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Diabetes mellitus is a systemic illness known to affect over 200,000 New Zealanders and possibly another 100,000 who are undiagnosed.1 It is generally accepted that patients with diabetes mellitus are more susceptible to infections, especially by rare organisms or at unusual sites.2We present a case of a patient whose first presentation with diabetes was with diabetic ketoacidosis (DKA) complicated by empyema, iliopsoas, suprapubic and periarticular abscesses.Case reportA 48-year-old Samoan man presented with polyuria, polydipsia, fevers, productive cough, right-sided chest pain and weight loss of 40 kg over a 2-month period. He was a non-smoker and drank no alcohol. He had no past medical history although he did have a strong family history of diabetes. Figure 1. CT chest showing bilobed right-sided empyema with gas and collapsed lower lobe He was found to have DKA with a beta-hydroxybutyrate of 8.82 mmol/L and an HbA1c of 191 mmol/mol. His C-reactive protein was 480 g/L and chest imaging demonstrated pneumonia along with a loculated right effusion. An 18 Fr Seldinger chest tube drained frank pus with a pH 6.58 and a positive culture of Streptococcus milleri with mixed anaerobes. On day 3 his chest drain started to bubble and subsequent CT scan (Figure 1) demonstrated a bronchopleural fistula. He then developed abdominal discomfort, and on day 8 a CT abdomen (Figure 2), and later a MRI abdomen, demonstrated a large right iliopsoas collection connecting to a suprapubic and right periarticular hip collection. Two percutaneous drains were inserted. All drains again cultured S. milleri. Image 2. CT abdomen showing large right-sided iliopsoas abscess (arrowed) A joint operation between the general, orthopaedic and cardiothoroacic surgeons was performed on day 24 involving a washout of the right hip periarticular collection and psoas abscess, and a right thoracotomy for repair of the bronchopleural fistula. He made a rapid improvement and was discharged on insulin and ongoing intravenous antibiotics. Discussion The incidence of empyema is thought to be increasing although the reason for this is not known.3 Case series from Japan, Canada and New Zealand demonstrate that S. milleri is a common isolate in community-acquired empyema with 12-50% of cases culturing this organism.4-6 Most patients with S. milleri empyema have an underlying illness or predisposing factor such as smoking, excessive alcohol intake, chronic obstructive pulmonary disease (COPD), diabetes mellitus or immunosuppresion.5 This patient was immunocompromised secondary to undiagnosed diabetes mellitus. Bronchopleural fistula (BPF) is relatively rare but is associated with severe or necrotizing pneumonia. It carries high morbidity and mortality.7 We proceeded to surgery due to an ongoing air leak. Success rate of surgery has been reported between 80 to 95%.7 The incidence of psoas abscess is unknown due to its rarity but has been described as 12 cases per 100,000 people with a male predominance.8 A psoas abscess can occur through haematogenous spread (primary) or through direct contact (secondary) such as from kidney or bowel.8 Presenting symptoms are generally non-specific with fevers, back/thigh/abdominal or hip pain, groin swelling, vomiting and limited mobility.8-10 If there is suspicion, examination should include the psoas sign. This is positive when there is worsening pain on extension and internal rotation of the hip, or pain with hip flexion on the affected side.8,10 The psoas sign was absent in this case which made diagnosis more difficult. Due to nonspecific symptoms, the diagnosis of psoas abscess is often delayed and this may contribute to the documented high mortality. In one study the length of time to diagnosis was 6-34 days.10 This case illustrates the need for a multidisciplinary approach and involved input from physicians, radiologists, general, cardiothoracic and orthopaedic surgeons. Undiagnosed diabetes can be life-threatening through both DKA and the risk of severe infection.

Summary

Abstract

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

Aim

Method

Results

Conclusion

Author Information

Lisa Liu, House Officer; Zi Wei Goh, House Officer; Bronwen Rhodes, Respiratory Physician; Christchurch Hospital, Christchurch

Acknowledgements

We thank the departments of general medicine, cardiothoracic, general surgery, orthopaedics, diabetes and radiology for their involvement in this patients care.

Correspondence

Bronwen Rhodes, Respiratory Department, Christchurch Hospital, PO Box 4710, Christchurch 8001. Fax: +64 (0)3 3640914

Correspondence Email

Bronwen.rhodes@cdhb.govt.nz

Competing Interests

NZ Guidelines Group. Evidence-based tools for managing patients with type 2 diabetes. http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-groupRajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Research and Clinical Practice. 1998 February: 39(2):123-128.Brims FJ, Lansley SM, Waterer GW, Lee YC. Empyema thoracis: new insights into an old disease. Eur Respir Rev. 2010 Sep 1;19(117):220-8.Lindstrom ST, Kolbe J. Community acquired parapneumonic thoracic empyema: predictors of outcome. Respirology. 1999; 4:173-9.Kobashi Y, Mouri K, Yagi S, et al. Clinical analysis of cases of empyema due to Streptococcus milleri group. Jpn J Infect Dis. 2008 Nov;61(6):484-6.Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct; 119(10): 877-83.Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005 Dec;128(6):3955-65.Lansdon AJ, Downing A, Roberts AW, Martin D. Psoas abscess formation in suboptimally controlled diabetes mellitus. Case Reports in Medicine. 2011 Article ID 249325: 3 pages.Tabrizian P, Nguyen SQ, Greenstein A, et al. Management and treatment of iliopsoas abscess. Arch Surg. 2009:144(10):946-949.Wu TL, Huang CH, Hwang DY, et al. Primary pyogenic abscess of psoas muscle. International orthopaedics. 1998:22:41-43.

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contact nzmj@nzma.org.nz

View Article PDF

Diabetes mellitus is a systemic illness known to affect over 200,000 New Zealanders and possibly another 100,000 who are undiagnosed.1 It is generally accepted that patients with diabetes mellitus are more susceptible to infections, especially by rare organisms or at unusual sites.2We present a case of a patient whose first presentation with diabetes was with diabetic ketoacidosis (DKA) complicated by empyema, iliopsoas, suprapubic and periarticular abscesses.Case reportA 48-year-old Samoan man presented with polyuria, polydipsia, fevers, productive cough, right-sided chest pain and weight loss of 40 kg over a 2-month period. He was a non-smoker and drank no alcohol. He had no past medical history although he did have a strong family history of diabetes. Figure 1. CT chest showing bilobed right-sided empyema with gas and collapsed lower lobe He was found to have DKA with a beta-hydroxybutyrate of 8.82 mmol/L and an HbA1c of 191 mmol/mol. His C-reactive protein was 480 g/L and chest imaging demonstrated pneumonia along with a loculated right effusion. An 18 Fr Seldinger chest tube drained frank pus with a pH 6.58 and a positive culture of Streptococcus milleri with mixed anaerobes. On day 3 his chest drain started to bubble and subsequent CT scan (Figure 1) demonstrated a bronchopleural fistula. He then developed abdominal discomfort, and on day 8 a CT abdomen (Figure 2), and later a MRI abdomen, demonstrated a large right iliopsoas collection connecting to a suprapubic and right periarticular hip collection. Two percutaneous drains were inserted. All drains again cultured S. milleri. Image 2. CT abdomen showing large right-sided iliopsoas abscess (arrowed) A joint operation between the general, orthopaedic and cardiothoroacic surgeons was performed on day 24 involving a washout of the right hip periarticular collection and psoas abscess, and a right thoracotomy for repair of the bronchopleural fistula. He made a rapid improvement and was discharged on insulin and ongoing intravenous antibiotics. Discussion The incidence of empyema is thought to be increasing although the reason for this is not known.3 Case series from Japan, Canada and New Zealand demonstrate that S. milleri is a common isolate in community-acquired empyema with 12-50% of cases culturing this organism.4-6 Most patients with S. milleri empyema have an underlying illness or predisposing factor such as smoking, excessive alcohol intake, chronic obstructive pulmonary disease (COPD), diabetes mellitus or immunosuppresion.5 This patient was immunocompromised secondary to undiagnosed diabetes mellitus. Bronchopleural fistula (BPF) is relatively rare but is associated with severe or necrotizing pneumonia. It carries high morbidity and mortality.7 We proceeded to surgery due to an ongoing air leak. Success rate of surgery has been reported between 80 to 95%.7 The incidence of psoas abscess is unknown due to its rarity but has been described as 12 cases per 100,000 people with a male predominance.8 A psoas abscess can occur through haematogenous spread (primary) or through direct contact (secondary) such as from kidney or bowel.8 Presenting symptoms are generally non-specific with fevers, back/thigh/abdominal or hip pain, groin swelling, vomiting and limited mobility.8-10 If there is suspicion, examination should include the psoas sign. This is positive when there is worsening pain on extension and internal rotation of the hip, or pain with hip flexion on the affected side.8,10 The psoas sign was absent in this case which made diagnosis more difficult. Due to nonspecific symptoms, the diagnosis of psoas abscess is often delayed and this may contribute to the documented high mortality. In one study the length of time to diagnosis was 6-34 days.10 This case illustrates the need for a multidisciplinary approach and involved input from physicians, radiologists, general, cardiothoracic and orthopaedic surgeons. Undiagnosed diabetes can be life-threatening through both DKA and the risk of severe infection.

Summary

Abstract

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

Aim

Method

Results

Conclusion

Author Information

Lisa Liu, House Officer; Zi Wei Goh, House Officer; Bronwen Rhodes, Respiratory Physician; Christchurch Hospital, Christchurch

Acknowledgements

We thank the departments of general medicine, cardiothoracic, general surgery, orthopaedics, diabetes and radiology for their involvement in this patients care.

Correspondence

Bronwen Rhodes, Respiratory Department, Christchurch Hospital, PO Box 4710, Christchurch 8001. Fax: +64 (0)3 3640914

Correspondence Email

Bronwen.rhodes@cdhb.govt.nz

Competing Interests

NZ Guidelines Group. Evidence-based tools for managing patients with type 2 diabetes. http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-groupRajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Research and Clinical Practice. 1998 February: 39(2):123-128.Brims FJ, Lansley SM, Waterer GW, Lee YC. Empyema thoracis: new insights into an old disease. Eur Respir Rev. 2010 Sep 1;19(117):220-8.Lindstrom ST, Kolbe J. Community acquired parapneumonic thoracic empyema: predictors of outcome. Respirology. 1999; 4:173-9.Kobashi Y, Mouri K, Yagi S, et al. Clinical analysis of cases of empyema due to Streptococcus milleri group. Jpn J Infect Dis. 2008 Nov;61(6):484-6.Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct; 119(10): 877-83.Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005 Dec;128(6):3955-65.Lansdon AJ, Downing A, Roberts AW, Martin D. Psoas abscess formation in suboptimally controlled diabetes mellitus. Case Reports in Medicine. 2011 Article ID 249325: 3 pages.Tabrizian P, Nguyen SQ, Greenstein A, et al. Management and treatment of iliopsoas abscess. Arch Surg. 2009:144(10):946-949.Wu TL, Huang CH, Hwang DY, et al. Primary pyogenic abscess of psoas muscle. International orthopaedics. 1998:22:41-43.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Diabetes mellitus is a systemic illness known to affect over 200,000 New Zealanders and possibly another 100,000 who are undiagnosed.1 It is generally accepted that patients with diabetes mellitus are more susceptible to infections, especially by rare organisms or at unusual sites.2We present a case of a patient whose first presentation with diabetes was with diabetic ketoacidosis (DKA) complicated by empyema, iliopsoas, suprapubic and periarticular abscesses.Case reportA 48-year-old Samoan man presented with polyuria, polydipsia, fevers, productive cough, right-sided chest pain and weight loss of 40 kg over a 2-month period. He was a non-smoker and drank no alcohol. He had no past medical history although he did have a strong family history of diabetes. Figure 1. CT chest showing bilobed right-sided empyema with gas and collapsed lower lobe He was found to have DKA with a beta-hydroxybutyrate of 8.82 mmol/L and an HbA1c of 191 mmol/mol. His C-reactive protein was 480 g/L and chest imaging demonstrated pneumonia along with a loculated right effusion. An 18 Fr Seldinger chest tube drained frank pus with a pH 6.58 and a positive culture of Streptococcus milleri with mixed anaerobes. On day 3 his chest drain started to bubble and subsequent CT scan (Figure 1) demonstrated a bronchopleural fistula. He then developed abdominal discomfort, and on day 8 a CT abdomen (Figure 2), and later a MRI abdomen, demonstrated a large right iliopsoas collection connecting to a suprapubic and right periarticular hip collection. Two percutaneous drains were inserted. All drains again cultured S. milleri. Image 2. CT abdomen showing large right-sided iliopsoas abscess (arrowed) A joint operation between the general, orthopaedic and cardiothoroacic surgeons was performed on day 24 involving a washout of the right hip periarticular collection and psoas abscess, and a right thoracotomy for repair of the bronchopleural fistula. He made a rapid improvement and was discharged on insulin and ongoing intravenous antibiotics. Discussion The incidence of empyema is thought to be increasing although the reason for this is not known.3 Case series from Japan, Canada and New Zealand demonstrate that S. milleri is a common isolate in community-acquired empyema with 12-50% of cases culturing this organism.4-6 Most patients with S. milleri empyema have an underlying illness or predisposing factor such as smoking, excessive alcohol intake, chronic obstructive pulmonary disease (COPD), diabetes mellitus or immunosuppresion.5 This patient was immunocompromised secondary to undiagnosed diabetes mellitus. Bronchopleural fistula (BPF) is relatively rare but is associated with severe or necrotizing pneumonia. It carries high morbidity and mortality.7 We proceeded to surgery due to an ongoing air leak. Success rate of surgery has been reported between 80 to 95%.7 The incidence of psoas abscess is unknown due to its rarity but has been described as 12 cases per 100,000 people with a male predominance.8 A psoas abscess can occur through haematogenous spread (primary) or through direct contact (secondary) such as from kidney or bowel.8 Presenting symptoms are generally non-specific with fevers, back/thigh/abdominal or hip pain, groin swelling, vomiting and limited mobility.8-10 If there is suspicion, examination should include the psoas sign. This is positive when there is worsening pain on extension and internal rotation of the hip, or pain with hip flexion on the affected side.8,10 The psoas sign was absent in this case which made diagnosis more difficult. Due to nonspecific symptoms, the diagnosis of psoas abscess is often delayed and this may contribute to the documented high mortality. In one study the length of time to diagnosis was 6-34 days.10 This case illustrates the need for a multidisciplinary approach and involved input from physicians, radiologists, general, cardiothoracic and orthopaedic surgeons. Undiagnosed diabetes can be life-threatening through both DKA and the risk of severe infection.

Summary

Abstract

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

Aim

Method

Results

Conclusion

Author Information

Lisa Liu, House Officer; Zi Wei Goh, House Officer; Bronwen Rhodes, Respiratory Physician; Christchurch Hospital, Christchurch

Acknowledgements

We thank the departments of general medicine, cardiothoracic, general surgery, orthopaedics, diabetes and radiology for their involvement in this patients care.

Correspondence

Bronwen Rhodes, Respiratory Department, Christchurch Hospital, PO Box 4710, Christchurch 8001. Fax: +64 (0)3 3640914

Correspondence Email

Bronwen.rhodes@cdhb.govt.nz

Competing Interests

NZ Guidelines Group. Evidence-based tools for managing patients with type 2 diabetes. http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-groupRajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Research and Clinical Practice. 1998 February: 39(2):123-128.Brims FJ, Lansley SM, Waterer GW, Lee YC. Empyema thoracis: new insights into an old disease. Eur Respir Rev. 2010 Sep 1;19(117):220-8.Lindstrom ST, Kolbe J. Community acquired parapneumonic thoracic empyema: predictors of outcome. Respirology. 1999; 4:173-9.Kobashi Y, Mouri K, Yagi S, et al. Clinical analysis of cases of empyema due to Streptococcus milleri group. Jpn J Infect Dis. 2008 Nov;61(6):484-6.Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct; 119(10): 877-83.Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005 Dec;128(6):3955-65.Lansdon AJ, Downing A, Roberts AW, Martin D. Psoas abscess formation in suboptimally controlled diabetes mellitus. Case Reports in Medicine. 2011 Article ID 249325: 3 pages.Tabrizian P, Nguyen SQ, Greenstein A, et al. Management and treatment of iliopsoas abscess. Arch Surg. 2009:144(10):946-949.Wu TL, Huang CH, Hwang DY, et al. Primary pyogenic abscess of psoas muscle. International orthopaedics. 1998:22:41-43.

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