Case Report

One In A Million: Psoas Abscess After Allograft Nephrectomy, An Unusual Presentation Of An Appendiceal Cancer

by Wesley H Chou1*, Jasper C Bash2, John M Barry1

1Department of Urology, Oregon Health & Science University, Portland, Oregon, United States

2Department of Urology, University of California, Los Angeles, Los Angeles, California, United States.

*Corresponding author: Wesley H Chou, Department of Urology, Oregon Health & Science University, Portland, Oregon, United States.

Received Date: 18 April 2024

Accepted Date: 22 April 2024

Published Date: 24 April 2024

Citation: Chou WH, Bash JC, Barry JM (2024) One In A Million: Psoas Abscess After Allograft Nephrectomy, An Unusual Presentation Of An Appendiceal Cancer. Ann Case Report 9: 1776. https://doi.org/10.29011/2574-7754.101776

Abstract

A 56-year-old woman with a prior allograft nephrectomy presented with recurrent right psoas abscesses. A pelvic laparotomy and appendectomy revealed a rare appendiceal goblet cell adenocarcinoma (GCA).

Keywords: Renal Transplant; Appendiceal Goblet Cell Adenocarcinoma; Psoas Abscess; Oncology

Introduction

Psoas abscess (PA) is uncommon and due to hematogenous spread or direct extension of pathogens. Herein is presented a patient with recurrent PAs after an allograft nephrectomy who was incidentally found to have a rare appendiceal tumor at laparotomy.

Clinical Case Presentation

A 56-year-old woman underwent deceased donor renal transplantation in 2009 for end stage renal disease due to focal segmental glomerulosclerosis. Due to recurrent transplant pyelonephritis, she underwent allograft nephrectomy in 2020. Between November 2021 and November 2022, she was hospitalized four times for recurrent PA (Figure 1).

 

Figure 1: Axial (A) and coronal (B) slices from a computed tomography scan obtained during the patient’s November 2021 hospitalization demonstrating a right psoas abscess.

During each hospitalization, she was treated with intravenous antibiotics and placement of a percutaneous drain. Cultures repeatedly grew Klebsiella pneumoniae.  Cross sectional imaging did not reveal any nidus for infection. Due to these recurrent infections, she underwent pelvic laparotomy in March 2023. The allograft bed, psoas, and surrounding bowel had severe scarring consistent with the prior infections. A scarred, tubular structure was excised from the area and sent for frozen microscopic examination. It was identified as appendix. Final pathology revealed a grade 3 appendiceal GCA with invasion through the muscularis propria into the subserosa (pT3). A robotic-assisted laparoscopic right hemicolectomy in September 2023 showed no residual malignancy. She has had no subsequent hospitalizations for PA.

Discussion

PA is an uncommon infectious process typically classified into primary and secondary types. The former involves hematogenous or lymphatic seeding such as from intravenous drug use or tuberculosis, with Staphylococcus aureus the common culprit pathogen. By contrast, secondary PA involves direct spread from adjacent structures and infectious processes, such as appendicitis, discitis, and osteomyelitis, and tends to be associated with enteric organisms. [1] Other processes that can lead to secondary PA include inflammatory bowel disease and malignancy. [2]

An English literature review revealed only 7 published cases of PA in kidney transplant recipients (Table 1). The time interval from transplant to diagnosis of PA varied from 2 months to 12 years. Proposed etiologies for PA included catheter placement for hemodialysis, prolonged hemodialysis, candiduria, and appendicular sinus. Infections associated with hemodialysis appeared to be the most common, presumably from seeding of an infected intravenous line.

Publication date

Sex

Age, years

Time from transplant

Presenting symptoms

Pathogens

Treatment

Proposed etiology

1994 [3]

F

45

2 years

Fever, abdominal and groin pain, reduced hip movement

Nocardia asteroides

Percutaneous then surgical drainage with antibiotics

Prolonged hemodialysis

1994 [4]

F

39

2 years

Fever, malaise

Mycobacterium fortuitum

Antibiotics

Not stated

2012 [5]

M

40

2 years

Reduced leg movement

Pseudomonas aeruginosa

Percutaneous drainage and antibiotics

Prolonged hemodialysis

2012 [6]

M

51

2 months

Lower back pain

Staphylococcus aureus

Percutaneous then surgical drainage with antibiotics

Hemodialysis line

2014 [7]

M

42

12 years

Fever, nausea, malaise

Candida albicans

Percutaneous drainage and antifungals followed by allograft nephrectomy

Candiduria

2015 [8]

M

58

11 years

Fever, weight loss, abdominal and groin pain, reduced hip movement

Nocardia beijingensis

Percutaneous drainage and antibiotics

Not stated

2016 [9]

M

61

10 years

Fever, abdominal pain, malaise

Enterococcus faecalis, alpha-hemolytic streptococci, Escherichia coli

Percutaneous drainage and antibiotics, appendectomy given appendicular sinus

Appendicular sinus

Table 1: Summary of literature regarding psoas abscess in kidney transplant recipients.

Pathogens cultured in the case reports included Staphylococcus aureus, Nocardia, Mycobacterium fortuitum, and enteric organisms such as Pseudomonas aeruginosa, Klebsiella, and Escherichia coli. Immunosuppression was commonly cited as increasing patient propensity to serious infections, although our patient was not on immunosuppressants at the time of her most recent recurrent PAs. As in the current case, the mainstay of treatment typically involves percutaneous drainage of the abscess and intravenous antibiotics. Surgical intervention was occasionally needed, and one patient underwent appendectomy for source control of an appendicular sinus.

The presence of an appendiceal GCA in this patient was unexpected but does not necessarily explain the delayed presentation of her PA after cessation of immunosuppression. This malignancy is exceedingly rare. A recent systematic review showed an incidence of 0.05-0.3 per 100,000 per year based on data from North American registries. [10] Only 369 cases of appendiceal GCA have been reported in the Surveillance, Epidemiology, and End Results (SEER) database from 1973-2001, with 80% occurring in Caucasian patients. [11] Median age at diagnosis is about 52 years without obvious predilection for gender, and on histology there is typically some neuroendocrine differentiation. [12]

Renal transplant patients are well known to have higher rates of malignancy and poorer outcomes once diagnosed, notably for skin cancers, renal cell carcinoma, and post-transplant lymphoproliferative disease. [13] Given the rarity of appendiceal GCA, it is not known if renal transplant status is a risk factor for this malignancy. There have not been other obvious risk factors for appendiceal GCA identified, although limited data from China show a possible association between appendiceal schistosomiasis and appendiceal GCA. [14]

Clinically, appendiceal GCA commonly presents as acute appendicitis, although a substantial minority of patients are asymptomatic at time of diagnosis. Other presenting symptoms include right lower quadrant pain, small bowel obstruction, and diarrhea, with about 10% of cases having widespread distant metastases, typically to the liver, ovaries, and the peritoneum. Chemotherapy regimens, when used, have been extrapolated from colorectal adenocarcinoma, and surgical treatment typically involves appendectomy and/or right hemicolectomy. Five-year overall survival ranges from 50-80% for loco-regional disease. [12]

Conclusion

To our knowledge, this remains the first report of an appendiceal GCA presenting with recurrent PA in a transplant recipient.  Although we could not definitively link GCA to the patient’s recurrent PA, this case highlights malignancy as a potential etiology for PA when it does not respond to appropriate antibiotics and drainage.

Additional Information: All authors declare that no financial support was received for this submitted work and do not have financial relationships with organization that may have interest in the submitted work.

References

  1. Santaella RO, Fishman EK, Lipsett PA (1995) Primary vs secondary iliopsoas abscess: Presentation, microbiology, and treatment. Arch Surg 130: 1309-13.
  2. Kikuchi S, Muro K, Yoh K, Iwabuchi S, Tomida C, et al. (1999) Two cases of psoas abscess with discitis by methicillin-resistant Staphylococcus aureus as a complication of femoral-vein catheterization for haemodialysis. Nephrol Dial Transplant 14: 1279-81.
  3. Shoihab S (1994) Nocardial psoas and perinephric abscess in a renal transplant treated by surgery and antibiotics. Nephrol Dial Transplant 9: 1209-10.
  4. Niranjankumar MS, Georgi A, Ananth S, V Anandi, J H Gaspar (1994) Mycobacterium fortuitum psoas abscess in a renal transplant recipient. Nephrol Dial Transplant 9: 80-2.
  5. Deepa R, Thasneem Banu S, Jayalakshmi G, Praveen JD (2012) Psoas and thyroid abscess in a renal allograft recipient. Indian J Pathol Microbiol 55: 593-4.
  6. Badurdeen AS, Rajakrishna PN, Herath HMNJ, Wazil AWM, N Nanayakkara. (2012) Bilateral psoas abscess in a renal transplant patient. Ceylon Med J 57: 175-6.
  7. Ozgur N, Seyahi N, Sili U, Oruc M, Mete B, et al. (2014) Candidal psoas abscess following persistent pyuria in a renal transplant recipient. Int Urol Nephrol 46: 269-73.
  8. Palavutitotai N, Chongtrakoo P, Ngamskulrungroj P, Chayakulkeeree M (2015) Nocardia beijingensis psoas abscess and subcutaneous Phaeohyphomycosis caused by Phaeocremonium parasiticum in a renal transplant recipient: The first case report in Thailand. Southeast Asian J Trop Med Public Health 46: 1049-54.
  9. Ghazanfar A, Khan Y, Popoola J. (2016) Appendicular sinus as a cause of a chronic psoas abscess in a renal transplant recipient: a case report. Exp Clin Transplant 14: 447-9.
  10. Palmer K, Weerasuriya S, Chandrakumaran K, Rous B, White BE, et al. (2022) Goblet cell adenocarcinoma of the appendix: A systematic review and incidence and survival of 1,225 cases from an English cancer registry. Front Oncol 12: 915028.
  11. McGory ML, Maggard MA, Kang H, Kang H, O’Connell JB, et al. (2005) Malignancies of the appendix: Beyond case series reports. Dis Colon Rectum 48: 2264-71.
  12. Pape U, Perren A, Niederle B, Gross D, Gress T, et al. (2012) ENETS consensus guidelines for the management of patients with neuroendocrine neoplasms from the jejuno-ileum and the appendix including goblet cell carcinomas. Neuroendocrinology 95: 135-56.
  13. Al-Adra D, Al-Qaoud T, Fowler K, Wong G (2022) De novo malignancies after kidney transplantation. CJASN 17: 434-43.
  14. Jiang Y, Long H, Li T, Wang W, Liu H, et al. (2012) Schistosomiasis may contribute to goblet cell carcinoid of the appendix. J Parasitol 98: 565-8.

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