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Year : 2012  |  Volume : 55  |  Issue : 4  |  Page : 593-594
Psoas and thyroid abscess in a renal allograft recipient


Institute of Microbiology, Madras Medical College & Rajiv Gandhi Govt. General Hospital, Chennai, Tamil Nadu, India

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Date of Web Publication4-Mar-2013
 

How to cite this article:
Deepa R, Banu S T, Jayalakshmi G, Parveen J D. Psoas and thyroid abscess in a renal allograft recipient. Indian J Pathol Microbiol 2012;55:593-4

How to cite this URL:
Deepa R, Banu S T, Jayalakshmi G, Parveen J D. Psoas and thyroid abscess in a renal allograft recipient. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Jun 19];55:593-4. Available from: http://www.ijpmonline.org/text.asp?2012/55/4/593/107840


Sir,

Psoas abscess and thyroid abscess are distinct clinical entities occurring in unique anatomic locations and rarely encountered in the same patient. Psoas abscess is traditionally reported as secondary to spinal tuberculosis, but other etiological agents are reported as well. [1],[2] This interesting case is presented because simultaneous psoas and thyroid abscess is rarely reported in the clinical literature. It also highlights the need to search for an occult source of infection in an immunosuppressed patient.

A 40-year-old male presented with difficulty in breathing, swelling in front of neck, and hoarseness of voice of 2 days duration. He also had painful, restricted movement of right lower limb. He underwent renal transplantation from a living related donor 2 years ago and was on immunosuppressive agents. He was on hemodialysis since 2 months for graft dysfunction. Neck examination revealed a diffuse fluctuant, tender mass 6 × 4 cm 2 . Diagnosis of thyroid abscess was confirmed by ultrasound examination. Open incision and drainage of the pus were done. Empirical parenteral therapy with ciprofloxacin and cefotaxime was started after aseptically obtaining pus, blood, and urine for culture.

Abdominal examination revealed a transverse scar in right lower abdomen and a tender vague mass of size 4 × 4 cm 2 right iliac fossa associated with flexor spasm of the right hip. Ultrasonography of abdomen and magnetic resonance imaging (MRI) confirmed right psoas abscess with transplanted kidney anteriorly and normal lumbar spine [Figure 1]. Ultrasound-guided pigtail percutaneous drainage of the right psoas abscess was done.
Figure 1: MRI showing right psoas abscess with transplanted kidney anteriorly

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Laboratory investigations revealed anemia, leucocytosis, and elevated renal function tests. Chest X-ray and thyroid function tests were normal. Direct gram stain of pus from both sites revealed plenty of pus cells and slender gram-negative bacilli [Figure 2]. Aerobic culture of pus showed pure growth of Pseudomonas aeruginosa. P. aeruginosa was also isolated from blood and urine culture (10 5 cfu/ml). All the isolates were sensitive to piperacillin-tazobactam 100 μg + 10 μg, piperacillin 100 μg, imipenem10 μg, and meropenem 10 μg and resistant to ceftazidime 30 μg, cefepime 30 μg, gentamicin 10 μg, amikacin 30 μg, ciprofloxacin 5 μg, and ofloxacin 5 μg (Himedia, Mumbai).
Figure 2: Direct gram stain of pus showing pus cells and slender gram-negative bacilli (Gram's, ×1000)

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The antibiotics were stepped up to piperacillin-tazobactam on the fourth day. A review of ultrasonogram of neck and abdomen on the ninth day was normal. Antibiotics were continued till the 11th day and stopped. Repeat culture of urine on the 13th day showed no growth.

Prolonged hemodialysis is a risk factor for asymptomatic bacteriuria. The incidence of asymptomatic bacteriuria in patients undergoing hemodialysis is about 28%. [3] Mandatory screening is recommended for the first 6 months of transplantation and antibiotic therapy given till urine culture becomes negative. [4]

Kidney recipients have more likely to have blood stream infections (BSI) 12 months after transplant with a primary urinary source than liver recipients. P. aeruginosa contributes to 3.2% of gram-negative BSI after 12 months of a solid organ transplant (SOT) in contrast to 22.8% within 1 month of a SOT. [5]

P. aeruginosa isolated from our patient was multidrug-resistant. Al Hasan et al. reported multidrug resistance in 10.3% of P. aeruginosa isolates from BSI in kidney recipients. About 20-35% of the isolates were resistant to piperacillin-tazobactam, imipinem, fluoroquinolones, and aminoglycosides. [5]

Secondary hematogenous seeding and immunosuppression are predisposing factors for thyroid and psoas abscesses, in the absence of underlying local disease. Tabrizian et al.[1] reported immunosuppression in 15% and bacteremia in 13% in secondary IPA. Two of these immunosuppressed patients were transplant recipients. Three large reviews of 501 cases of thyroid abscesses between 1900 and 2000 show P. aeruginosa as the causative organism in six cases. [2]

In conclusion, asymptomatic bacteruria can occur in renal allograft recipients even after 6 months post-transplant with associated factors such as prolonged hemodialysis. Screening and detection of such cases and appropriate antibiotic therapy will prevent bacteraemia and systemic complications

 
   References Top

1.Tabrizian P, Nguyen SQ, Greenstein A, Rajhbeharrysingh U, Divino CM. Management and treatment of iliopsoas abscess. Arch Surg 2009;144:946-9.  Back to cited text no. 1
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2.Jacobs A, Gros DA, Gradon JD. Thyroid Abscess Due to Acinetobacter calcoaceticus. Case report and review of causes of and current management strategies for thyroid abscesses. South Med J 2003;96:300-7.  Back to cited text no. 2
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3.Chaudhry A, Stone WJ, Breyer JA. Occurrence of pyuria and bacteriuria in asymptomatic hemodialysis patients. Am J Kidney Dis 1993;21:180-3.  Back to cited text no. 3
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4.Yacoub R, Akl NK. Urinary tract infections and asymptomatic bacteriuria in renal transplant recipients. J Glob Infect Dis 2011;3:383-9.  Back to cited text no. 4
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5.Al-Hasan MN, Razonable RR, Eckel-Passow JE, Baddour LM. Incidence rate and outcome of Gram-negative bloodstream infection in solid organ transplant. Am J Transplant 2009;9:835-43.  Back to cited text no. 5
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Correspondence Address:
R Deepa
Senior Assistant Professor of Microbiology, Institute of Microbiology Madras Medical College, Chennai 600003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.107840

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