Charity got an intrauterine fetal death at
term in January 2012. She delivered a macerated still birth apparently without
complications. She was therefore discharged with a short course of amoxyl in
order to prevent puerperal sepsis.
Unfortunately she was admitted again a
month later with symptoms and signs of acute peritonitis. She was taken to
theatre where we have found a huge amount of pus in the peritoneum. The pus was
sucked and the abdominal cavity washed. At this point it was possible to notice
that pus was coming out of a laceration of the posterior parietal peritoneum,
in front of the left psoas muscle. We thought of a psoas muscle abscess. We
tried to probe the laceration with fingers, in order to break down the internal
septations and to allow the pus to flow freely out of the abscess. A drainage
tube was inserted into the abscess and another one into the peritoneal cavity. The
recovery after operation was quick but the drainage tubes have continued to
collect pus for about 2 weeks. Eventually we were able to remove the tubes and
to discharge the patient.
Unfortunately a month later Charity was
admitted again because the small wounds left by the drainage tubes had opened
again and foul smelling pus was draining again out of them.
The patient was very sick and emaciated.
An U/S of the abdomen has ruled out any
peritoneal involvement; therefore the pus was coming again from the extra-peritoneal
space. Because we had not been able to find the exact origin of the pus with
U/S we have referred our patient for CT scan abdomen.
The CT scan was very clear, as you can
appreciate checking the attached photo: it was a big retro-renal abscess.
Charity was very anaemic and we had to
transfuse 2 pints of blood before scheduling the operation again. Finally, when
we reached an HB of 7 grams we decided to intervene.
The operation was an incision and drainage
under general anesthesia, with patient laying on her right side. Much pus was
collected and drainage tubes inserted. Now the patient is recovering very
quickly.
It is quite difficult to understand why the
patient, who is HIV negative, could get such a complicated disease. My opinion
is that, during delivery of the still birth, already she had a puerperal sepsis.
During the pushing efforts of delivery some septic embolus might have travelled
through the blood stream reaching the retro-peritoneal space.
When she got the first peritonitis already
it was because the retro-peritoneal abscess had burst into the peritoneal
cavity. Our operation was partly unsuccessful because we did not realize that
the origin of the pus was much higher than the laceration we saw (from behind
the kidney). Therefore our debridement was incomplete.
Sometime after the operation the retro-renal
abscess has found a new way out, creating a cutaneous sinus. But now we are
confident that, having drained the retro0renal abscess, the patient will
recover fully.
Dr Giuseppe Gaido
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