Recurrent Refractory Iliopsoas Abscess Requiring Definitive Open Surgical Drainage with Adjunctive Marsupialization: A Case Report

Abstract

Background: Iliopsoas abscess (IPA) is an uncommon yet potentially life-threatening retroperitoneal suppurative infection associated with significant morbidity and mortality, particularly among immunocompromised individuals. Clinical manifestations are frequently nonspecific, often resulting in delayed diagnosis and progression to systemic sepsis. Although broad-spectrum antimicrobial therapy combined with image-guided percutaneous drainage remains the cornerstone of treatment, recurrent or refractory disease may necessitate definitive surgical intervention. Case Presentation: We report the case of a 59-year-old female with poorly controlled diabetes mellitus and neurogenic bladder who presented with persistent pyrexia, right lumbar pain, and urinary tract infection. Initial radiological assessment demonstrated bilateral pyelitis, for which prolonged antimicrobial therapy was instituted. Despite extended intravenous antibiotic treatment and multiple image-guided percutaneous drainage procedures, the patient subsequently developed a persistent multiloculated left iliopsoas abscess with repeated recurrence. Serial computed tomography (CT) imaging demonstrated incomplete radiological resolution and progressive extension into the iliacus musculature. Owing to failure of conservative and minimally invasive management, the patient ultimately underwent definitive open surgical drainage with adjunctive marsupialization for durable source control and facilitation of postoperative cavity management. Discussion: This case underscores the therapeutic challenges posed by recurrent iliopsoas abscesses in immunocompromised hosts. Although percutaneous drainage is generally associated with high success rates, refractory disease may persist in the presence of multiloculated collections, chronic inflammatory cavities, or impaired host immunity. Open surgical drainage provides direct access for complete evacuation of purulent material and disruption of loculations. Adjunctive marsupialization, a technique more traditionally employed in the management of Bartholin gland pathology, may provide additional benefit through sustained drainage, enhanced postoperative wound surveillance, and reduction of recurrent cavity formation. Conclusion: Failure of prolonged antimicrobial therapy and repeated percutaneous drainage in iliopsoas abscess should prompt early consideration of definitive operative management. Adjunctive marsupialization may represent a valuable yet underreported surgical adjunct in the management of complex recurrent iliopsoas abscesses.