Microsporidial polymyositis in human immunodeficiency virus-infected patients, a rare life-threatening opportunistic infection: clinical suspicion, diagnosis, and management in resource-limited settings.

INTRODUCTION: Microsporidial myositis is a rare opportunistic infection that has been reported in HIV-infected and HIV-uninfected immunocompromised patients. METHODS: In this study we present a retrospective analysis of 5 cases of microsporidial myositis in HIV-infected patients, including the clinical, laboratory, and histologic features, and a review of the literature. RESULTS: Five young men with HIV infection [median CD4 count of 20 cells (range 14-144)/mm(3) ] who presented with signs and symptoms suggestive of myositis underwent EMG-NCV and muscle biopsy, which revealed signs compatible with microsporidial myositis. Early and aggressive treatment led to improvement in 3 patients. Two of the 5 patients died due to a delay in diagnosis, because the spores were mistaken for Candida without confirmatory stains or a high index of suspicion. CONCLUSIONS: Myositis in HIV-infected patients with low CD4 counts should be evaluated using muscle biopsy. A high index of suspicion is required for early diagnosis of microsporidial myositis in HIV-infected patients. Early diagnosis and immediate, aggressive treatment are the keys to favorable outcomes in these patients.

Tuberculous pyomyositis of the temporal muscle in a nonimmunocompromised woman: diagnosis by sonography.

Pyomyositis (PM) is an uncommon cause of acute bacterial infection occurring in skeletal muscle. This disease is rare in non-tropical areas, and PM caused by Mycobacterium is very rare in a non-immunocompromised person. The presence of temporal area swelling may lead to a differential diagnosis toward more common pathologies, such as a complication of mastoiditis or a neoplasm of the temporal area. This article describes a case of tuberculous pyomyositis in a non-immunocompromised woman, the diagnosis of which was confirmed by sonographically guided fine-needle aspiration.

[Invasive aspergillosis in autopsy material of patients treated at the Institute of Tuberculosis and Chest Diseases during the years 1993-2000]. / Inwazyjna aspergiloza w materiale autopsyjnym u chorych leczonych w Instytucie Gruzlicy i Chorób Pluc w latach 1993-2000.

The aim of this paper is an analysis of clinical documentation and results of autopsy of 21 patients (pts) who died of invasive aspergillosis (IA) in the Institute of Tuberculosis and Chest Diseases in years 1993-2000 and the assessment of predisposing factors for IA. In 17 pts IA was the main and in other 4 only an accessory cause of death. All pts were treated with corticosteroids and/or cytostatic drugs--because of lung cancer (11 pts), cancer in other site (2 pts), haematologic disorders (2 pts), Wegener's granulomatosis (1 pt), polymyositis (1 pt), idiopathic pulmonary fibrosis (1 pt) and other diseases (3 pts). In 15 out of 21 pts granulocytopenia was revealed (from 0.008 x 10(9)/L to 0.82 x 10(9)/L) on an average one month before death. In 15 pts IA was limited to the lungs, in 6 others there were also fungal lesions in brain, kidneys, liver, spleen and heart. Pts with disseminated form of IA had significantly lower granulocyte count and were treated with higher doses of corticosteroids than others. Immunosuppressive drugs and granulocytopenia can be regarded as predisposing factors. Fatal course of IA depended also on the late diagnosis.

Polymyositis associated with primary cytomegalovirus infection.

A case of polymyositis associated with primary cytomegalovirus infection in a 17-y-old girl is reported. The girl exhibited fever, sore throat, progressive myalgia and muscle weakness with elevated creatine kinase, atypical lymphocytosis and myopathic features in the electromyogram. Histopathologically, biopsied muscle met the criteria for polymyositis. Primary cytomegalovirus infection was proven by seroconversion of IgG as well as IgM antibodies. This is the first report of an association between cytomegalovirus infection and polymyositis.

Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality.

OBJECTIVE: Pneumonia due to Pneumocystis carinii has been increasingly reported in patients with connective tissue diseases, but the frequency of this complication is not known. We sought to determine the frequency of P carinii pneumonia (PCP) in patients with connective tissue diseases, and to determine the role that a hospital's acquired immunodeficiency syndrome (AIDS)-related experience may have in the diagnosis of PCP in these patients. METHODS: We used a state hospitalization registry to identify all patients with PCP and either rheumatoid arthritis, systemic lupus erythematosus, Wegener's granulomatosis, polymyositis, dermatomyositis, polyarteritis nodosa, or scleroderma who had an emergent or urgent hospitalization in California from 1983 to 1994. We compared patient and hospital characteristics between these patients and patients with connective tissue diseases hospitalized with other types of pneumonia. RESULTS: Two hundred twenty-three patients with connective tissue diseases were diagnosed with PCP in the 12-year study period. The frequency of PCP ranged from 89 cases/10,000 hospitalizations/year in patients with Wegener's granulomatosis to 2 cases/10,000 hospitalizations/year in patients with rheumatoid arthritis. Compared with 5,457 patients with connective tissue diseases and pneumonia due to other organisms, patients with PCP were more likely to be younger, to be male, to have private medical insurance, and to have systemic lupus erythematosus, Wegener's granulomatosis, inflammatory myopathy, or polyarteritis nodosa rather than rheumatoid arthritis, and were less likely to be African American. Hospital size, teaching status, urban/rural location, proportion of admissions due to AIDS or PCP, and proportion of patients with pneumonia undergoing bronchoscopy were each associated with the likelihood of diagnosis of PCP in univariate analyses, but only the number of patients with PCP being treated at a hospital (odds ratio [OR] 1.03 for each additional 10 cases/year, 95% confidence interval [95% CI] 1.01-1.05) was associated with the likelihood of diagnosis of PCP in multivariate analyses. Patients were also somewhat more likely to be diagnosed with PCP if there had previously been a case of PCP in a patient with a connective tissue disease at the same hospital (OR 135, 95% CI 0.98-1.85). In-hospital mortality was 45.7%, and was unrelated to hospital characteristics. CONCLUSION: PCP is an uncommon, but often fatal, occurrence in patients with connective tissue disease. A hospital's prior experience with patients with PCP is associated with the likelihood that this condition is diagnosed in patients with connective tissue diseases who present with pneumonia, suggesting that diagnostic suspicion is an important factor in the correct identification of affected patients.

A pediatric case of polymyositis associated with Mycoplasma pneumoniae infection.

We describe the case of a 10-year-old girl who developed polymyositis associated with a Mycoplasma pneumoniae infection. She exhibited mild muscle weakness without skin rash, markedly elevated serum levels of muscle enzymes, and infiltration of mononuclear cells in a muscle biopsy specimen. Efficacy of both oral prednisolone and of intravenous methylprednisolone pulse therapy for her disease was limited. However, other immunosuppressive drugs, cyclophosphamide and methotrexate, proved clinically effective. This is the first report of steroid-resistant polymyositis associated with M. pneumoniae infection in a child.

The spectrum of myositis and rhabdomyolysis associated with bacterial infection.

OBJECTIVE: (1) To describe the clinical and radiographic features of 6 patients with myositis or rhabdomyolysis associated with bacterial infection. (2) To analyze the role of computed tomography (CT) in myositis associated with bacterial infection. METHODS: Review of cases treated by the authors with literature review. RESULTS: Two patients had classical pyomyositis with Staphylococcus aureus as the etiologic agent. One patient had pyomyositis with Enterobacter cloacae (the first reported to our knowledge), 2 had myositis/fasciitis (one due to Clostridium perfringens and one due to S. aureus), and one had fatal toxic rhabdomyolysis in association with C. perfringens bacteremia without evidence of gas gangrene. No patient had a completely normal CT scan of affected muscles, but CT scans in 3 patients failed to show abscesses that were subsequently discovered at surgery, while in another patient CT scanning falsely suggested a large abscess that was not present at surgery. CONCLUSION: Infection associated muscle involvement represents a spectrum of clinical manifestations that include pyomyositis, myonecrosis, fasciitis/myositis, and toxic rhabdomyolysis. Diagnosis may be delayed by the often mild clinical presentation. CT scanning alone may be unreliable in distinguishing muscle abscess from swollen muscle unless combined with CT guided needle biopsy.

Acute polymyositis associated with W. bancrofti.

Two cases of acute polymyositis associated with W. bancrofti, presented with generalised painful swelling and weakness of the muscles. These patients had elevated muscle enzymes, a myopathic EMG pattern, inflammatory myopathy on biopsy and W. bancrofti in the peripheral blood smear. The clinical, improvement of the disorder and total clearance of microfilariae was obtained with the combination therapy of steroid and diethyl-carbamazine in comparison with steroid alone.

Polymyositis and dermatomyositis: no persistence of enterovirus or encephalomyocarditis virus RNA in muscle.

OBJECTIVES: A persistent infection of enteroviruses and cardioviruses has been implicated in polymyositis and dermatomyositis, but conventional hybridisation studies of the presence of enterovirus RNA and encephalomyocarditis (EMC) virus RNA in affected muscle have yielded conflicting results. To investigate further the possibility of viral persistence, the presence of viral RNA in muscle from patients with adult onset polymyositis and dermatomyositis was investigated using a polymerase chain reaction (PCR) technique. METHODS: Muscle tissue was obtained from 10 patients with polymyositis and five patients with dermatomyositis, all with adult onset active disease. A PCR was performed using primers with high specificity for enterovirus and EMC virus RNA, followed by Southern blot hybridisation with an oligonucleotide probe directed against the internal portion of the amplified product. A PCR directed against the Abelson tyrosine kinase mRNA served as an internal control for the presence and quality of RNA. RESULTS: A specific amplification for enterovirus or for EMC virus could not be seen in any of the muscle biopsy samples, despite a sensitivity of about 30 plaque forming units for enterovirus and of 100 plaque forming units for EMC virus. Southern blot hybridisation confirmed these results in that positive controls hybridised with the oligonucleotide probe, but no signal was obtained with the muscle specimens. CONCLUSION: A sensitive and specific PCR technique showed no evidence of the presence of enterovirus or EMC virus RNA in muscle samples from patients with polymyositis or dermatomyositis. These data do not support the proposal that viral RNA persistence plays a part in these idiopathic inflammatory myopathies.

Search for HIV proviral DNA and amplified sequences in the muscle biopsies of patients with HIV polymyositis.

We searched for the presence of human immunodeficiency virus (HIV) in fresh-frozen muscle biopsy specimens from 10 patients with HIV-associated polymyositis (HIV-PM) using (a) 35S-labeled HIV-RNA transcript of the virus and in situ hybridization, and (b) polymerase chain reaction and slot-blot hybridization utilizing primers amplifying sequences from the gag and pol genes of the HIV genome. With in situ hybridization, positive signals were detected in sparse lymphoid cells surrounding the muscle fibers, but not within the muscle fibers, in up to two consecutive sections in 6 of the 10 specimens. By the polymerase chain reaction, amplified HIV-specific sequences were noted in 2 specimens, but in only 2 of 8 consecutive sections, implying infection of lymphoid cells rather than muscle fibers. Muscle cultures from six specimens failed to show integrated HIV sequences within the myotubes. We conclude that HIV sequences or transcriptional products are not present within the muscle fibers or the cultured myotubes of patients with HIV-PM. This indicates that: (a) viral replication does not take place within the muscle; (b) integration of HIV proviral genome does not occur within the myonuclei or satellite cells; and (c) HIV-PM does not seem to be due to a persistent infection of the muscle fiber by the virus.

[Pyomyositis. Apropos of 5 cases]. / Les pyomyosites. A propos de cinq observations.

Four patients meeting the "classical" criteria for spontaneous pyomyositis are reported. No local cause was found. Risk factors included diabetes mellitus (2 patients), hemopathy (one patient), and alcohol abuse (one patient). Causative organisms (Staphylococcus aureus in 3 cases and Salmonella sp in one case) were recovered from blood cultures, an unusual occurrence. CT scan studies ensured the diagnosis in every case. An additional case of pyomyositis due to Staphylococcus aureus illustrates the difficulties in the definition of disease. This patient, whose muscle lesions were remarkably well visualized by MRI with injection of gadolinium, developed infection of the sacro-iliac joint adjacent to the muscular focus of infection. This patient may have had either "primary" pyomyositis with spread to the adjacent joint or "secondary" pyomyositis caused by the joint infection which was recognized only later. Advances in medical imaging techniques suggest that the nosology of pyomyositis should be broadened using this terminology. This would underscore the unique characteristics of "classical", "primary" pyomyositis and emphasize imaging, diagnostic and therapeutic facets of the disease which are shared by both entities.

Persistence of enterovirus RNA in muscle biopsy samples suggests that some cases of chronic fatigue syndrome result from a previous, inflammatory viral myopathy.

Molecular hybridization using an enterovirus group specific probe detected virus RNA in muscle biopsy samples from 25 of 96 cases of inflammatory muscle disease and similarly from 41 of 158 cases of postviral fatigue syndrome (PFS). Enterovirus RNA was detected in only two of 152 samples of control muscle. The inflammatory myopathy group comprised patients with polymyositis (PM), juvenile dermatomyositis (JDM) or adult dermatomyositis (DM), and all showed the presence of an inflammatory infiltrate and fiber necrosis on histological examination of a muscle biopsy sample. In contrast, muscle samples from the PFS group were histologically normal except for non-specific changes such as occasional single fiber atrophy. By analogy with enteroviral myocarditis, which can progress to a post-inflammatory disease with persistence of virus in myocardium and disposes to the rapid development of dilated cardiomyopathy, we propose that PFS syndrome may be a sequela of a previous inflammatory viral myopathy.

Lymphocyte subsets in muscle biopsies of human T-lymphotropic virus type I carriers with polymyositis.

Recent epidemiologic studies have shown that human T-lymphotropic virus type I (HTLV-I) is associated with polymyositis. To clarify the histological features of HTLV-I positive polymyositis, we studied muscle tissue from two groups of patients with polymyositis, those seropositive for HTLV-I (5 patients) and those seronegative (5 patients). We examined the lymphocyte subsets in muscle biopsies using monoclonal antibodies. In the endomysium, a variable number of T-lymphocytes and macrophages and a smaller proportion of B-lymphocytes were found in both groups. In both HTLV-I positive and negative patients a variable number of T-lymphocytes and macrophages, with a smaller number of B-lymphocytes, were found in the perimysium. As a whole, the T-lymphocytes were predominantly of the helper/inducer phenotype in both groups. We failed to find any specific phenotype distribution among T-cells infiltrating the muscle of HTLV-I carriers with polymyositis.

[HTLV-I clinical pathological spectrum]. / HTLV-I espectro clinico patologico.

HTLV-I has been revealed as the etiological factor of the Tropical Spastic Paraparesis (TSP) and of the T-cell leukemia-lymphoma of the adult (ATLL). Recently, it has also been associated to some forms of polymyositis, polyarthritis, polyneuropathies, Sjögren's syndrome, thrombocytopenia and lympho-alveolitis. The clinical and pathological spectrum of this retrovirus is analyzed taking into account the Chilean cases and those reported by the international medical literature.