cause of mortality in these patients.1 Patients with HD catheters have an elevated risk for catheter-related bacteremia,2 and Staphylococcus aureus is Correspondence to: Y-W. Fang, MD, Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95, Wen-Chang Rd, Shih-Lin, Taipei 111, Taiwan. E-mail: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible the content and writing this paper.
one of the main pathogens responsible for the higher mortality in such patients.3 Iliopsoas abscess is a somewhat rare condition in these patients. The causes of this abscess include osteomyelitis, discitis, enterocolitis, bacteremia, or adjacent acupuncture and cannulation.4–7 Iliopsoas abscess due to remote cannulation is easily neglected in HD patients because of anatomic irrelevance and the limited number of case reports in the literature. We present a patient undergoing HD who developed an iliopsoas abscess with infective endocarditis that originated from an infection of the tunneled jugular vein catheterization.
CASE REPORT A 47-year-old woman with end-stage renal disease (ESRD) had received automated peritoneal dialysis (PD) for 3
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12197
330
Case Reports
Figure 1 (A) Echocardiogram, showing tricuspid valve vegetation (white arrow), and axial enhanced computed tomography (CT). (B) Axial enhanced CT showing multiple bilateral pulmonary emboli (black arrow) in the periphery. (C) Multi-septated low-density area (6.5 × 3.8 cm) along the right iliopsoas muscle (white arrow).
years. Six months prior to the episode reported in this study, she exhibited refractory Pseudomonas aeruginosa peritonitis and the Tenckhoff catheter was removed. Since then, she has been receiving HD through a tunneled catheter in the right internal jugular vein. She presented to the emergency department with severe lower back pain and progressive shortness of breath. A physical examination indicated bilateral pretibial pitting edema, pale conjunctiva, and icteric sclera. A grade 3 systolic murmur over the left parasternal border was also noted during auscultation. Her vital signs were as follows: Blood pressure, 76/49 mmHg; body temperature, 36.8°C; pulse rate, 108 beats per minute; and respiration rate, 20 breaths per minute. Laboratory investigations indicated marked leukocytosis (white blood cell count, 44 × 103/ μL, reference range: 3.8–10 × 103/μL), anemia (hemoglobin, 7.9 g/dL, reference range: 11–16 g/dL), and jaundice (direct bilirubin, 2.2 mg/dL, reference range: 0.3–1.2 mg/ dL). She also had elevated blood urea nitrogen (53 mg/dL, reference range: 7–20 mg/dL), creatinine (6.3 mg/dL, reference range: 0.6–1.3 mg/dL), serum glutamic oxaloacetic transaminase (50 U/L, reference range: 12–38 U/L), erythrocyte sedimentation rate (>140 mm/h, reference range: 0–20 mm/h), and C-reactive protein (24.4 mg/dL, reference range: 0.2–3.0 mg/L). Since severe sepsis was suspected, so transthoracic echocardiography and enhanced computed tomography were conducted. The findings indicated a large vegetation over the tricuspid valve (Figure 1A), pulmonary emboli, and a multi-septated abscess (6.5 × 3.8 cm) on the right iliopsoas muscle that extended into the right periarticular portion of the hip bone (Figure 1B and C). This abscess
Hemodialysis International 2015; 19:330–351
was treated through open drainage, and the tunneled jugular vein catheter was removed. A new noncuffed double lumen was inserted via left femoral vein. Cultures of pus from the abscess, blood, and catheter-tip samples were all positive for methicillin-resistant Staphylococcus aureus (MRSA). We diagnosed this condition as iliopsoas abscess with concurrent infective endocarditis due to catheter-related MRSA infection, and administered intravenous daptomycin (350 mg every 3 days) accordingly. Her fever and low back pain gradually resolved after 2 weeks treatment. The patient was discharged after 6 weeks antibiotic treatment.
DISCUSSION Iliopsoas abscess is an uncommon condition that presents with pus formation in the iliopsoas compartment. The relative obscurity of this condition, coupled with vague clinical characteristics, complicates its diagnosis and treatment. One of the most common manifestations of this condition is local irritation, such as flank pain or pain in a lower limb. Other symptoms include fever, anorexia, weight loss, and general malaise.8 The incidence of iliopsoas abscess has been increasing in recent years. It is more evident in patients who are elderly and immunocompromised, such as those with malignancies, HIV infection, ESRD, and multi-systemic diseases.9 A secondary iliopsoas abscess can develop by direct invasion from a contiguous structure or via the bloodstream from a distant site. Early diagnosis and intervention, including broad-spectrum antibiotics and surgical drainage, can reduce the morbidity and mortality associated with this condition.
331
Case Reports
In 1987, Tillman et al. reported that four maintenance dialysis patients developed iliopsoas abscesses, two of these patients were on HD and had discitis and the other two patients were on PD and had unknown etiologies.6 After this report, there have been several additional case reports of this condition. The primary infection sources were reported as femoral vein catheterization with local anatomical changes in the lumbar veins,10,11 adjacent acupuncture,5 discitis,6,7 enterocolitis,4,7 systemic amyloidosis,12 arteriovenous shunt infection, endocarditis, and diverticulitis.7 Remote catheter infection (as in the present case) as the cause of iliopsoas abscess is apparently rare, and only one recent paper reported iliopsoas abscess as a complication of internal jugular vein catheter infection; however, the causal relationship was uncertain because the culture results of catheter tip and abscess were inconsistent.13 Moreover, the pathogens causing this abscess in hemodialysis patients were mostly MRSA,7,10,11,13 and most patients had better outcomes after surgical intervention and medical treatment. Because no MRSA endocarditis sign was noted before vascular access insertion and catheter was thought to be vulnerable for MRSA infection, a hypothesis was that the primary source of infection in our case was the tunneled jugular catheter, and she developed MRSA endocarditis, and ultimately, a right iliopsoas abscess. Septicemia is a common complication of prolonged catheter placement, but the development of psoas muscle abscess is rare. In the general population, very few cases of iliopsoas abscess are caused by MRSA infection,9 although the incidence of MRSA infection in dialysis patients in the United States is 100-fold higher than that in the general population.14 The major risk factors for MRSA in HD patients are frequent hospital visits and prolonged blood stream access with central venous catheters.15 The longterm usage of tunneled jugular vein catheters is common in maintenance HD patients when arteriovenous shunt creation is difficult. Thus, MRSA infection is a critical issue in such patients. In conclusion, a 47-year-old female undergoing maintenance HD presented with an iliopsoas abscess as a complication of an infected remote jugular vein catheter and MRSA endocarditis. Thus, iliopsoas abscess is a possible focus of infection even without contiguous catheter insertion in HD patients who present with severe low back pain. In addition, the possibility of concurrent endocarditis should be considered. Manuscript received March 2014; revised May 2014.
332
REFERENCES 1 Lukowsky LR, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh K. Patterns and predictors of early mortality in incident hemodialysis patients: New insights. Am J Nephrol. 2012; 35:548–558. 2 Katneni R, Hedayati SS. Central venous catheter-related bacteremia in chronic hemodialysis patients: Epidemiology and evidence-based management. Nat Clin Pract Nephrol. 2007; 3:256–266. 3 Inrig JK, Reed SD, Szczech LA, et al. Relationship between clinical outcomes and vascular access type among hemodialysis patients with Staphylococcus aureus bacteremia. Clin J Am Soc Nephrol. 2006; 1:518–524. 4 Kato A, Takahashi T, Watanabe T, Furuhashi M, Maruyama Y, Hishida A. Psoas abscess with osteomyelitis in a patient undergoing long-term hemodialysis. Am J Nephrol. 2001; 21:410–412. 5 Kim JW, Kim YS. Psoas abscess formation after acupuncture in a hemodialysis patient. Hemodial Int. 2010; 14:343–344. 6 Tillman BF, Gibson RL, Stone WJ. Psoas abscess in chronic dialysis patients. J Urol. 1987; 137:489–490. 7 Sato M, Iwasa Y, Otsubo S, et al. Psoas abscess in hemodialysis patients. Int Urol Nephrol. 2010; 42:1113–1116. 8 Mallick IH, Thoufeeq MH, Rajendran TP. Iliopsoas abscesses. Postgrad Med J. 2004; 80:459–462. 9 Navarro López V, Ramos JM, Meseguer V, et al. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine (Baltimore). 2009; 88:120–130. 10 Kikuchi S1, Muro K, Yoh K, et al. Two cases of psoas abscess with discitis by methicillin-resistant Staphylococcus aureus as a complication of femoral-vein catheterization for haemodialysis. Nephrol Dial Transplant. 1999; 14:1279–1281. 11 Lin CJ, Lin HC, Wu CJ, Chen HH, Chen YC. Psoas muscle abscess as a complication of femoral vein catheterization in a hemodialysis patient. South Med J. 2008; 101:566–567. 12 Dovas S, Liakopoulos V, Simopoulou T, et al. Psoas abscess in a dialysis patient with dialysis-related amyloidosis. Int Urol Nephrol. 2008; 40:543–546. 13 Peddi S, Ram R, Boreddy VD, Avssn S, Chennu KK, Vishnubotla SK. Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter. Hemodial Int. 2014; 18:192–194. 14 Centers for Disease Control and Prevention. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients—United States, 2005. MMWR Morb Mortal Wkly Rep. 2007; 56:197–199. 15 Nguyen DB1, Lessa FC, Belflower R, et al. Invasive methicillin-resistant Staphylococcus aureus infections among chronic dialysis patients in the United States, 2005–2011. Clin Infect Dis. 2013; 57:1393–1400.
Hemodialysis International 2015; 19:330–351
