Tropical Myositis: A Not-So-Tropical Diagnosis in a Febrile Type 1 Diabetic Patient.

INTRODUCTION: Tropical myositis - also known as pyomyositis - is a subacute, primary infection of skeletal muscle. Long considered a diagnosis exclusive to tropical climates, recently it has been reported increasingly in historically nontropical climates. We present a case of tropical myositis in Madison, Wisconsin, occurring in a febrile type 1 diabetic patient without travel or known exposure. CASE PRESENTATION: A 35-year-old male with a history of von Willebrand disease, type 1 diabetes, and financial insecurity resulting in insulin rationing presented with 2 weeks of generalized weakness. On exam, he had a multitude of large, erythematous "bumps" across his body, which had been increasing in size for more than 2 weeks. His blood glucose was 518, with leukocytosis and labs supportive of diabetic ketoacidosis. Computed tomography revealed extensive intramuscular and subcutaneous abscesses of the left chest, bilateral erector spinae, right gluteal muscles, bilateral thighs, left leg, and left upper and lower arm. Broad-spectrum antibiotics were initiated, as was treatment for diabetic ketoacidosis. Blood and urine cultures revealed oxacillin-susceptible Staphylococcus aureus. After clinical stabilization, he underwent initial incision and drainage of the abscesses. His condition would require 14 more operative incision and drainage procedures and wound closure attempts before he was discharged to a rehab facility after more than a month-long hospitalization. DISCUSSION: Severe tropical myositis is associated with high morbidity and high use of health care resources. The exponential rise in cases in the United States in recent years risks further stressing an already-burdened health care system. We explore potential causes of the increase in cases of tropical myositis in nontropical regions, including increasing rates of diabetes and poverty and climate change. Recent data suggest that the large majority of tropical myositis cases are caused by Panton-Valentine leukocidin toxin-producing Staphylococcus aureus strains. There is a theoretical mitigation of disease severity when patients receive early protein synthesis inhibitor antibiotic treatment, though these findings are limited to case reports and observational studies and lack controlled clinical trials. This case highlights the need for early identification, antibiotic administration, and surgical source control in suspected cases of tropical myositis.

Tubercular pyomyositis: A case series.

Tuberculosis is one of the endemic diseases in India. Tuberculosis can involve almost every organ of the body, however isolated muscle involvement is considered rare. We hereby report a series of three cases of tubercular pyomyositis to highlight the importance of high clinical suspicion in endemic countries like India, in both immunocompetent and immunocompromised individuals, presenting with persistent fever and musculoskeletal symptoms. A timely diagnosis with effective drainage and antitubercular therapy helps in good functional recovery.

Nocardia brasiliensis Pyomyositis in an Immunocompetent Patient Following Gardening Activity.

Nocardia pyomyositis in immunocompetent patients is a rare occurrence. The diagnosis may be missed or delayed with the risk of progressive infection and suboptimal or inappropriate treatment. We present the case of a 48-year-old immunocompetent firefighter diagnosed with pyomyositis caused by Nocardia brasiliensis acquired by direct skin inoculation from gardening activity. The patient developed a painful swelling on his right forearm that rapidly progressed proximally and deeper into the underlying muscle layer. Ultrasound imaging of his right forearm showed a 7-mm subcutaneous fluid collection with surrounding edema. Microbiologic analysis of the draining pus was confirmed to be N brasiliensis by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry. After incision and drainage deep to the muscle layer to evacuate the abscess and a few ineffective antibiotic options, the patient was treated with intravenous ceftriaxone and oral linezolid for 6 weeks. He was then de-escalated to oral moxifloxacin for an additional 4 months to complete a total antibiotic treatment duration of 6 months. The wound healed satisfactorily and was completely closed by the fourth month of antibiotic therapy. Six months after discontinuation of antibiotics, the patient continued to do well with complete resolution of the infection. In this article, we discussed the risk factors for Nocardia in immunocompetent settings, the occupational risks for Nocardia in our index patient, and the challenges encountered with diagnosis and treatment. Nocardia should be included in the differential diagnosis of cutaneous infections, particularly if there is no improvement of "cellulitis" with traditional antimicrobial regimens and the infection extends into the deeper muscle tissues.

Pyomyositis in the sternocleidomastoid muscle in a previously healthy 36-year-old woman.

Pyomyositis is a bacterial infection of striated muscle, usually located to muscles in the extremities or pelvis. We present a microbiologically unique case report of pyomyositis in the sternocleidomastoid muscle (the first of its kind in Denmark) caused by Staphylococcus epidermidis, S. capitis and possibly Streptococcus pneumoniae. Pyomyositis is very rare but can lead to critical complications such as endocarditis and sepsis. It is therefore important to know the condition when evaluating an infected patient with muscle pain. Treatment consists of antibiotics and - if relevant - surgical abscess drainage.

Clinical Characteristics and Management of Children and Adolescents Hospitalized With Pyomyositis.

BACKGROUND: Pyomyositis, a bacterial muscle infection, is an important differential diagnosis in children and adolescents with musculoskeletal pain. In contrast to tropical regions, it is rarely recognized in temperate countries, but incidence is increasing and major studies are missing. METHODS: This retrospective multicenter study included patients <18 years of age hospitalized with pyomyositis in 11 Swiss children's hospitals between January 2010 and December 2022. Cases were identified by ICD-10 code (Myositis; M60-M60.9), and data was extracted from electronic hospital records. RESULTS: Of 331 patients identified, 102 fulfilled the case definition. Patient age at presentation ranged from 2 weeks to 17 years (median 8 years). The majority had no underlying illness and all presented with fever and localized pain. At the respective site of pyomyositis, 100 (98%) had impaired movement and 39 (38%) presented with local swelling. Pelvic (57%) and leg (28%) muscles were mostly affected. Blood or tissue cultures were obtained in 94 (92%) and 59 (57%) patients, respectively. Of those, 55 (58%) blood and 52 (88%) tissue cultures were positive, mainly for Staphylococcus aureus (35 and 19, respectively) and Streptococcus pyogene s (12 and 15, respectively). All patients received antibiotic treatment during hospitalization for a median of 10 days (interquartile range: 7-17), followed by outpatient treatment for a further median of 16 days (interquartile range: 11-22) in 95 (93%) patients. Fifty-nine (57%) patients required surgery. CONCLUSIONS: Pyomyositis is a challenging diagnosis that requires a high level of awareness. Blood and/or tissue cultures revealed S. aureus and S. pyogenes as the predominant causative agents.

Isolated left sternocleidomastoid pyomyositis: a rare presentation of cervical sepsis.

An elderly gentleman self-presented to A+E with a 7-day history of significant and progressive left-sided neck pain, swelling and fevers, despite oral antibiotics from his general practitioner. Examination revealed a large left-sided neck mass involving levels 2-5 of the neck that was firm to palpate, with erythematous overlying skin.An urgent CT scan demonstrated a large collection throughout the length of the left sternocleidomastoid muscle (SCM), measuring 13×5.5×4 cm, with extensive adjacent inflammatory change. He was subsequently taken to theatre for washout and debridement, during which the collection was found to be loculated and isolated to the SCM, with surrounding structures spared.Postoperatively, he was managed with intravenous fluids and a total of 2 weeks of intravenous antibiotics. The wound partially dehisced during healing and the cavity was packed with flaminal and regularly dressed with input from the tissue viability team. This was then left to heal by secondary intention and the patient was followed up in clinic over the following weeks to ensure resolution.

Changing spectrum of primary pyomyositis in North India.

Recent data have demonstrated the changing epidemiology of primary pyomyositis worldwide. Our hospital-based retrospective study investigated the clinical and microbiological spectrum of primary pyomyositis between 2013 and 2021 in PGIMER (Chandigarh), India. Over a quarter had predisposing conditions, mainly diabetes mellitus and immunosuppressive therapy. Fever, muscle pain, local swelling and breathlessness were the usual presentations, with quadriceps, iliopsoas and gluteal muscles commonly affected. Staphylococcus aureus was the predominant cause, with c.50% methicillin-resistant strains. Almost two-thirds presented with metastatic infection (stage 3 pyomyositis), frequently with septic lung emboli. Patients with methicillin-sensitive and resistant Staphylococcus aureus had a similar incidence of metastatic infection. In-hospital mortality was c.10% and was strongly associated with a high international normalised ratio. Primary pyomyositis remains a significant problem, with a dramatic increase in community-associated methicillin-resistant Staphylococcus aureus.

Bacterial pyomyositis of the extraocular muscles: case report and systematic review.

OBJECTIVE: To describe the manifestations and treatment of extraocular muscle (EOM) bacterial pyomyositis. DESIGN: A systematic review following PRISMA guidelines and a case report. METHODS: PubMed and MEDLINE databases were searched for case reports and case series of EOM pyomyositis using the term "extraocular muscle" combined "pyomyositis" and "abscess". Patients were included as bacterial pyomyositis of the EOMs when there was a response to antibiotics alone or if a biopsy was consistent with the diagnosis. Patients were excluded when pyomyositis did not involve the EOMs or when diagnostic tests or treatment were not in keeping with the diagnosis of bacterial pyomyositis. An additional patient with bacterial myositis of the EOMs, treated locally, was added to the cases identified in the systematic review. Cases were grouped for analysis. RESULTS: There are 15 published cases of EOM bacterial pyomyositis including the one reported in this paper. Bacterial pyomyositis of the EOMs typically affects young males and is caused by Staphylococcus species. Most patients present with ophthalmoplegia (12/15; 80%), periocular edema (11/15; 73.3%), decreased vision (9/15; 60%) and proptosis (7/15; 46.7%). Treatment involves antibiotics alone or in combination with surgical drainage. CONCLUSIONS: Bacterial pyomyositis of the EOM presents with the same signs as orbital cellulitis. Radiographic imaging identifies a hypodense lesion with peripheral ring enhancement within the EOM. An approach to cystoid lesions of the EOMs is helpful in reaching the diagnosis. Cases can be resolved with antibiotics aimed at treating Staphylococcus, and surgical drainage may be required.

Primary pyomyositis and uveitis in a cat.

A 6-year-old neutered male Siamese cat was referred for investigation of hindlimb ataxia and blindness of 2 weeks' duration. A swollen right hind limb, with no history of trauma, and no evidence of an external wound, was observed on physical examination. Ophthalmic examination revealed bilateral absence of the menace response and changes consistent with uveitis. Blood tests identified changes consistent with inflammation including serum amyloid A elevation. Infectious disease testing was negative. Degenerate neutrophils and bacterial cocci were detected on fine needle aspiration cytology of the affected limb. Thoracic radiography and abdominal ultrasonography identified no abnormalities. Primary pyomyositis was suspected and clindamycin was prescribed following Penrose drain tube placement. In addition, eye drops containing tobramycin, atropine, and prednisolone were administered. The clinical signs and serum amyloid A level were markedly improved after 5 days of treatment. Based on the medical history and lack of other findings, the uveitis was suspected to be secondary to the pyomyositis. The clinical signs resolved completely, and no recurrence was reported within a 6-month follow-up period. To the best of our knowledge, primary pyomyositis with uveitis has not been previously reported in cats.

Pyomyositis associated with abscess formation caused by streptococcus pneumoniae in children: a case report and review of literature.

BACKGROUND: Pyomyositis is an unusual bacterial infection but potential severe in children. Staphylococcus Aureus is the main caused of this disease (70-90%), following by Streptococcus Pyogenes (4-16%). Streptococcus Pneumoniae rarely caused invasive muscular infections. We describe a case of pyomyositis caused by Streptococcus Pneumonia in an adolescent 12-year-old female. CASE PRESENTATION: I.L. referred to our hospital for high fever associated with right hip and abdominal pain. The blood exams showed increase of leukocytes with prevalence of neutrophils with high level of inflammatory markers (CRP 46,17 mg/dl; Procalcitonin 25,8 ng/ml). The abdomen ultrasonography was unremarkable. The CT and MRI of the abdomen and right hip revealed pyomyositis of the iliopsoas, piriformis and internal shutter associated with collection of pus between the muscular planes (Fig. 1). The patient was admitted to our paediatric care unit, and she was initially treatment with intravenous Ceftriaxone (100 mg/kg/day) and Vancomycin (60 mg/kg/day). On day 2, a pansensitive Streptococcus Pneumoniae was isolated from the blood culture, and the antibiotic treatment was changed to only IV Ceftriaxone. She was successively treated with IV Ceftriaxone for 3 weeks, then continued with oral Amoxicillin for a total of 6 weeks of therapy. The follow up showed a complete resolution of the pyomyositis and psoas abscess after 2 months. CONCLUSION: Pyomyositis associate with abscess is a rare and very dangerous disease in children. The clinical presentation can mimic symptoms of other pathologies like osteomyelitis or septic arthritis, so many times is hard to identify. The main risk factors include story of recent trauma and immunodeficiency, not present in our case report. The therapy involves the antibiotics and, if possible, abscess drainage. In literature there is much discussion about duration of antibiotic therapy.

Primary bacterial intercostal pyomyositis diagnosis: A case report.

RATIONALE: Pyomyositis is a microbial infection of the muscles and contributes to local abscess formation. Staphylococcus aureus frequently causes pyomyositis; however, transient bacteremia hinders positive blood cultures and needle aspiration does not yield pus, especially at the early disease stage. Therefore, identifying the pathogen is challenging, even if bacterial pyomyositis is suspected. Herein, we report a case of primary pyomyositis in an immunocompetent individual, with the identification of S aureus by repeated blood cultures. PATIENT CONCERNS: A 21-year-old healthy man presented with fever and pain from the left chest to the shoulder during motion. Physical examination revealed tenderness in the left chest wall that was focused on the subclavicular area. Ultrasonography showed soft tissue thickening around the intercostal muscles, and magnetic resonance imaging with short-tau inversion recovery showed hyperintensity at the same site. Oral nonsteroidal anti-inflammatory drugs for suspected virus-induced epidemic myalgia did not improve the patient's symptoms. Repeated blood cultures on days 0 and 8 were sterile. In contrast, inflammation of the soft tissue around the intercostal muscle was extended on ultrasonography. DIAGNOSES: The blood culture on day 15 was positive, revealing methicillin-susceptible S aureus JARB-OU2579 isolates, and the patient was treated with intravenous cefazolin. INTERVENTIONS: Computed tomography-guided needle aspiration from the soft tissue around the intercostal muscle without abscess formation was performed on day 17, and the culture revealed the same clone of S aureus. OUTCOMES: The patient was diagnosed with S aureus-induced primary intercostal pyomyositis and was successfully treated with intravenous cefazolin for 2 weeks followed by oral cephalexin for 6 weeks. LESSONS: The pyomyositis-causing pathogen can be identified by repeated blood cultures even when pyomyositis is non-purulent but suspected based on physical examination, ultrasonography, and magnetic resonance imaging findings.

Streptococcus agalactiae pyomyositis in a patient with primary biliary cholangitis: A case report.

Pyomyositis is an uncommon clinical scenario; it is usually associated with predisposing factors, including poorly controlled diabetes mellitus, trauma history, and immunocompromise. We discuss the case of an elderly woman with a 20-year history of diabetes mellitus and remissive breast cancer after modified radical mastectomy and subsequent chemotherapy 28 years previously. The patient presented with severe shoulder pain and gradual swelling. After examination, pyomyositis was diagnosed and debridement surgery was performed. Culture of the wound samples showed the growth of Streptococcus agalactiae. During hospitalization, primary biliary cholangitis (PBC) was diagnosed incidentally, accompanied by poor glycemic control. After treatment with antibiotics for pyomyositis and ursodeoxycholic acid for PBC, the infection resolved in 8 weeks, and her glycemic control was improved after PBC treatment. It is possible that the long-term untreated PBC worsened insulin resistance and aggravated diabetes mellitus in this patient. To the best of our knowledge, this is the first reported case of pyomyositis caused by an unusual pathogen, S. agalactiae, in a patient with newly diagnosed PBC.

Unprovoked piriformis myositis presenting in a pregnant patient.

A patient in her mid-30s presented to hospital at 25 weeks' gestation with acute onset of leg pain.Routine investigations were performed to rule out the common causes of leg and back pain in pregnancy, which were grossly normal. Piriformis pyomyositis was diagnosed on MRI and a collection was drained. Following an initial response to antibiotic therapy, the patient delivered by elective caesarean section, but the pain returned on postnatal day 2 and muscle inflammation was diagnosed again, requiring a repeat course of antibiotics.This case highlights a rare cause of leg pain in a pregnant patient, and the additional complexities of managing cases in the obstetric population.

Severe thoracic pyomyositis in a patient with systemic lupus erythematosus.

Pyomyositis may mimic deep vein thrombosis and be misdiagnosed in patients with systemic lupus erythematosus (SLE). We report here on patient with SLE with severe thoracic pyomyositis presented with right upper arm swelling and fever. The patient fully recovered after a serial surgical debridement and antibiotic therapy. Pyomyositis, as well as deep vein thrombosis, should be considered during the differential diagnosis of patients with SLE experiencing fever and unilateral limb oedema. CT and identification of causal pathogens are crucial in the diagnosis of pyomyositis. Early effective antibiotic treatment as well as surgical intervention can together bring about a better outcome.

Extensive pyomyositis secondary to paronychia-related MRSA infection: A case report.

RATIONALE: Pyomyositis is characterized by an insidious and multifactorial inflammatory process, which is often caused by hematogenous pathogen. Predisposing risk factors include immunodeficiency, diabetes, malignancy, or trauma. The spectrum of clinical presentation depends on disease severity, typically presented by fever and hip pain. We hereby present a case with extensive pyomyositis secondary to chronic paronychia infection. PATIENT CONCERNS: A 14-year-old immunocompetent male presented with fever and hip pain. The patient was initially surveyed for common infectious etiologies prior to the presentation of acute limping, which led to image confirmation of extensive pyomyositis. DIAGNOSIS: The patient presented with acute pain in the right hip accompanied by headache, myalgia of the right leg, and intermittent fever for a week. Physical examination disclosed limping gait, limited range of motion marked by restricted right hip flexion and right knee extension, and chronic paronychia with a nail correction brace of the left hallux. Diagnosis of pyomyositis was confirmed by magnetic resonance image. Methicillin-resistant strains of Staphylococcus aureus was isolated from the patient's blood and urine cultures within 2 days of collection. The same strain was also isolated from the pus culture collected via sonography-guided aspiration. INTERVENTIONS: Antibiotics treatment with oxacillin, teicoplanin, daptomycin, and fosfomycin were administered. Sonography-guided aspiration and computed tomography-guided pigtail drainage were arranged, along with nail extraction of his left hallux paronychia prior to discharge. Oral antibiotics fusidic acid was prescribed. Total antibiotics course of treatment was 4 weeks. OUTCOMES: The patient gradually defervesced and was afebrile after drainage. Followed limb doppler sonography showed regression of the abscess at his right lower limb. Gait and range of motion gradually recovered without sequelae. LESSONS: Ambulation and quality of life are greatly affected by the inflammatory process of pyomyositis. Detailed evaluation of predisposing factors should be done, even in immunocompetent individuals. Timely diagnosis is vital to successful treatment.