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Special Feature
September 2008

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Surgical Department, Leighton Hospital, Crewe, England.


Carl E.BredenbergMD

Arch Surg. 2008;143(9):913-914. doi:10.1001/archsurg.143.9.913

A 68-year-old man was admitted to the hospital with fever, right loin pain, and right hip stiffness of 3 days' duration. He has had 3 hospital admissions since February 2005 for right-sided psoas abscess. The abscess was treated with ultrasonographic-guided drainage twice, and 2 weeks before this admission, the patient had an open appendectomy through a Lanz incision with evacuation of the abscess. On physical examination, he was pyrexial and there was a palpable mass in his right loin region. His blood test results showed leukocytosis and an increased C-reactive protein level, and his blood culture results were negative for disease. Computed tomography (CT) showed a recurrent psoas abscess (Figure 1). Laparotomy and abscess evacuation were performed. The patient noted right iliac fossa pain on the fifth postoperative day. Computed tomography showed a track between the ascending colon and an abnormal-looking right iliac fossa area. Laparotomy and right hemicolectomy were performed. Histologic analysis of the bowel specimen revealed chronic inflammation and perforation. The precise etiology of the perforation was not found. The patient noted rigors and discharging pus from the surgical wound postoperatively. Disruption of the bowel anastomosis was postulated, and the patient was treated conservatively. Repeated CT of the abdomen showed no anastomotic leak. However, the appearance of the right psoas remains abnormal. The radiologist suggested magnetic resonance imaging (Figure 2).

Figure 1. 
Computed tomographic scan of the abdomen showing a recurrent psoas abscess (arrow).

Computed tomographic scan of the abdomen showing a recurrent psoas abscess (arrow).

Figure 2. 
Magnetic resonance image of the pelvis.

Magnetic resonance image of the pelvis.

What Is the Diagnosis?

A. Crohn disease

B. Appendicitis

C. Septic arthritis

D. Diverticulitis