Multifocal neuropathy and Horner's syndrome due to disseminated pyomyositis in an intravenous drug user.

BACKGROUND: The formation of abscesses with necrosis within large, striated muscles leads to pyomyositis, a condition relatively rarely encountered outside the tropics. Intravenous drug users and other immunocompromised individuals are predisposed toward this infection, which may occur due to local or haematogenous spread of infection to skeletal muscles previously damaged by trauma, exercise, or rhabdomyolysis. METHODS: We report a young male intravenous drug user with rhabdomyolysis due to use of a synthetic opioid, in whom disseminated pyomyositis was detected following evaluation for sciatic and radial neuropathies and Horner's syndrome and review available reports of peripheral nerve dysfunction in the setting of this uncommon infection. We searched online databases to identify all published reports on adult patients with pyomyositis complicated by peripheral nerve dysfunction. CONCLUSIONS: Peripheral nerve dysfunction may rarely occur via local spread of infection or compression from abscesses.

Primary Bacterial Pyomyositis in Children: A Systematic Review.

BACKGROUND: Tropical pyomyositis has had a recent increase in the United States, Europe, and other nontropical areas. The purpose of this study was to provide an accurate description of the demographics, presenting features, sites of involvement, microbiology, imaging modalities, medical and surgical management, complications, and predictors of clinical course. METHODS: We searched PubMed, Cochrane, Web of Science Collection, Scopus, and Embase databases yielding 156 studies. Of these, 23 articles were selected for statistical analysis. RESULTS: The average age at presentation was 8.4±1.9 years with males more commonly affected. Fever, painful limp, and localized pain were the most common presenting symptoms. Pelvis, lower extremity, trunk and spine, in descending order, were the most commonly affected locations. Iliopsoas, obturator musculature, and gluteus musculature were the most commonly affected muscle groups. The mean time to diagnosis was 6.6±3.05 days. Staphylococcus aureus was the most common offending organism. The mean length of hospital stay was 12.0±4.6 days. Medical management alone was successful in 40% of cases (143/361) with an average duration of 9.5±4.0 and 22.7±7.2 days of intravenous and oral antibiotics, respectively. Surgical management consisted of open drainage in 91.3% (199/218) or percutaneous drainage in 8.7% (19/218) of cases. Painful limp, fever, and larger values of white cell count and erythrocyte sedimentation rate were associated with an increased need for surgery. Obturator and calf muscle involvement were strongly associated with multifocal involvement. There were 42 complications in 41 patients (11.3%). Methicillin-resistant S. aureus was associated with an increased risk of complications. The most common complications were osteomyelitis, septicemia, and septic arthritis. CONCLUSIONS: Primary pyomyositis should be considered in cases suggesting pediatric infection. Magnetic resonance imaging is the most commonly used imaging modality; however, ultrasound is useful given its accessibility and low cost. Medical management alone can be successful, but surgical treatment is often needed. The prognosis is favorable. Early diagnosis, appropriate medical management, and potential surgical drainage are required for effective treatment. LEVEL OF EVIDENCE: Level IV-systematic review.

Pyomyositis and muscle abscess due to Salmonella enteritidis in a patient with Behçet's syndrome: a case report.

Salmonella infections usually present with gastrointestinal manifestations including enterocolitis especially in immunocompromised patients. Haematogenous dissemination and abscesses are very rare complications of Salmonella species. This case report documents a patient with Behçet's syndrome (BS) who has pyomyositis due to Salmonella species. A 43-year-old male patient with BS presented to the outpatient rheumatology clinic with bilateral acute-onset lower extremity pain. However, over a short time the pain gradually increased and was accompanied by fever. The magnetic resonance scans demonstrated pyomyositis and muscle abscess in the adductor and obturator muscles. The cultures showed Salmonella enteritidis infection. The patient was successfully treated with antibiotic therapy. This case is important since it is one of the first in the literature to report an adult patient with BS and Salmonella pyomyositis.

Point-of-Care Ultrasound to Diagnose Pyomyositis in a Child.

We report a case of a patient presenting with fever, right lower leg swelling, and pain who was found to have a fluid collection between muscle planes noted on point-of-care ultrasound. Point-of-care ultrasound raised the clinician's concern for deep musculoskeletal infection, leading to prompt initiation of antibiotics and magnetic resonance imaging.

Pyomyositis Diagnosed by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Currently, the role of ultrasound in diagnosing superficial abscesses is well validated, however, its role for deep space infections and intramuscular pathology is limited. Distinguishing between simple cellulitis and abscess is critical for emergency physicians (EP), as the treatment is very different. Management of cellulitis relies on antibiotic therapy, whereas abscess treatment requires incision and drainage. It is important that EPs can accurately distinguish between the two entities. CASE REPORT: We report a case of a 41-year-old man with a history of high blood pressure and poorly controlled diabetes who presented with right lateral thigh redness, warmth, and tenderness. A point-of-care ultrasound (POCUS) of the patient's right lateral thigh with a high-frequency linear (8 MHz) ultrasound probe showed a 2.93 × 3.38 × 6.0-cm complex fluid collection deep to the fascial plane, approximately 3.0 cm from the skin surface, that contained mixed echogenicities with posterior acoustic enhancement consistent with an intramuscular abscess of the vastus lateralis. The patient was diagnosed with pyomyositis of his vastus lateralis. He was started on vancomycin and admitted to the surgical service for antibiotic treatment and surgical drainage. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: This case demonstrates that the use of POCUS by EPs can facilitate the rapid recognition and treatment of a disease that is challenging to diagnose on physical examination and can be potentially life-threatening if missed. EPs can consider performing a POCUS when evaluating skin infections to ensure rapid diagnosis and appropriate medical care for a potentially severe condition.

Transgluteal Approach for Drainage of Obturator Internus Abscess in Pediatric Patients.

BACKGROUND: Of the locations of peripelvic pyomyositis, infection of the obturator musculature poses a difficult challenge for operative drainage. The anatomic location of the obturator muscles, especially the obturator internus, complicates operative debridement as the surgical approach must safely bypass a large number of neurovascular structures. Realizing the challenges and risks of approaches to the obturator musculature, the purpose of our study was to review a novel, yet simple, posterior approach to the obturator internus. METHODS: We reviewed a case series of children (age 0 to 18 y), who presented to our institution with obturator internus pyomyositis. The patients' demographics, vital signs, laboratory data, and radiographic findings from the initial evaluation were reviewed. Blood and intraoperative culture results were collected. Duration of symptoms and length of hospital stay were also reviewed. Cases of suspected obturator internus abscess were confirmed by magnetic resonance imaging of the pelvis. All patients in this study who met the operative indications were debrided using the posterior transgluteal approach. RESULTS: Five patients were identified who met criteria for isolated obturator internus pyomyositis. Four out of the 5 patients met operative indications and underwent drainage through a transgluteal approach. One patient responded well to antibiotic treatment; therefore, no surgery was indicated. Purulence was expressed in all 4 operative cases. Hospital length of stay ranged from 6 to 14 days. All patients were treated with an IV antibiotic course for 3 to 6 weeks. All patients returned to normal function and activity levels. There were no surgical complications. CONCLUSIONS: This case series has reviewed a new technique for the drainage of an isolated obturator internus abscess. The transgluteal posterior approach is a simple approach that is performed through a single incision with minimal soft-tissue dissection. It avoids the risks and challenges posed by other approaches. Most importantly, our case series, although small, in our experience, has shown that it is a safe and effective approach for drainage of obturator internus abscess. LEVEL OF EVIDENCE: Level IV.

Sonographic appearance of pyomyositis of the sternocleidomastoid muscle: A case report.

Pyomyositis in the neck has rarely been described. We present the sonographic findings in a case of pyomyositis of the sternocleidomastoid muscle. A 62-year-old man with poorly controlled diabetes presented with an induration of the neck and fever. On gray-scale sonography, a part of the sternocleidomastoid muscle appeared swollen and contained irregularly shaped hypoechoic areas. Power Doppler imaging showed increased vascularity in the muscle. Sonographic-guided aspiration confirmed abscesses in the sternocleidomastoid muscle. Surgical drainage was successfully performed along with antibiotic treatment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:520-523, 2017.

[Primary pyomyositis. Review of 32 cases diagnosed by ultrasound]. / Piomiositis primaria. Revisión de 32 casos diagnosticados por ecografía.

Primary pyomyositis is a bacterial infection of striated muscle which is acquired by hematogenous route. It is related to risk factors such as HIV/aids and other immuno suppressing diseases, and can be associated with local muscle stress factors. The most frequent etiology is Staphylococcus aureus. Its diagnostic delay may cause a fatal evolution. In this series 32 patients with primary pyomyositis diagnosed by ultrasound were evaluated. The most frequent risk factor was HIV/aids (61%). Local factors were detected in 21 (66%) cases: first, the practice of football. The monofocal form was observed in 19 (59%), the most commonly affected muscles were quadriceps, calves and psoas. Samples for bacteriological study were obtained in 30 cases, 22 blood culture and 27 abscess materials. In 30 cases the etiologic agent was isolated. Staphylococcus aureus accounted for 83.3% (25 cases) and Escherichia coli, Nocardia spp., Streptococcus agalactiae, nontuberculous mycobacteria, Pseudomonas aeruginosa were isolated in one case each. Seventeen patients received surgical treatment, aspirative punctures, 9; antibiotics alone, 4. Twenty eight (93.3%) patients had a good evolution; deaths, 2 (6.6%); unknown, 2. Main conclusions of this study were: due to the diverse and changing etiology of the primary pyomyositis it is important to recognize the etiological agent involved and their antibiotic susceptibility. The ultrasound performed the study in real time so it can be used to guide the puncture and to facilitate the immediate diagnosis. This makes the difference with other techniques and transforms it into a first-line method for the study of this disease.

Point-of-care ultrasound differentiates pyomyositis from cellulitis.

Pyomyositis (PM) is an infection of skeletal muscle, often associated with an abscess. Patients typically have predisposing risk factors or are immune compromised. The disease is often misdiagnosed, mistreated,and goes undetected until late in the patient's clinical course.We present a case of a patient without obvious predisposing risk factors who complained of right thigh pain, swelling, redness, and fevers for 4 days.Point-of-care ultrasound revealed muscle edema and subcutaneous emphysema without signs of an overlying cellulitis. Point-of-care ultrasound consequently led to an earlier diagnosis of PM and directly affected the immediate patient care in the emergency department.

Temperate pyomyositis: a pain in the belly.

Pyomyositis is a rare disease in temperate climates. This case is a unique presentation of pyomyositis of the rectus abdominal muscle mimicking an acute abdominal process. Most reported cases of pyomyositis are of extremity infections with Staphylococcus aureus.This report presents a case of polymicrobial pyomyositis from Haemophylus parainfluenza and Steptococcus viridians infection.

Point-of-care ultrasound in diagnosing pyomyositis: a report of three cases.

BACKGROUND: Pyomyositis is a bacterial infection of skeletal muscle that often results in deep intramuscular abscesses. The absence of external dermatologic manifestations in the early stages of pyomyositis makes this a challenging diagnosis. In addition, physical examination findings can be difficult to distinguish from more common processes, such as soft-tissue cellulitis. Clinicians can fail to diagnose this serious disease in a timely manner, resulting in delayed treatment and potential clinical deterioration from sepsis. Although advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) provide excellent detail, ultrasound (US) can also be used to detect this disease. US can be performed expeditiously at the bedside and is less expensive than CT or MRI. It allows the clinician to examine the deeper tissue planes of muscle, in which purulent fluid collections will develop as pyomyositis advances. CASE REPORT: Three patients presenting with leg pain were evaluated with point-of-care (POC) US and diagnosed with pyomyositis. The early diagnosis of this condition prompted rapid treatment with administration of appropriate antibiotics and involvement of orthopedic surgery. Aspiration of fluid allowed for detailed fluid analysis and bacterial cultures. Additional diagnostic imaging was performed, confirming the initial US diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC US can be helpful in identifying and further delineating intramuscular abscesses and can subsequently lead to expedited and appropriate care in patients who present with extremity pain, but lack significant dermatologic changes.

Primary Pyomyositis in Children is No More a Rare Condition: Presentation of 2 Clinical Cases.

Primary pyomyositis is a bacterial muscle infection which may lead to abscess formation and severe complications. Although this condition has long been considered "tropical" and rare, mostly affecting immunocompromised patients, cases of pyomyositis have recently raised significantly among healthy children in temperate climates. With these 2 cases we highlight the importance of an early recognition of this condition, allowing an immediate treatment and reducing complications.

Pyomyositis mimicking osteomyelitis detected by SPET/CT.

Pyomyositis is a relatively infrequent, sub-acute primary bacterial muscle infection, which due to its non specific clinical findings is unlikely to be early diagnosed especially in diabetic patients. This diagnostic delay may be fatal. Therefore, early diagnosis and prompt treatment are imperative. We present a poorly-controlled diabetic patient who was referred to our Nuclear Medicine department for a bone scan to evaluate osteomyelitis. Routine three-phase-planar-scintigraphy was falsely positive for osteomyelitis in the left fibula, however, single photon emission tomography (SPET/CT) images clearly showed abnormal uptake in the calf muscles rather than the bone with evidence of low-attenuation lesions in these muscles. SPET/CT and magnetic resonance imaging (MRI) provided essential information to the clinicians to consider other diagnoses rather than osteomyelitis. MRI showed inter and intra-muscular collections consistent with multiple abscesses. Based on medical history, SPET/CT and MRI findings, the diagnosis of pyomyositis was established. The patient underwent successfully multiple incision-drainage procedures with subsequent intravenous antibiotic treatment and was discharged after complete recovery. In conclusion we advocate the use of SPET/CT for the detection of pyomyositis.

Piriformis Pyomyositis Presenting as Migratory Hip to Knee Pain: A Case Report.

CASE: The authors report a case of piriformis pyomyositis in a teenage female patient with fever and left hip pain. Her pain migrated to the knee with concurrent near resolution of hip pain. Imaging revealed an abscess in the left piriformis with pus tracking along the sciatic nerve sheath. This was complicated by internal iliac vein thrombosis and an embolus to the lung. Open drainage was performed, followed by outpatient intravenous cloxacillin and oral warfarin, with complete resolution of symptoms. CONCLUSION: Piriformis pyomyositis is a rare condition with varying presentations. The threshold for suspicion should be low even in healthy young individuals.

Pyomositis: a report of three cases.

Pyomyositis, a subacute bacterial infection of muscles, is uncommon in children. Three children with pyomyositis and multiple abscesses caused by Staphylococcus aureus are reported. The intercostal muscles were involved in one case, the paraspinal muscles in another and in the third there was associated septic arthritis.