Subscapularis pyomyositis: a rare presentation of shoulder pain.

We present a rare case of a subscapularis pyomyositis in a 38-year-old woman and examine the diagnostic and surgical challenges posed. History and examination features were similar to that of septic shoulder arthritis without overlying features of warmth or erythema. Serological markers revealed a C-reactive protein of 221 mg/L and white cell count of 11.1×109/L. A dry shoulder aspirate was obtained. Contrast-enhanced MRI demonstrated a peripheral rim-enhancing lesion within the subscapularis muscle belly with lack of central enhancement. These features are consistently seen with an infective aetiology. A deltopectoral approach to surgical drainage was utilised and subsequent fluid cultures grew Panton-Valentine Leukocidin positive Staphylococcus aureus species. This rare bacterium is associated with an increased risk of osteomyelitis and despite making a full recovery, the patient was advised to reattend if any future shoulder pain was encountered.

Aspergillus myofasciitis in a chronic granulomatous disease patient: first case report.

Aspergillus myofasciitis is a rare infection of the muscles and their fascial sheaths that has been reported in patients with immune deficiencies of various kinds but, until now, not with chronic granulomatous disease (CGD). Patients affected by CGD are at high risk of invasive aspergillus infections. The case described involves a 14-year-old boy with a severe autosomal recessive CGD who was admitted to hospital with an Aspergillus myofasciitis of the left forearm. He was treated with liposomal amphotericin for 14 days and then with oral voriconazole for three months with an excellent clinical outcome. He did not evidence any recurrence in the following 30 months using itraconazole prophylaxis.

Tropical pyomyositis of erector spinae complicated with spinal epidural abscess.

STUDY DESIGN: This is a retrospective case series. OBJECTIVE: Tropical pyomyositis of erector spinae muscle (ESPM) is a rare muscular infection which may extend into the intraspinal canal to become spinal epidural abscess (ESPM-SEA). If left untreated, it may cause catatrophic spinal cord dysfunction and lead to irreversible paralysis. A series of eight such cases is presented, in order to provide proper surgical options and clarify the prognostic factors of the disease. SUMMARY OF BACKGROUND DATA: Merely six sporadic case reports had been found in the literature. Surgical debridement and laminectomy to drain the intraspinal abscess combined with systemic antibiotics were the choice of treatment to treat the disease with good therapeutic effect. METHODS: Inpatient charts of the patients were reviewed. The therapeutic effect and functional neurological recovery are correlated with the demographic characteristics of the patients, neurological deficits before drainage, and the different procedures of drainage. RESULTS: Old age, long ESPM-SEA (>6.5 vertebral segments), spinal cord dysfunction as well as complete paralysis before the interventional procedures are significantly correlated with poor functional neurological recovery (Sperman's coefficient correlation, all p<0.05). Pig-tail drainage of ESPM combined with adequate systemic antibiotics could cure if infection presents with lumbar radiculopathy only, but it failed to rescue the spinal cord dysfunction in two patients present with complete paralysis. Surgical drainage of ESPM with mini-laminotomy to drain ESPM-SEA combined with systemic antibiotics provided good functional recovery of patients, despite of prolonged pre-operative complete paralysis. CONCLUSION: Early drainage of the ESPM and related epidural abscess combined with systemic antibiotics can provide excellent therapeutic effect of ESPM-SEA. Open drainage with mini-laminotomy is superior to pig-tail drainage when spinal cord dysfunction occurred associated with ESPM-SEA.

Medial approach for drainage of the obturator musculature in children.

BACKGROUND: In a recent study designed to determine the anatomic location of infection in children presenting with acute hip pain, fever, and elevated inflammatory markers, we demonstrated the incidence of infection of the musculature surrounding the hip to be greater than twice that of septic arthritis. Importantly, the obturator musculature was infected in >60% of cases. Situated deep in the pelvis, surrounding the obturator foramen, debridement of these muscles and placement of a drain traditionally requires an extensive ilioinguinal or Pfannenstiel approach, placing significant risk to the surrounding neurovascular structures. We hypothesized that the obturator internus and externus could be successfully debrided using a limited medial approach. METHODS: An IRB-approved prospective study of children (0 to 18 y) evaluated in the pediatric emergency department by an orthopaedic surgeon to rule out septic hip arthritis at a tertiary care children's hospital (July 1, 2010 to June 30, 2012) was conducted. Infected obturator musculature was identified and confirmed using magnetic resonance imaging. Cadaveric dissection was performed comparing the ilioinguinal, Pfannenstiel, and proposed minimally invasive medial approach. The proposed approach was utilized to debride and place drains in 7 consecutive patients. RESULTS: Anatomic information gained from magnetic resonance images of patients with abscess within the obturator musculature, and from the results of cadaveric studies, allowed for planning of a novel surgical approach. We found that through the surgical approach used to perform an osteotomy of the ischium (Tonnis) the obturator externus could be debrided through the adductor brevis and the obturator internus could be debrided through the obturator foramen. Using our medial approach, resolution of symptoms in all children who underwent surgical drainage resulted without complication. CONCLUSIONS: Our medial approach can safely access the obturator musculature for abscess decompression and drain placement with successful results. Advantages to this approach include: lower risk to neurovascular structures within the pelvis, less soft tissue trauma, and similarity to current techniques used for adductor lengthening, medial reduction of the dislocated hip, and osteotomy of the ischium. LEVEL OF EVIDENCE: Level II.

Surgical aspects of bacterial infection in African children.

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.

Hip abductors pyomyositis: a case report and review of the literature.

Pyomyositis, an acute hematogenous intramuscular bacterial infection, is an unusual disease in temperate climates. We present the case of a 15-year-old girl who was referred to our centre with pain, fever, and limping.  Magnetic resonance imaging and surgery showed diffuse pus collection in the hip abductor muscles. With increased incidence of this disease in immunocompromised patients in temperate areas, physicians must become familiar with its signs and symptoms to facilitate early diagnosis.

Bilateral hip pain caused by adductor pyomyositis as the initial presentation of chronic myeloid leukemia in a 17-year-old child.

Pyomyositis is a pyogenic muscular tissue infection mainly occurring in immunocompromised patients. Chronic myeloid leukemia (CML) accounts for only 2-3% of cases of childhood leukemia. Herein, we report on a 17-year-old male with bilateral hip pain caused by adductor pyomyositis before beginning the treatment course of CML. CML was diagnosed by bone marrow chromosome study and was treated initially with imatinib but switched to hydroxyurea 5 days later because of poor cytoreduction response. Subsequently, white blood cell counts decreased gradually; however, the hyperleukocytosis condition resolved very slowly again until we switched back to imatinib use on the 40(th) day of hospitalization. Pyomyositis was diagnosed by magnetic resonance imaging. Oxacillin was administered to cover Staphylococcus aureus, the most common pathogen of pyomyositis. Bilateral hip pain improved within 72 hours after antibiotic usage, but follow-up magnetic resonance imaging after 15 days of treatment revealed well-defined abscess and osteomyelitis of both femoral heads. Abscess incision and drainage were performed, and cultures of the drained pus grew no microorganisms. The patient completed 5 weeks of oxacillin treatment after the operation and recovered with a full range of motion of both hips. There was no residual disability. This is the first report of bilateral hip pain caused by pyomyositis as the initial presentation of CML. Pyomyositis needs to be considered in the differential diagnosis of hip pain in pediatric patients.

Spinal epidural abscess due to tropical pyomyositis in immunocompetent adolescents.

Pyomyositis, a suppurative infection of skeletal muscle, is a disease not frequently encountered by neurosurgical providers. While previously considered an infection localized to tropical and semitropical locations, clinical reports of pyomyositis in temperate climates have increased over the past decade. Paraspinal involvement is uncommon in pyomyositis; however, the potential exists for spread into the epidural space resulting in a spinal epidural abscess (SEA). Early diagnosis of an SEA is frequently hampered by the absence of specific signs, unfamiliarity with the disease, atypical manifestations, and a broad differential diagnosis that includes more common causes of back pain. To date, 1 such case of paraspinal pyomyositis associated with an SEA has been reported in the neurosurgical literature. The authors present 2 cases of pyomyositis with an SEA and review the epidemiology, pathophysiology, diagnostic workup, and management of this disorder.

Forearm pyomyositis in a breast cancer patient on chemotherapy.

Pyomyositis, a pyogenic infection of the muscle, is an uncommon diagnosis in chemotherapy patients with 20 cases reported in the literature.(1-7) These infections typically occur in large muscle groups, and can result in significant morbidity if not treated urgently. The presented case is the first to report pyomyositis in the forearm of a cancer patient (breast) on chemotherapy. Clinical suspicion is needed for rapid diagnosis and treatment, so that compartment syndrome is avoided and full neuromuscular recovery may be attained.

Streptococcus anginosus (Streptococcus milleri Group) Pyomyositis in a 50-Year-Old Man with Acquired Immunodeficiency Syndrome: Case Report and Review of Literature.

We describe the first reported case of bacterial pyomyositis of the right thigh caused by Streptococcus anginosus (S. milleri group) in an HIV-infected patient. The clinical presentation was complicated by multiple ring-enhancing lesions detected on magnetic resonance imaging of the brain. Evaluation for central nervous system toxoplasmosis,syphilis, and cryptococcal infection was negative. Aggressive antibiotic therapy directed against S. anginosus and surgical debridement were limb salvaging. Clinicians should considerS. anginosus as a causative pathogen in HIV-associated pyomyositis, particularly in complex presentations. Prompt surgical drainage may minimize complications due to S. anginosus, a pathogen associated with significant sequelae due to its invasive nature.

Tropical pyomyositis of the hip short external rotators associated with elevated intra compartmental pressure.

Two boys with the clinical and radiographic picture of acute tropical pyomyositis of the short external rotators of the hip were treated surgically followed by parenteral antibiotics (Figure 1). Intraoperatively, no pus was found. Histopathology specimens from 1 patient demonstrated small foci of degenerative changes and necrosis without evidence of infection (Figure 2). Prior to decompressing the muscle in the second patient, intramuscular pressure was measured and found to be significantly elevated. Surgical decompression was performed and both patients fully recovered after a course of intravenous antibiotics. Tropical pyomyositis' clinical presentation is often insidious with a variable course accounting for its frequent missed or late diagnosis. Often the illness progresses through three stages - invasive, suppurative, and late. Patients progress from a diffuse muscle inflammation to abscess formation and sepsis. Staphylococcus aureus is responsible for the infection in >75% of the cases. The quadriceps, iliopsoas, and gluteal muscles are most commonly affected. Multiple reports addressed the optimal treatment of tropical pyomyositis. Traditionally, surgical treatment was advocated. However, there are reports of successful nonsurgical or minimally invasive treatment. Based on our experience, it is suggested that the sequence of events in the development of tropical pyomyositis is an initial insult such as vigorous exercise, leading to elevated compartment pressure, resulting in a compartment syndrome. If simultaneous bactermia occurs, the vulnerable muscle is seeded with the infectious organism and abscess formation follows. That may explain other authors' findings that early aspiration, combined with antibiotic treatment, may be sufficient to decompress the muscle, prevent abscess formation and result in full recovery.

Tuberculous pyomyositis of the thigh masquerading as malignancy with concomitant tuberculous flexor tenosynovitis and dactylitis of the hand.

Multifocal involvement of the skeleton is extremely rare, with tuberculous pyomyositis and tenosynovitis of the wrist being uncommon presentations of skeletal tuberculosis (TB). We present an immunocompetent 68-year-old woman with concomitant presentation of these uncommon forms of extrapulmonary TB heralded by tuberculous pyomyositis. Tuberculous pyomyositis can often masquerade as malignancy, leading to misdiagnosis and patients being mistakenly referred to oncologists for management. This delayed the institution of appropriate drug therapy. Similarly, because of its rarity, tuberculous tenosynovitis may be overlooked as a cause of chronic tenosynovitis. In the absence of pathognomonic imaging findings, the diagnosis ultimately rests on histopathological and microbiological confirmation. This case highlights the importance of maintaining a high index of suspicion of the protean manifestations of extrapulmonary TB, not only in high-risk populations, but in immunocompetent individuals as well. It also illustrates the advantage of a clinically-directed multidisciplinary approach in early recognition and treatment of this entity.

Salmonella gas-forming femoral osteomyelitis and pyomyositis: the first case and review of the literature.

The authors describe the first case of Salmonella serogroup D gas-forming femoral osteomyelitis and pyomyositis in a 51-year-old man with non-Hodgkin lymphoma. The patient was successfully treated with surgical debridement as well as clindamycin plus ceftriaxone, and then switched to ciprofloxacin. However, he eventually died due to multidrug-resistant Acinetobacter baumannii pneumonia. In addition, five cases of Salmonella gas-forming pyomyositis in the literature were reviewed.