今日の臨床サポート

腸腰筋膿瘍

著者: 関川喜之 関東労災病院 総合内科

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2020/02/14
参考ガイドライン:
  1. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases 2014;59(2):147–59
  1. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults, Clinical Infectious Diseases 2015;61(6):e26–46
  1. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis, Clinical Infectious Diseases 2016;63(7):e147–95
  1. 日本感染症学会/日本化学療法学会:JAID/JSC感染症治療ガイド2019
  1. 日本結核病学会:結核診療ガイドライン 改訂第3版

概要・推奨   

  1. 腸腰筋は大腰筋と腸骨筋、小腰筋から成り、同部位に膿瘍を形成する。
  1. 原発巣不明で血行性やリンパ管性に感染する原発性膿瘍(primary abscess)と隣接臓器より直達性に感染する続発性膿瘍(secondary abscess)に分類される。
  1. 起因微生物はStaphylococcus aureusが多い。
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  1. 原発性膿瘍もしくは化膿性脊椎炎に続発する場合の経験的治療はStaphylococcus aureusに対してセファゾリンもしくはバンコマイシンを検討する。特に、数カ月以内の抗菌薬使用や長期入院、透析、HIV、過去のMRSA検出歴、CVカテーテルやFoleyカテーテルなどデバイス留置、違法静注薬物使用、コンタクトスポーツ(ラグビーやサッカーなど)がある場合はMRSAを想定しバンコマイシンを使用する(推奨度2)。
  1. 腹腔内臓器に続発する場合の経験的治療はStaphylococcus aureusに加えて腸内細菌と嫌気性菌をカバーし、バンコマイシン+アンピシリン・スルバクタム or ピペラシリン・タゾバクタム or カルバペネム or セフトリアキソン+メトロニダゾール(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
関川喜之 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

病態・疫学・診察

定義  
  1. 腸腰筋とは、第12胸椎~第5腰椎から起こり大腿骨小転子に終わる大腰筋と、腸骨内面の腸骨窩から起こり大腿骨小転子に終わる腸骨筋、大腰筋前面にある小腰筋(半数では欠如)から成り、股関節を屈曲させる筋群(図<図表>)であり、腸腰筋膿瘍は同部位に膿瘍が形成される(図<図表>)。
 
腸腰筋の解剖学図

腸腰筋は、大腰筋、腸骨筋、小腰筋から成る。

出典

 
左腸腰筋膿瘍

左大腰筋に膿瘍を認める。

疫学  
  1. 本邦での頻度は不明。CTやMRIの発達により増加傾向と考えられる。英国の報告によれば、100万人あたり4例の頻度である[1]
  1. 原発性膿瘍の危険因子は、糖尿病、違法静注薬物使用者、HIV、腎不全、その他の免疫不全者が挙げられる[2]。小児、若年成人、熱帯地域の発展途上国に多い[3]
  1. 続発性膿瘍の危険因子は、後述する原疾患を持つ場合や鼠径部・腰椎・寛骨部の外傷や同部位の医療器具(インストゥルメント)の留置が挙げられる(表<図表>

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文献 

著者: D C Bartolo, S R Ebbs, M J Cooper
雑誌名: Int J Colorectal Dis. 1987 Jun;2(2):72-6. doi: 10.1007/bf01647695.
Abstract/Text A consecutive series of 16 cases of psoas abscess managed over a 10-year period at the Bristol Royal Infirmary is presented. Tuberculosis accounted for 4 patients all normally resident in the United Kingdom. Intraabdominal inflammatory disorders accounted for 9 of the cases with Crohn's disease being the commonest of these with 5 cases. The remaining patients comprised 3 with primary staphylococcal abscesses, one appendicitis, one diverticulitis and 2 with colonic carcinoma. Diagnostic delay was common. Ultrasonography together with guided aspiration of pus was the most useful investigation giving the diagnosis in cases due to tuberculosis and staphylococci. The presence of gut associated organisms was indicative of gastrointestinal pathology. Four patients died and significant morbidity occurred in a further 5. We recommend effective dependent drainage together with resection of diseased gut in the cases of gastrointestinal origin.

PMID 3625011  Int J Colorectal Dis. 1987 Jun;2(2):72-6. doi: 10.1007/・・・
著者: Thomas Mückley, Tanja Schütz, Martin Kirschner, Michael Potulski, Gunther Hofmann, Volker Bühren
雑誌名: Spine (Phila Pa 1976). 2003 Mar 15;28(6):E106-13. doi: 10.1097/01.BRS.0000050402.11769.09.
Abstract/Text STUDY DESIGN: Case report, literature review, discussion.
OBJECTIVES: To emphasize the role of the spine as primary source of infection for psoas abscess.
SUMMARY OF BACKGROUND DATA: Spine-associated psoas abscesses increase with more frequent invasive procedures of the spine and recurring tuberculosis in industrialized countries. Diagnosis is often delayed by misinterpretation as arthritis, joint infection, or urologic or abdominal disorders.
METHODS: We present six cases of psoas abscesses associated with spinal infections that were treated in our hospital from January to December 2001. Diagnostic and treatment concepts are discussed.
RESULTS: Our data emphasize the importance of the spine as primary source of infection and suggest an increase in the incidence of secondary psoas abscess. Treatment includes open surgical drainage and antibiotic therapy. In patients with high operative risk and uniloculated abscess, a CT-guided percutaneous abscess drainage can be sufficient. It is essential to combine abscess drainage with causative treatment of the primary infectious focus. Related to the spine, this includes treatment of spondylodiscitis or implant infection after spinal surgery. Usually, several operations are necessary to eradicate bone and soft-tissue infection and restore spinal stability. Continuous antibiotic therapy over a period of 2-3 weeks after normalization of infectious parameters is recommended.
CONCLUSION: The spine as primary source of infection for secondary psoas abscess should always be included in differential diagnosis. Because the prognosis of psoas abscess can be improved by early diagnosis and prompt onset of therapy, it needs to be considered in patients with infection and back or hip pain or history of spinal surgery.

PMID 12642773  Spine (Phila Pa 1976). 2003 Mar 15;28(6):E106-13. doi: ・・・
著者: M A Ricci, F B Rose, K K Meyer
雑誌名: World J Surg. 1986 Oct;10(5):834-43. doi: 10.1007/bf01655254.
Abstract/Text
PMID 3776220  World J Surg. 1986 Oct;10(5):834-43. doi: 10.1007/bf016・・・
著者: Vicente Navarro López, José M Ramos, Victoria Meseguer, José Luis Pérez Arellano, Regino Serrano, Miguel Angel García Ordóñez, Galo Peralta, Vicente Boix, Javier Pardo, Alicia Conde, Fernando Salgado, Félix Gutiérrez, GTI-SEMI Group
雑誌名: Medicine (Baltimore). 2009 Mar;88(2):120-30. doi: 10.1097/MD.0b013e31819d2748.
Abstract/Text To describe the microbiology and outcome of iliopsoas abscess (IPA) in a large case series, we analyzed 124 cases of IPA collected from 1990 through 2004 in 11 hospitals in Spain. Twenty-seven (21.8%) patients had primary and 97 (78.2%) had secondary IPA. The main sources of infection were bone (50.5%), gastrointestinal tract (24.7%), and urinary tract (17.5%). A definitive microbial diagnosis was achieved in 93 (75%) cases. Abscess culture was the most frequent procedure leading to microbial diagnosis, followed by blood cultures. Staphylococcus aureus, Escherichia coli, and Bacteroides species were the most frequent microbial causes: S. aureus was the most common organism in patients with primary abscesses (42.9%) and with abscesses of skeletal origin (35.2%), whereas E. coli was the leading organism in those with abscesses of urinary (61.5%) and gastrointestinal (42.1%) tracts. Mycobacterium tuberculosis was found in 15 patients, 4 of them associated with human immunodeficiency virus (HIV) infection. Twenty (21.5%) cases had polymicrobial infections; these were more common among patients with abscesses of gastrointestinal origin. Information on clinical outcome was available for 120 patients; 19 (15.8%) had a relapse and 6 (5%) died due to complications related to the IPA. Patients who died were older and more likely to have bacteremia and E. coli isolated from cultures. In conclusion, secondary IPA is more prevalent than primary IPA. Among those with secondary IPA, most abscesses are secondary to a skeletal source. A bacterial etiology can be identified in most cases. The overall prognosis of patients with this condition is good.

PMID 19282703  Medicine (Baltimore). 2009 Mar;88(2):120-30. doi: 10.10・・・
著者: M Ogihara, T Masaki, T Watanabe, K Hatano, K Matsuda, N Yahagi, M Ichinose, A Seichi, T Muto
雑誌名: Surg Today. 2000;30(8):759-63. doi: 10.1007/s005950070093.
Abstract/Text We describe herein the case of a psoas abscess complicating Crohn's disease, and present a review of the literature on this unusual disease entity. A 22-year-old Japanese man with a 5-year history of Crohn's ileocolitis presented with right lower abdominal and hip pain, and a diagnosis of right psoas abscess was subsequently made by abdominal computed tomography (CT). Following the administration of antibiotics and CT-guided percutaneous drainage of the abscess, the patient's symptoms temporarily improved; however, 2 weeks later, the abscess cavity was found to have extended around the periarticular tissue of the right hip joint. To prevent the development of septic arthritis of the hip joint, surgical drainage of the abscess cavity and ileocecal resection were immediately performed, after which the patient's condition greatly improved. The resected specimen showed Crohn's ileocolitis with an external fistula in the terminal ileum which was considered to have caused the psoas abscess. Since psoas abscess in Crohn's disease can result in serious complications such as septic arthritis of the hip joint if left untreated, aggressive treatment should be initiated without delay.

PMID 10955745  Surg Today. 2000;30(8):759-63. doi: 10.1007/s0059500700・・・
著者: I H Mallick, M H Thoufeeq, T P Rajendran
雑誌名: Postgrad Med J. 2004 Aug;80(946):459-62. doi: 10.1136/pgmj.2003.017665.
Abstract/Text Iliopsoas abscess is a relatively uncommon condition that can present with vague clinical features. Its insidious onset and occult characteristics can cause diagnostic delays, resulting in high mortality and morbidity. The epidemiology, aetiology, clinical features, and management of iliopsoas abscess are discussed.

PMID 15299155  Postgrad Med J. 2004 Aug;80(946):459-62. doi: 10.1136/p・・・
著者: M F Lin, Y J Lau, B S Hu, Z Y Shi, Y H Lin
雑誌名: J Microbiol Immunol Infect. 1999 Dec;32(4):261-8.
Abstract/Text From 1993 to 1998, 29 pyogenic psoas abscesses occurring in 27 patients were seen in Taichung Veterans General Hospital. Their age range was 25 to 85 years. Diabetes mellitus was the leading underlying disease. Fever and pain in the flank area, back and hip were the usual manifestations. The duration of symptoms prior to the diagnosis ranged from 3 days to 6 months. Most abscesses were diagnosed by computed tomography (CT) images and proven by abscess cultures, which were divided into primary and secondary types. Eighteen of 29 abscesses were regarded as primary. Staphylococcus aureus was the most common pathogen in the primary abscesses, followed by Streptococcus agalactiae, Escherichia coli, viridans streptococci, S. epidermidis, and Salmonella spp.. In the secondary abscess category, E. coli was the leading organism in this series, followed by S. aureus, Klebsiella pneumoniae, viridans streptococci and Candida albicans. The associated conditions included epidural abscess, osteomyelitis, septic arthritis, perirenal abscess, pulmonary tuberculosis, empyema, hydronephrosis and trauma history. The initial empiric therapy comprised mostly of cefazolin or oxacillin with or without an aminoglycoside. Thirteen patients underwent percutaneous drainage, while six received surgical debridement, including two with a recurrent abscess. One patient had both drainage and debridement. Others received medical treatment only. Two of the patients with primary abscess died in spite of percutaneous drainage. Therefore, open drainage, besides appropriate antibiotic treatment, is still required to control complex abscesses with sepsis.

PMID 10650491  J Microbiol Immunol Infect. 1999 Dec;32(4):261-8.
著者: Toshihiko Takada, Kazuhiko Terada, Hideki Kajiwara, Yoshiyuki Ohira
雑誌名: Intern Med. 2015;54(20):2589-93. doi: 10.2169/internalmedicine.54.4927. Epub 2015 Oct 15.
Abstract/Text Objective Patients diagnosed with psoas abscess have a high mortality rate. The major cause of its poor prognosis is delayed treatment. Therefore, making a correct diagnosis rapidly is important. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered to be the gold standards as imaging modalities that have a high sensitivity for detecting psoas abscess. There have been few reports regarding the limitations of these methods, but psoas abscess in its early stage may go undetected by CT and MRI. Methods Detection of psoas abscess by CT and MRI was investigated in the present study through a retrospective review of 15 patients in whom psoas abscess was diagnosed during a course of ten years at our hospital. Results In all patients, psoas abscess was diagnosed by at least a plain CT, enhanced CT, and/or plain MRI. The interval between the onset of symptoms and diagnosis was 20.9±17.9 days (mean ± standard deviation). In three patients, repeat imaging identified a psoas abscess, whereas initial imaging failed to detect it. The overall sensitivity of plain CT, enhanced CT, and plain MRI for psoas abscess was 78%, 86%, and 88%, respectively. From six days after the onset of symptoms, the sensitivity of each modality was 100%, while the sensitivity from day one to five days was only 33%, 50%, and 50%, respectively. Conclusion Although CT and MRI are considered to be gold standard modalities for diagnosing psoas abscess, both methods can fail to notice this condition in its early stage.

PMID 26466693  Intern Med. 2015;54(20):2589-93. doi: 10.2169/internalm・・・
著者: Bharat R Dave, Ranganatha Babu Kurupati, Dipak Shah, Devanand Degulamadi, Nitu Borgohain, Ajay Krishnan
雑誌名: Indian J Orthop. 2014 Jan;48(1):67-73. doi: 10.4103/0019-5413.125506.
Abstract/Text BACKGROUND: Percutaneous aspiration of abscesses under ultrasonography (USG) and computer tomography (CT) scan has been well described. With recurrence rate reported as high as 66%. The open drainage and percutaneous continuous drainage (PCD) has reduced the recurrence rate. The disadvantage of PCD under CT is radiation hazard and problems of asepsis. Hence a technique of clinically guided percutaneous continuous drainage of the psoas abscess without real-time imaging overcomes these problems. We describe clinically guided PCD of psoas abscess and its outcome.
MATERIALS AND METHODS: Twenty-nine patients with dorsolumbar spondylodiscitis without gross neural deficit with psoas abscess of size >5 cm were selected for PCD. It was done as a day care procedure under local anesthesia. Sequentially, aspiration followed by guide pin-guided trocar and catheter insertion was done without image guidance. Culture sensitivity was done and chemotherapy initiated and catheter kept till the drainage was <10 ml for 48 hours. Outcome assessment was done with relief of pain, successful abscess drainage and ODI (Oswestry Disability Index) score at 2 years.
RESULTS: PCD was successful in all cases. Back and radicular pain improved in all cases. Average procedure time was 24.30 minutes, drain output was 234.40 ml, and the drainage duration was 7.90 days. One patient required surgical stabilisation due to progression of the spondylodiscitis resulting in instability inspite of successful drainage of abscess. Problems with the procedure were noticed in six patients. Multiple attempts (n = 2), persistent discharge (n = 1) for 2 weeks, blocked catheter (n = 2) and catheter pull out (n = 1) occurred with no effect on the outcome. The average ODI score improved from 62.47 to 5.51 at 2 years.
CONCLUSIONS: Clinically guided PCD is an efficient, safe and easy procedure in drainage of psoas abscess.

PMID 24600066  Indian J Orthop. 2014 Jan;48(1):67-73. doi: 10.4103/001・・・
著者: Wael N Yacoub, Helen J Sohn, Sirius Chan, Mikael Petrosyan, Hope M Vermaire, Rebecca L Kelso, Shirin Towfigh, Rodney J Mason
雑誌名: Am J Surg. 2008 Aug;196(2):223-7. doi: 10.1016/j.amjsurg.2007.07.032. Epub 2008 May 7.
Abstract/Text BACKGROUND: Surgeons are increasingly encountering psoas abscesses.
METHODS: We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm.
RESULTS: Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%.
CONCLUSIONS: Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.

PMID 18466865  Am J Surg. 2008 Aug;196(2):223-7. doi: 10.1016/j.amjsur・・・

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