SURGICAL INFECTIONS Volume 15, Number 00, 2014 ª Mary Ann Liebert, Inc. DOI 10.1089/sur.2012.104
Puerperal Retroperitoneal Abscess Caused by Clostridium difficile: Case Report and Review of the Literature Tuangsit Wataganara,1 Anuwat Sutantawibul,1 Sanitra Anuwutnavin,1 Amornrut Leelaporn,2 and Young Rongrungruang 3
Abstract
Background: Retroperitoneal infection can be lethal. Optimal management is still elusive to describe because of the small number of case reports. We presented here a case of retroperitoneal abscess caused by Clostridium difficile arising in the puerperal period. Methods: Case report and review of recent English-language literature. Results: The patient presented with surgical incision dehiscence. A gas-forming fluid collection was discovered in the pelvic retroperitoneal fascia by computed tomography, but the patient did not show marked symptoms of sepsis. Emergency laparotomy drainage and debridement were performed. Clostridium difficile was isolated, and she was treated with a three-week course of vancomycin. The patient recovered without major morbidity. Recent case reports describe variation in the course of the disease and management options for puerperal retroperitoneal infection. Conclusion: Puerperal retroperitoneal abscess caused by C. difficile can present with minimal symptoms. Prompt recognition, early surgical intervention, and optimal use of antibiotics can reduce morbidity and prevent death.
I
ioamnionitis. Her cervix was unfavorable; therefore, hysterotomy was performed to evacuate the infected conceptus. No intra-operative complication was reported during the surgery. However, total wound dehiscence occurred on the fifth day postoperatively. Gram staining of wound discharge showed mixed bacteria, including oval, sub-terminal spore-bearing Gram-positive bacilli, which was suggestive of a non-perfringens Clostridium (Fig. 1). Rectovaginal examination found a pelvic collection with crepitus. Emergency computed tomography (CT) showed large pockets of gas-containing fluid in the retroperitoneal space. Other, smaller fluid collections were present between bowel loops (Fig. 2). Her vital signs remained stable, except for a low-grade fever. The patient agreed to a prompt re-exploratory laparotomy including the possibility of hysterectomy. Prior to the surgery, both ureters were catheterized cystoscopically. A large amount of pus was drained from the retroperitoneal pelvic
nfection in the retroperitoneal space is aggressive. It may also have an atypical presentation [1]. This serious infection occurs rarely in the postpartum period. With limited experience in this specific circumstance, optimal management is controversial. We describe a case of retroperitoneal abscess caused by Clostridium difficile arising after hysterotomy in the second trimester. In addition, variation in the clinical course and management of puerperal retroperitoneal infection was reviewed from the recent English-language literature.
Case Report
A 25-year old nulliparous Thai woman presented with unexplained fetal demise at 22 wk gestation. Medical termination was performed using vaginal misoprostol and intravenous oxytocin. There was spontaneous rupture of the membranes two days later, and she soon developed chor-
1 Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, 2Department of Microbiology, and 3Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand. Presented at the First Global Congress of Maternal and Infant Health, Barcelona, Spain, September 26–28, 2010.
1
2
WATAGANARA ET AL.
FIG. 1. Gram stain of material from surgical site shows large gram-positive bacilli with oval sub-terminal spores. Spore formation was more prominent after culture.
collections by blunt and sharp dissections of the necrotic endopelvic fascia until a bleeding tissue plane was reached (Fig. 3). Collections between the bowel loops also were evacuated. Systematic examination of the small and large bowel excluded injury from the previous operation. The decision was made to preserve the uterus because her uterus appeared to be free from infection, and the Gram stain suggested a non-virulent strain of Clostridium spp. Operating time was 3 h, with an estimated blood loss of 500 mL. Percutaneous drains were placed. The skin and subcutaneous tissue were left open for delayed primary closure five days later. Vancomycin was given empirically at a dose of 1 g q 12 h IV for five days. Bacterial culture of the retroperitoneal collection revealed mixed aerobic and anaerobic bacteria, including Clostridium spp. The Clostridium was identified subsequently as C. difficile by its phenotype and 16S ribosomal DNA sequencing. Tests for toxin genes (A, B, and binary) were negative. After the patient became afebrile, she was switched to oral vancomycin 500 mg q 6 h for the next two weeks. No other antibiotics were used. The patient recovered without morbidity.
FIG. 2. Computed tomography reveals gas-containing collection in endopelvic fascia. Disruption of abdominal incision is noted.
Discussion
Retroperitoneal infection is a serious obstetric complication. The mortality rate can be as high as 20%, especially if the infection is complicated by necrotizing fasciitis [2,3]. Symptoms of sepsis may not correlate with the size of the retroperitoneal collection. Aerobic bacteria are identified most frequently as the major cause [4,5]. However, co-infection with anaerobic bacteria may occur, although its real incidence may be underestimated. If Clostridium spp. is suspected from the Gram stain, identification to the species level essential to guide the treatment. Definitive risk factors for puerperal retroperitoneal infection are still unclear. We were able to identify 12 recent reports of retroperitoneal infection associated with miscarriage or delivery (Table 1). An association between the route of delivery and retroperitoneal infection is still elusive. According to the data in Table 1, most retroperitoneal infections developed after vaginal delivery (nine of 12), followed by miscarriage (n = 2), and cesarean delivery (n = 1). The higher proportion of retroperitoneal infection after vaginal delivery may be either because of the higher number of such deliveries or the less aseptic nature of vaginal birth compared with cesarean section. Chorioamnionitis was diagnosed in two of nine patients with necrotizing fasciitis following cesarean delivery [3]. Impaired immunity during pregnancy, concurrent use of non-steroidal anti-inflammatory drugs, diabetes mellitus, malnutrition, older age, and peripheral vascular diseases can contribute to post-partum infection [6]. The psoas muscle is the most common site of ascending infection because of its rich vascular supply and direct lymphatic drainage from the genital tract. Psoas abscess may present as pelvic pain, edema, and sepsis, as shown in seven of the case reports summarized in Table 1 [2]. Sonography is the main imaging modality to diagnose pelvic collections, but CT or magnetic resonance imaging may be helpful in equivocal cases because of their superior soft-tissue contrast and larger field of view [7,8]. In addition to ascending infection from the genital tract, surgical site infection, iatrogenic bowel injury, and hematogenous spread from an extra-abdominal site can lead to retroperitoneal abscess [9,10]. There is substantial diversity in the clinical manifestations of puerperal retroperitoneal infection that may not be associated with the route of infection. For example, an
PUERPERAL RETROPERITONEAL ABSCESS
3
FIG. 3. Intra-operative and post-operative findings. (A) Low midline incision was extended for adequate exposure. (B) Necrotic endopelvic tissue was dissected. (C) Healthy appearance of uterus and both adnexae. (D) Healed surgical site after delayed primary closure.
infection after a simple vacuum aspiration led to a serious case of psoas abscess, which required laparotomy for drainage [11], whereas another case of surgical site infection of cesarean section incision led to a minor psoas abscess that was treated successfully with aspiration and a short course of antibiotics [9]. Estimation of the true prevalence of puerperal retroperitoneal infection may be difficult because of under-reporting of cases with adverse outcomes. Variation in management of puerperal retroperitoneal infection is notable. A long course of antibiotics alone may be adequate for an isolated, small psoas abscess [9, 12–14]. A combination of antibiotics and simple aspiration may be adequate for a collection of moderate size [7, 9]. If the collection is large but still contained in the retroperitoneal space, percutaneous drainage may be established with CT or ultrasound guidance to prevent recurrence [15–19]. Laparoscopy was used to guide the placement of continuous drainage in a pediatric case [20]. Exploratory laparotomy for drainage and extensive debridement can be lifesaving if the infection has spread beyond the retroperitoneal space [11]. Adequate drainage and extensive debridement should be accomplished in a single operation. Re-exploration is associated with increased morbidity [21]. Careful preoperative preparation such as bilateral ureteral catheterization can facilitate adequate dissection of the pelvic fascia and prevent injury to the ureters. Prompt action is crucial, as delayed management can result in permanent disability such as hip joint damage [17]. It is important to exclude the more virulent species of Clostridium, especially C. perfringens, which causes gas gangrene, or C. sordellii, which causes toxic shock syndrome
[22, 23]. Toxins produced by these Clostridium spp. are highly lethal. Because no antitoxins are available, prompt removal of the uterus is necessary. Clinically, profound septic shock is common in infection with virulent strains of Clostridium. Gram stain remains an excellent bedside test to identify the type of Clostridium by its morphology. Clostridium perfringens is a large gram-positive bacillus without spores. A large gram-positive bacillus with oval, sub-terminal spores, was present in our patient, could be either the virulent C. sordellii or the more benign C. difficile. The minor systemic symptoms in our patient were consistent C. difficile. This organism is a normal inhabitant of the genital tract in 18% of women [24]. Genetic typing assay can confirm the species and identify the primary source of infection for the purpose of tracing the origin of the infection [25]. In conclusion, our case illustrates a favorable outcome of puerperal retroperitoneal abscess treated with surgical intervention and antibiotics. This serious obstetric infection may not be preventable, but a timely, definitive approach can reduce the morbidity. Although our patient did not have obvious sepsis, her diagnosis could have been made earlier by checking for signs of infection of the incision in the first few days after her first operation. Individual risk factors, such as her chorioamnionitis, have to be recognized. The value of a strict aseptic protocol during surgery cannot be overemphasized. Prophylactic antibiotics have been proved to reduce serious infectious morbidity after abdominal delivery [26]. Alternative interventions may be available in the future with advancing knowledge of critical care, better antibiotics, or partially hyperbaric oxygen therapy [2, 27].
4
1
1
Yagi et al., 2005 [12] Patil et al., 2006 [14]
Young et al., 2010 [28]
Kumar et al., 2009 [20] Kwan et al., 2009 [8]
Vaginal
Vaginal
1
1
Vacuum aspiration
Dilation and curettage for incomplete abortion
1
1
Vaginal
Vaginal
Vaginal
Cesarean section
1
1
Vaginal
1
Shahabi et al., 2002 [17]
Sokolov et al., 2007 [2] Bhattacharya et al., 2008 [18] Cedric et al., 2009 [27]
Vaginal
1
Saylam et al., 2002 [10]
Vaginal
2
Segal et al., 1996 [16]
Vaginal
Mode of Delivery
1
No. of cases
Shah et al., 1992 [15]
Publication
Hip pain, fever
Pelvic pain, fever
Abdominal pain, fever
Flank pain, chills
Pelvic and sciatic pain, fever
Back pain
Pelvic and leg pain
Hip pain, fever
Pelvic pain, fever
Surgical site infection, back pain
Flank pain, fever
Hip pain, fever
Presentation
Psoas abscess
Iliopsoas abscess
Psoas abscess
Sacroiliitis and gluteal abscess
Psoas abscess
Iliopsoas pyomyositis
Psoas abscess
Iliopsoas fasciitis
Psoas abscess
Psoas abscess and sacroiliitis
Retroperitoneal abscess with sacroiliac joint disruption Retroperitoneal abscess
Diagnosis
Day 5
Week 4
Day 6
Day 2
Week 2
Day 9
Day 3
Day 2
Day 7: Infected incision; day 8: Psoas abscess Day 2
Case 1: Day 1 Case 2: Day 10
Day 23
Time of Onset
Coagulase-negative Staphylococcus
Unable to identify
Staphylococcus agalactiae, b-hemolytic Streptococcus, Lancefield Group B Undisclosed
Methicillin-resistant S. aureus Group B Streptococcus
Streptococcus pyogenes Unable to identify
Mixed infection with viridans Streptococcus
Case 1: Unable to identify Case 2: Escherichia coli and Acinetobacter spp. Staphylococcus aureus
Pneumococcus
Organism(s) Isolated
Table 1. Recent Reports of Puerperal Retroperitoneal Infection
Antibiotics, laparotomy Antibiotics, percutaneous ultrasound-guided aspiration Antibiotics, CTguided percutaneous drainage
Antibiotics
Incision and drainage, antibiotics
Percutaneous drainage, antibiotics Antibiotics
Antibiotics, percutaneous computed tomography (CT)guided drainage Antibiotics
Antibiotics, percutaneous aspiration
Antibiotics, percutaneous drainage, daily irrigation
Antibiotics, percutaneous drainage.
Treatment
None
None
None
Sacroiliac joint damage
None
None
None
None
None
None
Case 1: Hip joint damage Case 2: None
None
Morbidity
PUERPERAL RETROPERITONEAL ABSCESS Acknowledgment
We thank the dedicating nursing staff at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. We thank the patient for her consent to this report. Author Disclosure Statement
The authors have no conflicts of interest. References
1. Pruyn SC. Acute necrotizing fasciitis of the endopelvic fascia. Obstet Gynecol 1978;52(1 Suppl):25–45. 2. Gallup DG, Freedman MA, Meguiar RV, et al. Necrotizing fasciitis in gynecologic and obstetric patients: A surgical emergency. Am J Obstet Gynecol 2002;187:305–310. 3. Goepfert AR, Guinn DA, Andrews WW, Hauth JC. Necrotizing fasciitis after cesarean delivery. Obstet Gynecol 1997;89:409–412. 4. McHenry CR, Azar T, Ramahi AJ, Collins PL. Monomicrobial necrotizing fasciitis complicating pregnancy and puerperium. Obstet Gynecol 1996;87:823–826. 5. Daif JL, Levie M, Chudnoff S, et al. Group A Streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy. Obstet Gynecol 2009;113:504–506. 6. Gonza´lez Castro A, Rodriguez-Borregan JC, Obeso T, et al. Necrotizing fasciitis after cesarean section. Arch Gynecol Obstet 2008;277:579–581. 7. Kwan A, Bhanshaly A, Wright C. Iliopsoas abscess: An usual cause of postpartum sepsis. Obstet Med 2009;2: 30–31. 8. Riyad MN, Sallam MA, Nur A. Pyogenic psoas abscess: Discussion of its epidemiology, etiology, bacteriology, diagnosis, treatment and prognosis—Case report. Kuwait Med J 2003;35:44–47. 9. Saylam K, Anaf V, Kirkpatrick C. Successful medical management of multifocal psoas abscess following cesarean section: Report of a case and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002;102:211–214. 10. Castiglioni B, Gautam A, Citron DM, et al. Clostridium innocuum bacteremia secondary to infected hematoma with gas formation in a kidney transplant recipient. Transpl Infect Dis 2003;5:199–202. 11. Kumar S, Malhotra N, Chanana C, Lal S. Psoas abscess in obstetrics. Arch Gynecol Obstet 2009;279:247–249. 12. Yagi H, Fukushima K, Satoh S, et al. Postpartum retroperitoneal fasciitis: A case report and review of literature. Am J Perinatol 2005;22:109–113. 13. Sokolov KM, Kreye E, Miller LG, et al. Postpartum iliopsoas pyomyositis due to community-acquired methicillinresistant Staphylococcus aureus. Obstet Gynecol 2007;110: 535–538.
5
14. Yacoub WN, Sohn HJ, Chan S, et al. Psoas abscess rarely requires surgical intervention. Am J Surg 2008;196:223–227. 15. Patil A, Gatongi DK, Haque L, Mires G. Primary psoas abscess following spontaneous vaginal delivery. J Obstet Gynaecol 2006;26:565–569. 16. Shah PN, Rane VA, Moolgaoker AS. Retroperitoneal abscess complicating a normal delivery. Br J Obstet Gynaecol 1992;99:160–161. 17. Segal S, Gemer O, Sestopal-Epelman M, et al. Retroperitoneal abscess after normal delivery: A report of two cases. J Reprod Med 1996;41:276–278. 18. Shahabi S, Klein JP, Rinaudo PF. Primary psoas abscess complicating a normal vaginal delivery. Obstet Gynecol 2002;99:906–909. 19. Bhattacharya R, Gobrial H, Barrington JW, Isaacs J. Psoas abscess after uncomplicated vaginal delivery: An unusual case. J Obstet Gynaecol 2008;28:544–546. 20. Katara AN, Shah RS, Bhandarkar DS, Unadkat RJ. Retroperitoneoscopic drainage of a psoas abscess. J Pediatr Surg 2004;39:e4–e5. 21. Sudarsky LA, Laschinger JC, Coppa GE, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 1987;206:661–665. 22. Rorbye C, Petersen LS, Nilas L. Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome. Acta Obstet Gynecol Scand 2000;79:1134–1135. 23. Kurashina R, Shimada H, Matsushima T, et al. Spontaneous uterine perforation due to clostridial gas gangrene associated with endometrial carcinoma. J Nippon Med Sch 2010; 77:166–169. 24. Hafiz S, McEntegart MG, Morton RS, Waitkins SA. Clostridium defficiel [sic] in the urogenital tract of males and females. Lancet 1975;1:420–421. 25. Tabaqchali S, Holland D, O’Farrell S, Silman R. Typing scheme for Clostridium difficile: Its application in clinical and epidemiological studies. Lancet 1984;1:935–938. 26. Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section: A systematic review and meta-analysis. Br J Obstet Gynaecol 2013;120:661–669. 27. Hung JH, Wang JH, Chen CY, et al. Hyperbaric oxygen therapy for cesarean section wound in diabetes mellitus gravida. J Chin Med Assoc 2008;71:373–376.
Address correspondence to: Dr. Tuangsit Wataganara Division of Maternal–Fetal Medicine Department of Obstetrics and Gynecology Faculty of Medicine Siriraj Hospital 2 Prannok Road, Bangkoknoi Bangkok, Thailand 10800 E-mail: [email protected]
Puerperal Retroperitoneal Abscess Caused by Clostridium difficile: Case Report and Review of the Literature Tuangsit Wataganara,1 Anuwat Sutantawibul,1 Sanitra Anuwutnavin,1 Amornrut Leelaporn,2 and Young Rongrungruang 3
Abstract
Background: Retroperitoneal infection can be lethal. Optimal management is still elusive to describe because of the small number of case reports. We presented here a case of retroperitoneal abscess caused by Clostridium difficile arising in the puerperal period. Methods: Case report and review of recent English-language literature. Results: The patient presented with surgical incision dehiscence. A gas-forming fluid collection was discovered in the pelvic retroperitoneal fascia by computed tomography, but the patient did not show marked symptoms of sepsis. Emergency laparotomy drainage and debridement were performed. Clostridium difficile was isolated, and she was treated with a three-week course of vancomycin. The patient recovered without major morbidity. Recent case reports describe variation in the course of the disease and management options for puerperal retroperitoneal infection. Conclusion: Puerperal retroperitoneal abscess caused by C. difficile can present with minimal symptoms. Prompt recognition, early surgical intervention, and optimal use of antibiotics can reduce morbidity and prevent death.
I
ioamnionitis. Her cervix was unfavorable; therefore, hysterotomy was performed to evacuate the infected conceptus. No intra-operative complication was reported during the surgery. However, total wound dehiscence occurred on the fifth day postoperatively. Gram staining of wound discharge showed mixed bacteria, including oval, sub-terminal spore-bearing Gram-positive bacilli, which was suggestive of a non-perfringens Clostridium (Fig. 1). Rectovaginal examination found a pelvic collection with crepitus. Emergency computed tomography (CT) showed large pockets of gas-containing fluid in the retroperitoneal space. Other, smaller fluid collections were present between bowel loops (Fig. 2). Her vital signs remained stable, except for a low-grade fever. The patient agreed to a prompt re-exploratory laparotomy including the possibility of hysterectomy. Prior to the surgery, both ureters were catheterized cystoscopically. A large amount of pus was drained from the retroperitoneal pelvic
nfection in the retroperitoneal space is aggressive. It may also have an atypical presentation [1]. This serious infection occurs rarely in the postpartum period. With limited experience in this specific circumstance, optimal management is controversial. We describe a case of retroperitoneal abscess caused by Clostridium difficile arising after hysterotomy in the second trimester. In addition, variation in the clinical course and management of puerperal retroperitoneal infection was reviewed from the recent English-language literature.
Case Report
A 25-year old nulliparous Thai woman presented with unexplained fetal demise at 22 wk gestation. Medical termination was performed using vaginal misoprostol and intravenous oxytocin. There was spontaneous rupture of the membranes two days later, and she soon developed chor-
1 Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, 2Department of Microbiology, and 3Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand. Presented at the First Global Congress of Maternal and Infant Health, Barcelona, Spain, September 26–28, 2010.
1
2
WATAGANARA ET AL.
FIG. 1. Gram stain of material from surgical site shows large gram-positive bacilli with oval sub-terminal spores. Spore formation was more prominent after culture.
collections by blunt and sharp dissections of the necrotic endopelvic fascia until a bleeding tissue plane was reached (Fig. 3). Collections between the bowel loops also were evacuated. Systematic examination of the small and large bowel excluded injury from the previous operation. The decision was made to preserve the uterus because her uterus appeared to be free from infection, and the Gram stain suggested a non-virulent strain of Clostridium spp. Operating time was 3 h, with an estimated blood loss of 500 mL. Percutaneous drains were placed. The skin and subcutaneous tissue were left open for delayed primary closure five days later. Vancomycin was given empirically at a dose of 1 g q 12 h IV for five days. Bacterial culture of the retroperitoneal collection revealed mixed aerobic and anaerobic bacteria, including Clostridium spp. The Clostridium was identified subsequently as C. difficile by its phenotype and 16S ribosomal DNA sequencing. Tests for toxin genes (A, B, and binary) were negative. After the patient became afebrile, she was switched to oral vancomycin 500 mg q 6 h for the next two weeks. No other antibiotics were used. The patient recovered without morbidity.
FIG. 2. Computed tomography reveals gas-containing collection in endopelvic fascia. Disruption of abdominal incision is noted.
Discussion
Retroperitoneal infection is a serious obstetric complication. The mortality rate can be as high as 20%, especially if the infection is complicated by necrotizing fasciitis [2,3]. Symptoms of sepsis may not correlate with the size of the retroperitoneal collection. Aerobic bacteria are identified most frequently as the major cause [4,5]. However, co-infection with anaerobic bacteria may occur, although its real incidence may be underestimated. If Clostridium spp. is suspected from the Gram stain, identification to the species level essential to guide the treatment. Definitive risk factors for puerperal retroperitoneal infection are still unclear. We were able to identify 12 recent reports of retroperitoneal infection associated with miscarriage or delivery (Table 1). An association between the route of delivery and retroperitoneal infection is still elusive. According to the data in Table 1, most retroperitoneal infections developed after vaginal delivery (nine of 12), followed by miscarriage (n = 2), and cesarean delivery (n = 1). The higher proportion of retroperitoneal infection after vaginal delivery may be either because of the higher number of such deliveries or the less aseptic nature of vaginal birth compared with cesarean section. Chorioamnionitis was diagnosed in two of nine patients with necrotizing fasciitis following cesarean delivery [3]. Impaired immunity during pregnancy, concurrent use of non-steroidal anti-inflammatory drugs, diabetes mellitus, malnutrition, older age, and peripheral vascular diseases can contribute to post-partum infection [6]. The psoas muscle is the most common site of ascending infection because of its rich vascular supply and direct lymphatic drainage from the genital tract. Psoas abscess may present as pelvic pain, edema, and sepsis, as shown in seven of the case reports summarized in Table 1 [2]. Sonography is the main imaging modality to diagnose pelvic collections, but CT or magnetic resonance imaging may be helpful in equivocal cases because of their superior soft-tissue contrast and larger field of view [7,8]. In addition to ascending infection from the genital tract, surgical site infection, iatrogenic bowel injury, and hematogenous spread from an extra-abdominal site can lead to retroperitoneal abscess [9,10]. There is substantial diversity in the clinical manifestations of puerperal retroperitoneal infection that may not be associated with the route of infection. For example, an
PUERPERAL RETROPERITONEAL ABSCESS
3
FIG. 3. Intra-operative and post-operative findings. (A) Low midline incision was extended for adequate exposure. (B) Necrotic endopelvic tissue was dissected. (C) Healthy appearance of uterus and both adnexae. (D) Healed surgical site after delayed primary closure.
infection after a simple vacuum aspiration led to a serious case of psoas abscess, which required laparotomy for drainage [11], whereas another case of surgical site infection of cesarean section incision led to a minor psoas abscess that was treated successfully with aspiration and a short course of antibiotics [9]. Estimation of the true prevalence of puerperal retroperitoneal infection may be difficult because of under-reporting of cases with adverse outcomes. Variation in management of puerperal retroperitoneal infection is notable. A long course of antibiotics alone may be adequate for an isolated, small psoas abscess [9, 12–14]. A combination of antibiotics and simple aspiration may be adequate for a collection of moderate size [7, 9]. If the collection is large but still contained in the retroperitoneal space, percutaneous drainage may be established with CT or ultrasound guidance to prevent recurrence [15–19]. Laparoscopy was used to guide the placement of continuous drainage in a pediatric case [20]. Exploratory laparotomy for drainage and extensive debridement can be lifesaving if the infection has spread beyond the retroperitoneal space [11]. Adequate drainage and extensive debridement should be accomplished in a single operation. Re-exploration is associated with increased morbidity [21]. Careful preoperative preparation such as bilateral ureteral catheterization can facilitate adequate dissection of the pelvic fascia and prevent injury to the ureters. Prompt action is crucial, as delayed management can result in permanent disability such as hip joint damage [17]. It is important to exclude the more virulent species of Clostridium, especially C. perfringens, which causes gas gangrene, or C. sordellii, which causes toxic shock syndrome
[22, 23]. Toxins produced by these Clostridium spp. are highly lethal. Because no antitoxins are available, prompt removal of the uterus is necessary. Clinically, profound septic shock is common in infection with virulent strains of Clostridium. Gram stain remains an excellent bedside test to identify the type of Clostridium by its morphology. Clostridium perfringens is a large gram-positive bacillus without spores. A large gram-positive bacillus with oval, sub-terminal spores, was present in our patient, could be either the virulent C. sordellii or the more benign C. difficile. The minor systemic symptoms in our patient were consistent C. difficile. This organism is a normal inhabitant of the genital tract in 18% of women [24]. Genetic typing assay can confirm the species and identify the primary source of infection for the purpose of tracing the origin of the infection [25]. In conclusion, our case illustrates a favorable outcome of puerperal retroperitoneal abscess treated with surgical intervention and antibiotics. This serious obstetric infection may not be preventable, but a timely, definitive approach can reduce the morbidity. Although our patient did not have obvious sepsis, her diagnosis could have been made earlier by checking for signs of infection of the incision in the first few days after her first operation. Individual risk factors, such as her chorioamnionitis, have to be recognized. The value of a strict aseptic protocol during surgery cannot be overemphasized. Prophylactic antibiotics have been proved to reduce serious infectious morbidity after abdominal delivery [26]. Alternative interventions may be available in the future with advancing knowledge of critical care, better antibiotics, or partially hyperbaric oxygen therapy [2, 27].
4
1
1
Yagi et al., 2005 [12] Patil et al., 2006 [14]
Young et al., 2010 [28]
Kumar et al., 2009 [20] Kwan et al., 2009 [8]
Vaginal
Vaginal
1
1
Vacuum aspiration
Dilation and curettage for incomplete abortion
1
1
Vaginal
Vaginal
Vaginal
Cesarean section
1
1
Vaginal
1
Shahabi et al., 2002 [17]
Sokolov et al., 2007 [2] Bhattacharya et al., 2008 [18] Cedric et al., 2009 [27]
Vaginal
1
Saylam et al., 2002 [10]
Vaginal
2
Segal et al., 1996 [16]
Vaginal
Mode of Delivery
1
No. of cases
Shah et al., 1992 [15]
Publication
Hip pain, fever
Pelvic pain, fever
Abdominal pain, fever
Flank pain, chills
Pelvic and sciatic pain, fever
Back pain
Pelvic and leg pain
Hip pain, fever
Pelvic pain, fever
Surgical site infection, back pain
Flank pain, fever
Hip pain, fever
Presentation
Psoas abscess
Iliopsoas abscess
Psoas abscess
Sacroiliitis and gluteal abscess
Psoas abscess
Iliopsoas pyomyositis
Psoas abscess
Iliopsoas fasciitis
Psoas abscess
Psoas abscess and sacroiliitis
Retroperitoneal abscess with sacroiliac joint disruption Retroperitoneal abscess
Diagnosis
Day 5
Week 4
Day 6
Day 2
Week 2
Day 9
Day 3
Day 2
Day 7: Infected incision; day 8: Psoas abscess Day 2
Case 1: Day 1 Case 2: Day 10
Day 23
Time of Onset
Coagulase-negative Staphylococcus
Unable to identify
Staphylococcus agalactiae, b-hemolytic Streptococcus, Lancefield Group B Undisclosed
Methicillin-resistant S. aureus Group B Streptococcus
Streptococcus pyogenes Unable to identify
Mixed infection with viridans Streptococcus
Case 1: Unable to identify Case 2: Escherichia coli and Acinetobacter spp. Staphylococcus aureus
Pneumococcus
Organism(s) Isolated
Table 1. Recent Reports of Puerperal Retroperitoneal Infection
Antibiotics, laparotomy Antibiotics, percutaneous ultrasound-guided aspiration Antibiotics, CTguided percutaneous drainage
Antibiotics
Incision and drainage, antibiotics
Percutaneous drainage, antibiotics Antibiotics
Antibiotics, percutaneous computed tomography (CT)guided drainage Antibiotics
Antibiotics, percutaneous aspiration
Antibiotics, percutaneous drainage, daily irrigation
Antibiotics, percutaneous drainage.
Treatment
None
None
None
Sacroiliac joint damage
None
None
None
None
None
None
Case 1: Hip joint damage Case 2: None
None
Morbidity
PUERPERAL RETROPERITONEAL ABSCESS Acknowledgment
We thank the dedicating nursing staff at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. We thank the patient for her consent to this report. Author Disclosure Statement
The authors have no conflicts of interest. References
1. Pruyn SC. Acute necrotizing fasciitis of the endopelvic fascia. Obstet Gynecol 1978;52(1 Suppl):25–45. 2. Gallup DG, Freedman MA, Meguiar RV, et al. Necrotizing fasciitis in gynecologic and obstetric patients: A surgical emergency. Am J Obstet Gynecol 2002;187:305–310. 3. Goepfert AR, Guinn DA, Andrews WW, Hauth JC. Necrotizing fasciitis after cesarean delivery. Obstet Gynecol 1997;89:409–412. 4. McHenry CR, Azar T, Ramahi AJ, Collins PL. Monomicrobial necrotizing fasciitis complicating pregnancy and puerperium. Obstet Gynecol 1996;87:823–826. 5. Daif JL, Levie M, Chudnoff S, et al. Group A Streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy. Obstet Gynecol 2009;113:504–506. 6. Gonza´lez Castro A, Rodriguez-Borregan JC, Obeso T, et al. Necrotizing fasciitis after cesarean section. Arch Gynecol Obstet 2008;277:579–581. 7. Kwan A, Bhanshaly A, Wright C. Iliopsoas abscess: An usual cause of postpartum sepsis. Obstet Med 2009;2: 30–31. 8. Riyad MN, Sallam MA, Nur A. Pyogenic psoas abscess: Discussion of its epidemiology, etiology, bacteriology, diagnosis, treatment and prognosis—Case report. Kuwait Med J 2003;35:44–47. 9. Saylam K, Anaf V, Kirkpatrick C. Successful medical management of multifocal psoas abscess following cesarean section: Report of a case and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002;102:211–214. 10. Castiglioni B, Gautam A, Citron DM, et al. Clostridium innocuum bacteremia secondary to infected hematoma with gas formation in a kidney transplant recipient. Transpl Infect Dis 2003;5:199–202. 11. Kumar S, Malhotra N, Chanana C, Lal S. Psoas abscess in obstetrics. Arch Gynecol Obstet 2009;279:247–249. 12. Yagi H, Fukushima K, Satoh S, et al. Postpartum retroperitoneal fasciitis: A case report and review of literature. Am J Perinatol 2005;22:109–113. 13. Sokolov KM, Kreye E, Miller LG, et al. Postpartum iliopsoas pyomyositis due to community-acquired methicillinresistant Staphylococcus aureus. Obstet Gynecol 2007;110: 535–538.
5
14. Yacoub WN, Sohn HJ, Chan S, et al. Psoas abscess rarely requires surgical intervention. Am J Surg 2008;196:223–227. 15. Patil A, Gatongi DK, Haque L, Mires G. Primary psoas abscess following spontaneous vaginal delivery. J Obstet Gynaecol 2006;26:565–569. 16. Shah PN, Rane VA, Moolgaoker AS. Retroperitoneal abscess complicating a normal delivery. Br J Obstet Gynaecol 1992;99:160–161. 17. Segal S, Gemer O, Sestopal-Epelman M, et al. Retroperitoneal abscess after normal delivery: A report of two cases. J Reprod Med 1996;41:276–278. 18. Shahabi S, Klein JP, Rinaudo PF. Primary psoas abscess complicating a normal vaginal delivery. Obstet Gynecol 2002;99:906–909. 19. Bhattacharya R, Gobrial H, Barrington JW, Isaacs J. Psoas abscess after uncomplicated vaginal delivery: An unusual case. J Obstet Gynaecol 2008;28:544–546. 20. Katara AN, Shah RS, Bhandarkar DS, Unadkat RJ. Retroperitoneoscopic drainage of a psoas abscess. J Pediatr Surg 2004;39:e4–e5. 21. Sudarsky LA, Laschinger JC, Coppa GE, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 1987;206:661–665. 22. Rorbye C, Petersen LS, Nilas L. Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome. Acta Obstet Gynecol Scand 2000;79:1134–1135. 23. Kurashina R, Shimada H, Matsushima T, et al. Spontaneous uterine perforation due to clostridial gas gangrene associated with endometrial carcinoma. J Nippon Med Sch 2010; 77:166–169. 24. Hafiz S, McEntegart MG, Morton RS, Waitkins SA. Clostridium defficiel [sic] in the urogenital tract of males and females. Lancet 1975;1:420–421. 25. Tabaqchali S, Holland D, O’Farrell S, Silman R. Typing scheme for Clostridium difficile: Its application in clinical and epidemiological studies. Lancet 1984;1:935–938. 26. Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section: A systematic review and meta-analysis. Br J Obstet Gynaecol 2013;120:661–669. 27. Hung JH, Wang JH, Chen CY, et al. Hyperbaric oxygen therapy for cesarean section wound in diabetes mellitus gravida. J Chin Med Assoc 2008;71:373–376.
Address correspondence to: Dr. Tuangsit Wataganara Division of Maternal–Fetal Medicine Department of Obstetrics and Gynecology Faculty of Medicine Siriraj Hospital 2 Prannok Road, Bangkoknoi Bangkok, Thailand 10800 E-mail: [email protected]
