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An 82 year old man was admitted to a district general hospital with a two week history of pyrexia, low back pain referred down the left leg, and progressive weakness of his left leg. On examination he was pyrexic, 38.5°C, with signs of lower motor neurone lesion extending from L2 to S1 with no other findings. His haemoglobin concentration was 78 g/l, white cell count 7.7 × 109/l, and erythrocyte sedimentation rate 115 mm/hour.
Computed tomography for the LS spine showed no cord compression and identified a lesion at the left psoas muscle. Subsequently, computed tomography of the abdomen was performed (see fig 1). This was followed by aspiration and a core biopsy under computed tomographic guidance. Bacteriology was negative and cytology non-conclusive. The patient was treated empirically with antibiotics and his symptoms gradually settled down.
Seven weeks later, the patient experienced sudden severe abdominal pain and a large mass was apparent in the left side of the abdomen. Computed tomography with enhancement was performed (see fig2).
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