A 59-year-old man with a personal history of chronic alcoholism and smoking for years, who had suffered an episode of upper gastrointestinal haemorrhage secondary to anti-inflammatory analgesics as complications. His urological history included a prostate syndrome of two years' evolution with no secondary complications.
She came to the emergency department for intermittent febrile syndrome of four days' evolution, associated with urinary incontinence in the last 48 hours, together with dysuria and sacral pain radiating to both lower limbs and worsening with movement. Rectal tenesmus of recent onset was also associated. On arrival at the emergency department, fever of up to 39ºC was observed, the patient was haemodynamically stable, confused, drowsy and sweaty.
On physical examination, the abdomen was globular, soft and depressible, not peritonitised. Painful on palpation in the bilateral lumbar area at L5-S1, as well as in the hypogastric area and perineal region. There is no impression of a bladder balloon. The genital examination was normal, and the rectal examination showed a slightly painful rectal volume I adenomatosis. The neurological examination shows decreased strength in both lower limbs in the upper third and sensitivity is preserved. Patellar and Achilles reflexes are present.
Urgent blood and biochemistry tests showed: haemoglobin 14.2 g/dl, haematocrit 41.5%, leucocytes 20,300 (neutrophils 72.9%), glucose 212 mg/dl, creatinine 1.11 mg/dl, sodium 135 mEq/l, potassium 3.8 mEq/l, sedimentation rate 100 mm/h. Urinalysis with negative leucocytes, negative nitrites and normal sediment. The analysis was completed with a coagulation study which showed a prothrombin activity of 83%, a cephalin time of 27.2 sg, and fibrinogen of 574 mg/dl.
An urgent abdomino-pelvic CT scan was requested at the outset, showing multiple simple cysts in the kidneys and left renal lithiasis. No dilatation of the urinary tract. The prostate was enlarged, with two hypodense lesions in both lateral lobes measuring 3.3 cm and 3 cm, compatible with prostatic abscess.

Empirical antibiotic treatment with Ceftriaxone 1 g/12 h, Ampicillin 1 g/6 h and Gentamicin 240 mg/24 h was then started.
With the diagnosis of prostatic abscess, we decided to drain the collection under control with ECTR and urinary diversion.
In the operating theatre, a lumbar puncture was performed prior to intradural anaesthesia. A cloudy-yellowish cerebrospinal fluid was observed and a sample was sent to microbiology and biochemistry, 1070 leukocytes were isolated (85% polymorphonuclear).
On the other hand, the diagnosis of prostatic abscess was confirmed in the TCPR, which showed two collections of 30 and 28 mm affecting the left and right lobe respectively, the rest of the prostate being heterogeneous with no clear abscessed areas. By means of perineal puncture-drainage we evacuated 10 cc of pus from the collections described, leaving a cystostomy tube in place for drainage. We diverted the urine via suprapubic cystostomy.

From the culture of the samples (prostatic and lumbar puncture), sensitive S. aureus oxicilin was isolated, so we started treatment with Cloxacillin 2 g/24 and Rifampicin 300 mg/12h, and requested an urgent lumbar MRI which was reported as a subdural empyema, with no signs of spondylodiscitis.

Subsequent control based on new ECTR showed a clear improvement, although it was necessary to drain again a hyperechogenic area in the right prostatic lobe, evacuating 4 cc of purulent material. Subsequent check-ups did not reveal any new suspicious areas. A transesophageal echography was also performed, which ruled out secondary endocarditis, and a new lumbar MRI scan was performed after six weeks of antibiotic treatment, which showed complete resolution of the subdural empyema.