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Case Report |
1 Department of Medical Microbiology and Immunology, St Elisabeth Hospital, Tilburg, The Netherlands
2 Department of Internal Medicine, St Elisabeth Hospital, Tilburg, The Netherlands
3 Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands
Correspondence
I. H. M. van Loo
ivlo{at}lmib.azm.nl
Received 30 January 2007
Accepted 8 August 2007
Present address: Department of Medical Microbiology and Infectious Diseases, University Hospital Maastricht, The Netherlands. 
Present address: Intensive Care Unit, University Hospital Maastricht, The Netherlands.
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Case report |
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On physical examination, blood pressure was 120/75 mmHg, pulse rate 94 beats min–1 and body temperature 37.4 °C. Examination of heart, lungs and abdomen revealed no abnormalities. In the left gluteal region, a firm mass, approximately 11 cm in diameter, was palpable. This mass was painful on palpation and the skin above it showed a purple discoloration.
Laboratory results showed an erythrocyte sedimentation rate of 108 mm h–1, haemoglobulin of 9.3 mmol l–1, leukocyte count of 22.3x109 l–1, thrombocyte count of 529x109 l–1, urea level of 13.9 mmol l–1, creatinine level of 129 µmol l–1, aspartate aminotransferase of 55 U l–1, alanine aminotransferase of 72 U l–1, 
-glutamyltransferase of 150 U l–1 and lactate dehydrogenase of 541 U l–1. He was admitted to the internal ward for further evaluation of the lesion.
Ultrasonography of the left gluteal region showed a hypoechogenic, lobulated structure of unclear nature. On CT scan the amorphous soft tissue mass was 10x4x8 cm in size and located between the left acetabulum and sacrum (Fig. 1
). The most likely diagnosis was considered to be a sarcoma.
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To determine whether an underlying malignancy was present, MRI of the pelvic cavity and gluteal region was performed. This showed a multilocular, fluid-containing structure. It was a largely bilobar process, partly located in the pelvic cavity and partly in the gluteal and piriformis muscles. The rectum appeared to be compressed by this mass, but it was well delineated from it.
Antibiotic therapy was started with erythromycin (4 d.d. 1000 mg intraveneously) and a drain was placed. After 2 days, the patient developed a fever of more than 39 °C, indicating insufficient drainage of the abscess. Subsequently, two more drains were placed and spontaneous cutaneous drainage occurred at another site. The drainage sites were surgically connected via incisions and silicon tubes for proper rinsing facilities. No connection with the rectum was found. Thereafter no fever relapses occurred and after 4 days the silicon tubes were removed. Rinsing was performed twice daily. Erythromycin (4 d.d. 1000 mg intraveneously) was switched to clarithromycin (2 d.d. 500 mg orally) and continued for 6 weeks. The patient was discharged after 5.5 weeks of hospital stay and recovered completely.
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Discussion |
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He underwent dental surgery 8 months prior to hospital admission. The patient in the case reported by Vargas et al. (2006) was treated for peridontitis and dental caries 3 months before presentation with a brain abscess. Although the period between dental surgery and the presentation of the abscess seems to be rather long for the surgery to be related to the infection, it was the only risk factor identified in our patient.
Haematogenic dissemination of bacteria is the most likely explanation for the formation of deep abscesses. Positive blood cultures have been found in several cases of deep tissue infections, e.g. pyothorax, endocarditis, osteomyelitis, brain abscess and soft tissue abscesses (reviewed by Skov et al., 1998). Blood cultures taken in the period before puncture of the mass lesion stayed negative, however.
To our knowledge, this is the second case report in which A. haemolyticum is the causal agent of an abscess mimicking a tumour. Dobinsky et al. (1999) reported a case of a previously healthy man who presented to the dermatologist with a mammary tumour. At physical examination, the mass was most likely a benign or malignant tumour. During surgical exploration, however, a collection of pus was recovered, revealing A. haemolyticum in a mixed culture with Bacteroides species.
Bacterial culture showed a pure culture of A. haemolyticum. The bacterium was identified on the basis of a Gram stain of the colony and catalase, API Coryne and reverse CAMP effect tests (Funke et al., 1997). By disc diffusion, the isolate was susceptible to all antibiotics except cotrimoxazole and ciprofloxacin. Resistance to these antibiotics has been described previously (Carlson, 2000; Vargas et al., 2006). Although isolates may be susceptible to β-lactam antibiotics in vitro, therapy failure with these antibiotics has been described (Banck & Nyman 1986; Carlson et al., 1994; Nyman et al., 1990). Many different antibiotics have been used for treatment of soft tissue and deep-seated infections (Skov et al., 1998; Tan et al., 2006). Because good clinical and microbiological results were obtained with macrolides, our patient was treated first with erythromycin intraveneously and later on with clarithromycin orally (Carlson et al., 1994; Carlson, 2000; Waagner, 1991).
This case report describes an unusual presentation of an abscess due to A. haemolyticum in an elderly man without an apparent underlying condition. This is the second reported case of soft tissue abscess due to A. haemolyticum that initially was diagnosed as a mass lesion. The unusual presentation led to a delay in final diagnosis and treatment. After proper antibiotic and surgical treatment, the patient recovered completely.
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