Why‐not‐doing‐high‐tech‐test Syndrome

A 69‐year‐old man presented with fever, chill, and malaise. A thorough physical examination brought the correct diagnosis of psoas abscess to light. In this case, a physical examination is the only way to correct diagnosis.


| INTRODUC TI ON
A 69-year-old Japanese man presented with fever, shaking chill, and malaise. He was well until 3 days before presentation, when he developed gradually worthening general malaise. In the morning of the presentation day, the patient developed fever and dull pain over the entire chest, abdomen, and back, which disabled him to walk by himself. Because of the worsening symptoms, the patient presented to the emergency room (ER). On questioning, he denied palpitation, headache, diarrhea, constipation, melena, hematochezia, cough, and sputum.
Fever is undoubtedly one of the most common symptoms for primary care physicians. Fever itself is a low-yield finding, or can produce an enormous variety of differential diagnoses. Thus, accompanying symptoms are of great importance in seeing febrile patients.
For example, dyspnea, cough, and chest pain are usually related to respiratory diseases such as pneumonia and pulmonary embolism. His past medical history included myocardial infarction 12 years before, stroke 9 years before, and uncontrolled type 2 diabetes mellitus with unknown time of onset. He stopped visiting any healthcare services for 2 years because of his financial issues. He did not take any regular medication. He had no known drug and food allergy. He smoked 40 cigarettes daily since he was seventeen, but he quitted smoking when he was 60 years old. He seldom drank alcohol.
The patient is a cellular immunocompromised host given his diabetes mellitus uncontrolled for a long time. Hence, he has a high risk of severe bacterial infection, which includes necrotizing fasciitis with or without osteomyelitis, bloodborne infection and abscess formation, and emphysematous infection with cystitis, pyelonephritis, or cholecystitis. His past heavy smoking history increases the likelihood of a respiratory infection such as pneumonia and lung abscess.
He also has a high risk of cerebrovascular and cardiovascular events. Aortic dissection sometimes produces fever, which may be the only manifestation of that disease. An acute phase of ischemic stroke and hemorrhage of the central nervous system may present with fever. However, if brain stroke had happened, neurological focal symptoms may have been present.
Finally, the patient admitted that he had no medication nor alcohol. Thus, drug-induced fever or withdrawal from alcohol or a certain drug such as benzodiazepine and antipsychotics is less likely, although we should not easily rule out even if the history from the patient seems reliable. The patient's quick SOFA score was two, which indicated that the probability of his developing sepsis was increased. The elevated lactate level also supported this diagnosis. If the patient had hypertension on a daily basis, which often coincides with diabetes mellitus and other atherosclerotic risk factors, his blood pressure in the ER was relatively low, and distributive or hypovolemic shock should be  A digit examination revealed smooth and nontender prostate. On the day 18, CT-guided abscess drainage was performed.
Bacterial culture of drained abscess turned out to be positive for Klebsiella pneumoniae. After the procedure, his fever was alleviated and his general condition improved. The drainage catheter was discontinued on the day 33. However, on day 35 in the hospital, fever recurred. A contrast CT scan on the day 37 revealed abscess stretching along the pathway of the drainage catheter. On day 42, surgical intervertebral disc drainage was performed. Fever did not recur after the surgery. He was discharged from the hospital on the day 106.

| D ISCUSS I ON
Psoas abscess is a relatively rare condition. Its incidence was reported as 4/1 000 000 in 1970s to 80s. 2 Development of diagnostic tools including CT scan is thought to have raised the incidence, but the conditions are still not common. 3,4 The mortality rate of psoas abscess is as high as 8.1% to 8.7%. 4,5 Diagnostic delay may lead to septic shock and death, and an appropriate therapy must be initiated immediately. 6  High intensity on STIR images was seen on the first and second vertebrae examination. 10 As mentioned above, the prompt and precise diagnosis of psoas abscess is not made by high-tech medicine. Instead, it is only accomplished by high-touch medicine, or "medicine based on a carefully constructed medical history couples with a pertinent physical examination and critical assessment of the information thus obtained." 10 This case explicitly indicates that modern physicians should put much value on history-taking and physical examination again.

| CON CLUS ION
Psoas abscess is an infectious condition with a high mortality rate, which frequently requires surgical drainage. Although imaging tests play a key role in the diagnosis, especially at the early stage, these tests have relatively low sensitivities, albeit a prompt identification of the condition must be important. Physical examination is a costeffective diagnostic procedure and sometimes sheds light on the hidden diagnosis in a swifter way than high-tech procedures such as CT or MRI because of its availability and less invasive nature. In diagnostically challenging cases, physicians should be wary of bedside clinical findings, even if subtle ones.
Here are the key points of this article. Firstly, an early-stage psoas abscess may be undetectable by imaging tests such as contrast-enhanced CT. Secondly, no tests except for a thorough bedside physical examination may not provide a clue to detect psoas abscess.
Lastly, clinicians should be aware of the sensitivity and specificity of the test they order in order to make a reasonable decision and reach a correct diagnosis.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.