Iliopsoas and Gluteal Abscesses in a Patient with Regional Enteritis

A 24-year-old male with a five-month history of regional enteritis treated with the tumor necrosis factor-alpha antagonist certolizumab presented with increasing back pain and progressive loss of mobility. Evaluation with computed tomography (CT) and magnetic resonance imaging showed a retroperitoneal mass suggestive of a sarcoma. Right hydronephrosis was relieved with a ureteral stent, but progressive difficulty walking necessitated mechanical aids. A temperature of 39°C prompted hospitalization, and repeat CT scanning showed a multi-loculated retroperitoneal mass with an air–fluid interface (Figs. 1A, B) extending through the sciatic notch into the right gluteus maximus muscle. Attempted biopsy of the buttock yielded 65 mL of pus and stool; he was then transferred to our institution.

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FIG. 1.

Iliopsoas and gluteal abscesses in patient with regional enteritis. (A) Computed tomography scan shows right ureteral stent (white arrow), iliopsoas abscess (short black arrow), and gluteal abscess (long black arrow). (B) Multi-loculated gluteal abscesses.

Loop ileostomy and drainage of the gluteal abscess were performed for source control. Cultures yielded Escherichia coli, Streptococcus intermedius, and Prevotella bivia, and he was treated with intravenous levofloxacin and metronidazole. Unassisted ambulation was restored. Approximately three months later, the patient underwent diagnostic laparoscopy. In addition to ileocolic disease, a diseased rectosigmoid colon was adherent to the sacrum. Attempted laparoscopic resection was converted to open ileocecectomy, proctosigmoidectomy, and coloproctostomy, preserving the loop ileostomy. His hospital course was uneventful, and he was discharged home on post-operative day 5.

Fistulas and abscesses are recognized complications of regional enteritis, occurring in 10%–30% of patients at some point [1]. Abscesses are frequently complex, associated with intestinal fistulas, and may be even more common in immunosuppressed patients [2]. Psoas abscesses are characteristic of ileocolic disease, but gluteal and thigh abscesses are rare [3,4]. An important management tenet is to obtain source control of the abscesses, control sepsis, optimize the patient's general condition and nutrition acutely, and perform elective surgery subsequently on the involved intestine. Percutaneous drainage has emerged as a component of first-line treatment [5]. Factors that have been associated with failure of percutaneous drainage include steroid use, specific disease phenotypes, and multiple or multi-loculated abscesses [2].