On examination, he was hypoxic (94% oxygen saturation), hypothermic (35.6°C) and tachycardic with new onset, fast atrial fibrillation (rate 142/minute), but normotensive. In addition, he was diffusely tender in the supra-pubic region and in both loins, especially on the right. Neurological examination was normal other than MRC grade 4/5 power in the lower limbs. Blood tests demonstrated a marked inflammatory response with raised CRP (373 mg/L) buy Luminespib and Acadesine nmr predominantly neutrophilic

leucocytosis (20.5 × 109/L). Acute kidney injury (urea 31.4 mmol/L; creatinine 244 μmol/L) and mildy deranged liver function tests (alkaline phosphatase 343 IU/L; GGT 183 IU/L; ALT 52 IU/L; bilirubin 14 μmol/L) were evident. Arterial blood gases demonstrated a metabolic acidosis selleck chemicals (pH 7.32; base excess −8 mEq/L). A chest radiograph was normal. Urinalysis was positive for leucocytes and erythrocytes only. Blood cultures were taken and broad spectrum antibiotics were commenced for presumed urosepsis. 24 hours after admission, the right hand became diffusely swollen, erythematous and tender, and the patient continued to experience pyrexia. His urine cultures yielded Serratia marcescens sensitive to the antibiotics. Ultrasonography of the urinary tract failed to demonstrate hydronephrosis. Ultrasonography of the right

hand showed generalised soft tissue oedema with a 1 cm deep fluid filled collection containing echogenic material overlying the MCP joints.The following day, the acute kidney injury worsened (urea 43.4 mmol/L; creatinine 351 μmol/L). An urgent CT thorax/abdomen/pelvis demonstrated an unexpected finding of bilateral iliopsoas abscesses, most extensive on the right side which contained a considerable volume

of gas (Figures 1 and 2). Figure 1 Transverse view on CT of the bilateral iliopsoas abscesses. Figure 2 CT demonstrated Sagittal View of Abdomen and Pelvis demonstrating gas locules in Right Iliopsoas Region. The patient proceeded to theatre for drainage of the abscesses. During intubation the anaesthetist noted the oropharynx was sloughy and inflamed and accordingly biopsies were taken. Bilateral groin incisions were used to approach the iliopsoas muscles in the extra-peritoneal Roflumilast plane. On the right side the abscess cavity involved the entire length of the iliopsoas muscle and contained 100 ml of cream coloured pus as well as gas. On the left side an estimated 40 ml of pus was contained within the lower psoas muscle. There was no evidence of communication with the replaced hip joints on either side. Drains were placed into the cavities. The hand abscess was also drained and samples from all sites were sent to microbiology. The patient was then transferred post-operatively to ICU for inotropic support (noradrenaline) and ongoing fluid resuscitation. 72 hours after admission the blood cultures returned a yield of F. necrophorum and subsequently tazocin and metronidazole were commenced.