Bilateral Gluteal Abscess in Crohn's

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					Case report: Bilateral gluteal abscess mistaken for Crohn’s related
spondyloarthropathy


J G Sutton, M Jamison and W Ahmed


Department of Gastroenterology, Ysbyty Gwynedd, North West Wales NHS Trust,
Bangor, North Wales, LL56 2PW


Abstract
Abscesses and fistulae formation are common complications of Crohn’s disease.
However it is unusual for retroperitoneal abscesses to extend beyond the psoas and
iliac spaces. There have been reported cases of gluteal abscess formation in Crohn’s.
This is the first case of bilateral gluteal abscesses in Crohn’s, the bilateral nature of
the abscesses led to confusion with the diagnosis, which was misdiagnosed as Crohn’s
related spondyloarthropathy.


Case
An 18-year-old male presented with a nine-month history of lower abdominal pain,
diarrhoea and weight loss. His inflammatory markers were elevated. This was treated
on clinical suspicion as Crohn’s disease, with an ultrasound of the abdomen
suggesting prominence of the terminal ileum. Barium follow through examination of
the small bowel appeared normal. However his symptoms settled with corticosteroids
and relapsed on stopping treatment. With three admissions with recurrent symptoms
over the nine month period


On the fourth admission he presented with colicky right iliac fossa pain and a two-
week history of watery diarrhoea without blood or mucus. On this occasion he also
complained of bilateral leg pain. On examination he was emaciated, pale and toxic
with a sinus tachycardia but normotensive. Abdominal examination revealed right
iliac fossa tenderness with no signs of peritonism. Rectal examination was
unremarkable. Examination of the lower limbs revealed no neurological deficit, and a
full range of pain free movements.




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Blood investigation showed a marked leucocytosis, elevated C-reactive protein, and
thrombocythaemia.


He was treated as an acute flare up of Crohn’s disease with intravenous
hydrocortisone and azathioprine. Initially he responded well with decreased
symptoms and reduction of C-reactive protein.


On day five of admission he complained of severe bilateral hip pain. Radiograph of
the pelvis showed no abnormality. His thrombocythaemia persisted. Rheumatological
review was requested and a provisional diagnosis of Crohn’s related
spondyloarthropathy was made and the patient was commenced on non-steroidal anti-
inflammatory medication.


On day eight his abdominal pain worsened and he still complained of severe bilateral
hip pain. He was then given TNFα inhibitor (Infliximab), both as a treatment for his
spondyloarthropathy and his Crohn’s disease.


By day twelve he had developed tender red indurated areas over both trochanteric
regions. Radiograph of the pelvis was repeated, and this showed gas in the soft tissues
over both the trochanters (figure 1). Clinical examination now revealed crepitus in
both buttocks. An urgent single contrast barium enema revealed a small leak of
contrast in the presacral soft tissues, with the probable source being the rectum or
sigmoid.


Laparotomy was performed and revealed the terminal ileum to be adherent to the
rectosigmoid junction with a large abscess posterior to the rectum, tracking laterally
and inferiorly. The terminal ileum and caecum were resected and an ileostomy
brought out in the right iliac fossa. The abscesses were drained per abdomen and the
gluteal skin left intact. Operative histology confirmed the diagnosis of Crohn’s
disease. The patient was commenced on broad-spectrum antibiotics


The patient had a slow recovery post-operatively, remaining septic for several days.
Magnetic resonance imaging showed a residual gluteal abscess, which was treated
conservatively. His inflammatory markers gradually normalized and he was


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discharged on day thirty-four. Follow up at two months has showed that he has
regained all his weight and is symptom free.


Discussion


The incidence of intraperitoneal abscesses in Crohn’s disease is approximately 12-
28%1. With abscess formation occurring more frequently in predominately small
bowel disease, as compared to colorectal disease2. The incidence of retroperitoneal
abscess is much lower, 2.7-4.3%3. With a marked male preponderance3.
Retroperitoneal abscesses have been reported in a variety of anatomical sites, such as
iliac, psoas, lumbrosacral and lumbocrural4. It is also known that abscesses do not
always terminate at the psoas or iliac spaces5. The abscess may track inferiorly
breaching the obturator fascia, passing through the greater sciatic formina resulting in
abscesses in the gluteal and posterior upper thigh5, 6(figure 2). Four gluteal abscesses
being reported in the literature4, 5, 7. However we believe that this is the only reported
case of bilateral gluteal abscess formation.


This case demonstrates the difficulty of making the diagnosis in such patients. The
diagnosis is problematic, with 10% of abscesses unsuspected and only discovered at
laparotomy performed for medically unresponsive disease2. In this gentleman’s case
the diagnosis was delayed due to the bilateral nature of the abscesses leading to
bilateral hip pain and thus a mistaken diagnosis of Crohn’s related
spondyloarthropathy. This is confounded by the fact that inflammatory markers are
unreliable in indicating sepsis in a patient already suffering from a chronic
inflammatory condition. In addition treatment with corticosteroids can further mask
the host inflammatory response. This effect was exaggerated in this case due to the
concomitant administration of TNF inhibitor. The diagnosis was finally reached due
to the patient’s rapid deterioration, and radiographic findings of gas in the soft tissues,
alongside clinical findings of fluctuant masses as well as crepitus in both buttocks, a
late sign4!


This non-specific presentation is typical of retroperitoneal abscesses, which usually
present with weight loss, abdominal pain, and toxaemia8. The clinical features can



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also mimic a retrocaecal appendix5, with a positive psoas sign. Another possible
feature can be pain radiating to the ipsilateral groin and thigh due to irritation of the
genitofemoral nerve5.


Treatment of this complication involves drainage either surgically or under
radiological guidance2. With recent papers favouring the latter approach2. Then
medical treatment to stabilise the patient’s condition prior to definitive surgery2. In
this case the patient received emergency surgery, and recovered well.


References:


   1. Steinberg DM, Cooke WT, Alexander-Williams J. Abscess and fistulae in
       Crohn’s disease. Gut 1973; 14:865.
   2. Jawhari A, Kamm MA, Ong C, Forbes A, Bartram CI, Hawley PR. Intra-
       abdominal and pelvic abscess in Crohn’s disease: results of non-invasive and
       surgical management. British Journal of Surgery 1998; 85:367-371.
   3. Ribeiro MB, Greenstein AJ, Yasunobu Y, Aufses AH. Intra-abdominal
       abscess in regional enteritis. Annals of Surgery 1991; 213(1):32-36.
   4. Hussien M, Mudd DG. Crohn’s disease presenting as a left gluteal abscess.
       International Journal of Clinical Practice 2001; 55(3):217-218.
   5. Mayer DA, Zingdale RG, Tsapogas MJ. Case study: Gluteal abscess due to
       Crohn’s disease. Ostomy Wound Management 1993; 39:30-34.
   6. Denton ERE, Jamieson CP, Rankin SC. Case report: Abscess of the adductor
       muscles of the thigh- an unusual complication of Crohn’s disease. The British
       Journal of Radiology 1996; 69:865-866.
   7. Sangwan YP, Schoetz DJJR, Murray JJ et al. Perianal Crohn’s disease: results
       of local surgical treatment. Diseases of the Colon and Rectum 1996;
       39(5):529-535.
   8. Funayama Y. Psoas abscess complication in Crohn’s disease: report of two
       cases. Surgery Today 1996; 26:345-348.




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