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Since psoas muscle abscess is not a common disease, especially among children, it is often confused with diseases that have the same symptoms and pathology. The psoas muscle abscess is mistakenly recognized as a disease caused by trauma or some minor external injury. It is certainly not true as long as multiple internal processes can be observed. Moreover, the disease is difficult to detect due to inappropriate method of diagnosis, even though some sophisticated techniques are applied. The main confusion, however, is based on symptoms of fever and abdominal pain, which are usually recognized as minor infection, poisoning, etc. These symptoms are typical of many infections, thus, it is hard to identify an infected area of a patient’s organism. Furthermore, establishing a relevant diagnosis can be influenced by accompanying symptoms and diseases. Therefore, nurses as well as doctors should always be aware of the fact that psoas muscle abscess is a result of infection, which is why fever and abdominal pain are present.
A 12-year-old girl has been admitted with a three-week history of fever up to 39 degrees occurring one or two times a day. The girl was treated in numerous clinics with diagnosis of urinary tract variation. A medical history as well as family history of the girl does not demonstrate any abnormalities. Prenatal and neonatal periods do not show any deviations, and thus, the girl is considered to be born healthy. She was given Augmentin, Cefuroxime, and Bactrim on different occasions. There are no diabetes or specific substances that cause allergic reaction mentioned in the medical history of the girl.
The patient has abdominal pain dull in nature. The pain is described by the girl as located in the right part of the abdomen with some radiation to the back. The girl also complains about the pain becoming stronger in sitting position while weakening in lying supine. Accordingly, fever keeps occurring with the same frequency of one or two times a day. The temperature does not change; it is 39 degrees on a daily basis. Screening of the patient’s abdominal area has demonstrated no abnormalities in the urinary bladder and the uterus. However, obstruction of the right kidney has been observed.
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The screening results suggest that the girl has obstruction of the right kidney with a potential superadded infection. Compensatory enlargement of the left kidney is also confirmed. The right kidney is globally destroyed with replacement of the parenchyma with multiple low attenuation non-enhancing tissue. Some of the tiny low attenuation spots appear at the range of fat attenuation. In addition, multiple stones in kidneys are detected. Stranding of paranephric as well as perinephric fat is also observed. Thus, psoas abscess is diagnosed.
Since there are an excessive number of researches on psoas muscle abscess, it is appropriate to focus on the most basic elements of theoretical framework. As Atkinson Morris, Ng, and Friedman suggest (2006), psoas muscle abscess occurs quite rarely among children. However, patients at pre-pubertal age are the most vulnerable for infections. Muscle psoas is usually caused by tuberculous spondylitis. If it is not timely addressed, it causes psoas muscle abscess with a proactive culturing of Staphylococcus aureus. Since the girl is 12, such evidence can be justified. As a result, a classic presentation of the disease includes fever, pain in back, and limping.
Besides back and abdominal pains, Schwaitzberg et al. (1985) admit hip pain and passive extension of kidneys. In addition, resistance to the primary cause of infection usually results in a relative rotation. Schwaitzberg et al. (1985) also consider trauma to be the primary reason for such presentation. Moreover, trauma can be a predisposing factor, but it is not necessarily present in such cases (Karli et al., 2014). Furthermore, ultrasonography or computerized tomography is required for clarification of kidney processes and identification of any abnormalities in the urine bladder and other related organs (Landi et al., 2011).
On the contrary, John Song, Merv Letts, and Ron Monson (2001) assume that infection causes inflammation. As a result, the inflammation produces a painful spasm. Therefore, spasm as well as inflammation should be eliminated with the help of abscess drainage and use of antibiotics intravenously. Such treatment is quite simple, but it addresses the causes of the disease (Karli et al., 2014). Nevertheless, it will produce a positive effect under the stipulation that a patient does not have any other complications. However, a need for surgical drainage is not explicit as Song, Letts, and Monson (2001) confirm that image-guided aspiration is much better solution to existing conditions. It is becoming increasingly apparent that some inconsistency between case report and literature can be observed, which is why a detailed discussion and clarification should be provided.
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In regard to consistency of the case report with the literature review, evident similarities should be indicated. The case report as well as literature review suggest that infection is the original cause of disease. The girl has been having fever and abdominal pain on a day-to-day basis. It is difficult to ignore the fact that these symptoms are a clear reaction to the inflammation. Sympathetic neural system of a child reacts to external irritations in such a way, thus, the presence of Staphylococcus aureus can be justified (Metheny, 2012).
Similarly, the case report and the literature review admit various internal processes and changes at the tissue level. For instance, kidney movement and emerging abscess with excessive level of fluids are mentioned in the literature review as well as the case report. Hence, the girl obviously has a psoas abscess. Thus, she is expected to receive immediate diagnosis and related treatment since delay can result in septic shock. Actually, methods of diagnosis are also appropriately chosen in the literature review and the case report. The use of ultrasonography and computerized tomography is apparent in this case. The decision is definitely relevant because 60% of the cases are successfully solved due to an appropriate diagnosis (Karli et al., 2014). Moreover, the suggested methods of diagnosis are radiology-free, affordable, and simple from the perspective of disease identification. Likewise, ways of treatment mentioned in the case report are consistent with the literature review. Drainage and complex intravenous antibiotic treatment demonstrate a good patient’s response and sufficiently fast recovery (Karli et al., 2014). Compliance of the case report with basic points of the literature review is explicit, but some discrepancies are also found.
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As a matter of fact, in the case report, passive extension of the right kidney is admitted. The literature review describes only rotation of kidneys, therefore, diagnosis can be different. However, the rest of the symptoms and diagnostic evidence prove that the girl has psoas muscle abscess. Thus, obstruction of the kidney is a result of stones and fat stranding. Furthermore, the case report, several spots of weakened tissues on the right kidney are mentioned. Regarding these facts, it may be concluded that psoas muscle abscess is caused by infection, and obstruction of the kidney is resulted from the resistance to the primary disease.
Thus, hip pain cannot be recognized as the primary disease. It occurs after development of the abscess, therefore, it cannot be the primary disease. Pain in hip is usually associated with development of psoas muscle abscess. For this reason, external injury or trauma cannot influence muscle abscess. They may become predisposing factors that cause proactive extracellular fluids flow, but they do not cause the muscle abscess (Metheny, 2012). Therefore, the girl has been infected with agents of tuberculous spondylitis. Actually, it is also a discrepancy detected in the case report. Since psoas muscle abscess is a result of infection, extension of the right kidney is a result of stones’ presence and corresponding internal processes in the kidney tissues. It is worth saying, however, that the abscess might have not occurred without the kidney’s extension. Proactive production of fluids intensified development of the abscess. The evidence of psoas muscle abscess at pre-pubertal age is not a frequent phenomenon, but such “supplementary” signs as kidney stones may result in the rapid development of the abscess. Hence, the girl must undergo non-surgical drainage of abscess and a complex treatment with intravenous antibiotics. Overall, the diagnosis has been appropriately established, even though some deficiencies can be mentioned.
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It is appropriate to make a general comment on the fact that psoas muscle abscess is initially caused by infection and developed inflammation. In the case under analysis, the girl has accompanying kidney stones, which intensify the development of the abscess. Trauma or physical injury can be predisposing factors and thus, any other influences should be considered. Pain in hips usually signifies intensification of the abscess, while abdominal pain and fever are a distinct reaction to the inflammation. Such methods of diagnosis as ultrasonography or computerized tomography are sufficiently effective as long as they render maximal accuracy and do not presuppose any radiological effects. As for the ways of treatment, children of pre-pubertal age should be treated with non-surgical means of abscess drainage. The infection has to be neutralized with a complex treatment that includes intravenous antibiotics.
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