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Background
Owing to the low incidence, difficult accessibility and non-specific features of psoas abscess (PAs), there are often delays in the diagnosis and management of this condition, which can potentially result in prolonged sepsis, increased morbidity and mortality. Being aware of the many non-specific ways a PA can present, and having a patient present with such vague clinical features, aid in making an appropriate management plan. As seen in many cases of PA, the collection of clinical features and their severity at the time of presentation to accident and emergency (A&E) result in referral to several specialities; this case required joint management between general medicine, general surgery and plastic surgery.
Case presentation
A 55-year-old man was referred to A&E with a painful, swollen right thigh and buttock. He was initially suspected of having cellulitis of the right thigh, and was admitted to the medical receiving ward and started on intravenous antibiotics. However, the patient's condition deteriorated and he was subsequently referred to plastic surgery when he became systemically unwell, with suspected necrotising fasciitis. On examination, he was thin, pale and pyrexic. The abdomen was distended and tender, and bowel sounds were present. The appearance of the skin over the buttock and thigh was unremarkable with only mild erythaema and a small patch of cellulitis visible. There were no blisters or bruising characteristic of a necrotising fasciitis. Tenderness and guarding were noted in the right iliac fossa and pain was elicited on palpation of the lower back, exacerbated by hip movement. Crepitus was noted over the proximal anterior compartment of the thigh and the patient was unable to flex his hip.
A further medical history, taken on admission, revealed that the patient had suffered from a worsening pain in his back, hip and thigh that radiated to his right knee for the past month. He was unable to weight bear on his right side. He had previously been referred to physiotherapy as this pain was suspected to be a mechanical problem. He also reported a history of anorexia, right iliac fossa pain, constipation and watery diarrhoea during the same period.
Further blood tests and CT scan were requested to detect necrotising myositis or underlying intra-abdominal pathology.
Investigations
Blood tests showed microcytic hypochromic anaemia (haemoglobin 89 g/L,...