Extensive thigh pyomyositis secondary to cystic fistulae due to anaerobic-bacterial infection in a kidney transplant recipient.

BACKGROUND: Managing infectious complications after kidney transplantation (KT) remains a major challenge. Infections are the leading non-cardiovascular cause of death among kidney transplant recipients (KTr). The urinary tract is particularly vulnerable to infections in this group, leading to high levels of morbidity and mortality, as well as significant economic costs. CASE PRESENTATION: This case report presents the first documented instance of extensive thigh pyomyositis resulting from cystic fistulae in an 84-year-old KTr. The patient was referred to our hospital with acute onset fever, pain in the inner thighs and pyuria. A CT scan revealed bilateral pyomyositis of the thighs, characterized by multiple abscesses in the adductor muscles and hydroaerobic levels. Additionally, cystic fistulae complicated by pubic symphysis osteitis were identified. CONCLUSION: In KTr, lower limb pyomyositis resulting from a urinary tract infection is an extremely rare and significantly worsens the overall prognosis for these patients.

Imaging features of soft-tissue infections.

Skin and soft tissues are among the most common sites of infections. Infections can involve the superficial epidermis to deep muscles and bones. Most infections spread through contiguous structures, although hematogenous spread can occur in the setting of an immunocompromised state and with atypical infections. While clinical diagnosis of infections is possible, it often lacks specificity, necessitating the use of imaging for confirmation. Cross-sectional imaging with US, CT, and MRI is frequently performed not just for diagnosis, but to delineate the extent of infection and to aid in management. Nonetheless, the imaging features have considerable overlap, and as such, it is essential to integrate imaging features with clinical features for managing soft tissue infections. Radiologists must be aware of the imaging features of different infections and their mimics, as well as the pros and cons of each imaging technique to properly use them for appropriate clinical situations. In this review, we summarize the most recent evidence-based features of key soft tissue infections.

Dysphagia and Trismus After Tooth Extraction : Clinical Conondrum.

Clinicians should consider disorders of masticatory muscle including lateral pterygoid muscle as a differential diagnosis in patients presenting with dysphagia and trismus after tooth extraction.

A case of extraocular muscle pyomyositis in an elderly patient with diabetes mellitus.

Pyomyositis is a bacterial infection of skeletal muscle leading to abscess formation. Younger males are predominantly involved, but pyomyositis may occur in all ages and sexes. Underlying systemic disease or accompanying immunocompromised states may increase the risk of pyomyositis. This is a report of a 72-year-old, male, with uncontrolled diabetes mellitus, presenting initially as a case of orbital cellulitis. Magnetic resonance imaging confirmed the presence of an abscess in the left lateral rectus. Antibiotic therapy was promptly initiated, and drainage of the abscess was performed via a transconjunctival approach. Pyomyositis resolved post-surgery and medical therapy. Residual exotropia was noted at the eighth month of follow-up necessitating subsequent strabismus surgery. Nine months post-treatment, left lateral rectus pyomyositis did not recur.

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.

A prospective study on skin and soft tissue infections: a fact-finding mission from a tertiary centre in north India.

OBJECTIVE: Despite the high prevalence and poor outcome of skin and soft tissue infections (SSTIs), very few studies from India have dealt with the subject. We planned a prospective study of inpatients with SSTIs to study the aetiology, clinical presentation (severity) and outcome of patients with SSTIs in our facility. METHOD: Patients with SSTIs involving >5% body surface area (BSA) and/or systemic signs were admitted to the surgery department of a teaching tertiary level hospital in Delhi, India, and were clinically classified into cellulitis, necrotising soft tissue infections (NSTIs), pyomyositis, and abscess. Demographic and clinical variables such as: age; sex; occupation; history of trauma/insect or animal bites; duration of illness; presenting symptoms and signs; comorbid conditions; predisposing factors such as lymphoedema or venous disease; hospital course; treatment instituted; complications; hospital outcome; presence of crepitus, bullae, gangrene, muscle necrosis and compartment syndrome were recorded. The chief outcome parameters were death and length of hospital stay; others, such as abscess drainage, the need for plastic surgical procedures and amputations were also noted. RESULTS: Out of 250 patients enrolled in the study, 145 (58%) had NSTIs, 64 (26%) had abscesses, 15 (6%) had cellulitis and 26 (10%) had pyomyositis. Mortality was observed with NSTIs (27/145, 19%) and with pyomyositis (3/26, 11.5%). Factors affecting mortality by univariate analysis in the NSTI group were: abnormal pulse; hypotension; tachypnea; bullae; increased blood urea and serum creatinine; inotrope or ventilator support (all with p<0.001); local tenderness, gangrene, dialysis support and BSA (9.33±6.44 versus 5.12±3.62; p<0.05 for the last four). No factor was found to be significant on multivariate analysis. Variables associated with hospital stay >12 days were immunocompromise, pus discharge, ulceration or gangrene, and after interventions such as blood transfusion, drainage or skin grafting. CONCLUSION: High prevalence of NSTI and pyomyositis with high mortality was observed in our SSTI patients, often in immunocompetent young individuals. Epidemiological studies focused on virulent strains of Staphylococcus aureus may be required to identify the cause, since Staphylococcal toxins have been implicated in other infections.

Point-of-Care Ultrasound Identifies Pyomyositis Secondary to Intramuscular Testosterone Injection: Report of Two Cases.

BACKGROUND: Intramuscular (i.m.) injections are a commonly utilized route for medication delivery. Intramuscular-associated soft tissue infections are rare and can include pyomyositis and i.m. abscess. Intramuscular testosterone injections have not been previously implicated in causing pyomyositis. Point-of-care ultrasound is an important bedside tool that can identify pyomyositis and differentiate this infection from more common entities such as cellulitis. CASE REPORTS: We present two cases of i.m. testosterone-associated pyomyositis. In both cases, the physical examination features were consistent with simple cellulitis. However, point-of-care ultrasound evaluation revealed changes consistent with pyomyositis in each case. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although uncommon, i.m. injections such as testosterone carry a risk of soft tissue infection. As demonstrated in the above cases, ultrasound can be helpful in making the differentiation between simple cellulitis and pyomyositis. The emergency physician should be cognizant of this complication of therapeutic i.m. injections, as well as the diagnostic efficacy of point-of-care ultrasound in evaluating the extent and location of the soft tissue infection.

Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician.

BACKGROUND: Skin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality. OBJECTIVE: This review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective. DISCUSSION: NSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome. CONCLUSION: NSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.

Meticillin-susceptible Staphylococcus aureus pyomyositis and cellulitis in right thigh of a 15-year-old boy: a case study.

Pyomyositis is a purulent infection of striated muscle and postoperative management remains the mainstay. If delayed primary wound closure is not managed in a timely manner, it often results in recurrent infection and sinus tract creation. Cavity wounds with sinus formation are known to complicate treatment, are problematic to manage and persist for long periods of time. The aim of this case report is to present the challenges in the assessment and management of a sinus tract with deep cavity wound, between the vastus lateralis and biceps femoris muscles, originating from liquefaction of a haematoma. Our review of the literature revealed limited research evidence in the management of deep cavity wounds. This is a rare case where the sinus tract route which leads to the rim-shaped cavity is embedded deep between the muscles, posing a high risk of recurrent infection from the premature closure of the wound tract. Successful management was attributed to: the accuracy in the initial wound assessment; appropriate dressing plans; the rationale for each action; and an outcome goal as each treatment progressed. Daily dressing change and reassessment of the wound was required to ensure progress and to address any complications in a timely manner. Finally, concerns of the patient and their family and regular discussions on the treatment plans are important to encourage adherence with management goals.

Magnetic resonance imaging of musculoskeletal infections.

Magnetic resonance imaging (MRI) is a powerful imaging modality in the evaluation of musculoskeletal (MSK) soft tissue, joint, and bone infections. It allows prompt diagnosis and assessment of the extent of disease, which permits timely treatment to optimize long-term clinical outcomes. MRI is highly sensitive and specific in detecting the common findings of MSK infections, such as superficial and deep soft tissue oedema, joint, bursal and tendon sheath effusions, lymphadenopathy, bone marrow oedema, erosive bone changes and periostitis, and bone and cartilage destruction and sequestration. Contrast-enhanced MRI allows detection of non-enhancing fluid collections and necrotic tissues, rim-enhancing abscesses, heterogeneously or diffusely enhancing phlegmons, and enhancing active synovitis. Diffusion-weighted imaging (DWI) is useful in detecting soft-tissue abscesses, particularly in patients who cannot receive gadolinium-based intravenous contrast. MRI is less sensitive than computed tomography (CT) in detecting soft-tissue gas. This article describes the pathophysiology of pyogenic MSK infections, including the route of contamination and common causative organisms, typical MR imaging findings of various soft tissue infections including cellulitis, superficial and deep fasciitis and necrotizing fasciitis, pyomyositis, infectious bursitis, infectious tenosynovitis, and infectious lymphadenitis, and of joint and bone infections including septic arthritis and osteomyelitis (acute, subacute, and chronic). The authors also discuss MRI findings and pitfalls related to infected hardware and diabetic foot infections, and briefly review standards of treatment of various pyogenic MSK infections.

Factors associated with pyomyositis: A systematic review and meta-analysis.

OBJECTIVES: Pyomyositis, an acute bacterial infection of skeletal muscle usually resulting in abscess formation, is well recognised in tropical regions where it can account for up to 4% of adult surgical admissions. It is increasingly being reported from high-income temperate countries. Pyomyositis occurs across all ages and in both sexes. Mortality ranges from 1% to 23%. Many risk factors have been suggested. We aimed to identify factors associated with pyomyositis. METHODS: We undertook a systematic review and meta-analysis, using PubMed, EMBASE, Scopus and the Cochran Library and hand-searching published papers. The random-effects model meta-analysis was used to calculate pooled estimated odd ratios with the corresponding 95% confidence interval. RESULTS: All studies in the systematic review (n = 25) and the meta-analysis (n = 12) were hospital-based. Seven only included children. Relatively few studies have been published in the last decade, the majority of which are from high-income temperate settings. Staphylococcus aureus was the main organism isolated. Males under the age of 20 predominated, and mortality of up to 20% was reported. Factors associated with pyomyositis were HIV infection (OR = 4.82; 95% CI: 1.67-13.92) and fulfilling an AIDS surveillance definition (OR = 6.08; 95% CI: 2.79-13.23). CONCLUSIONS: Our meta-analysis indicated significant associations between pyomyositis infection and HIV/AIDS. Major gaps in our understanding of the epidemiology, pathogenesis, clinical presentation, and outcome remain, highlighting the need for further research and more systematic studies. Pyomyositis merits consideration as a neglected tropical disease.

A toddler with a persisting limp after a minor trauma.

A 3-year-old toddler was admitted for a 5-day history of worsening painful limping on his left leg. History was remarkable only for a minor trauma 2 days before the onset of symptoms; the boy fell on his buttocks but was walking normally in the following days. No fever was reported. Pain was also present at night, with no response to oral ibuprofen.On physical examination, the patient refused to stand on his left leg, palpation of the left buttock evoked pain, and exorotation and abduction of the left hip were only moderately limited, without local signs of inflammation such as redness, swelling or skin warming. Blood tests showed elevated erythrocyte sedimentation rate (ESR) (98 mm/hour, normal value <20 mm/hour) with normal C reactive protein (CRP) level (0.5 mg/dL, normal value <0.5 mg/dL). His white cell count was 12 110 x 109/L, haemoglobin was 127 g/L and PLT was 430 x 109/L. Creatine kinase values were within the normal range.An X-ray of the pelvis was unremarkable. An ultrasound of the left hip showed a 2 mm articular effusion.

Multifocal extraocular muscle pyomyositis: A case report and review of literature.

Pyomyositis is a rare condition which occurs most often in large skeletal muscles. Pyomyositis of extraocular muscles is a very rare entity. The authors describe a case of 2 sites of pyomyositis of extraocular muscles. A 20-year-old man presented with right periocular pain, redness, and proptosis for 1 week.Computed tomography showed well-circumscribed masses with enhancing rims in the medial and inferior rectus muscles. The patient underwent orbital drainage surgery and received an intravenous antibiotic. Haemoculture and pus culture could not identify an organism. Systemic steroid was administered after the infection was controlled, in regard to scar prevention.

Tropical pyomyositis: an update.

Tropical pyomyositis (TP) is a life-threatening bacterial infection of the skeletal muscle that occurs particularly among children, young adults and those with immunocompromised conditions. The appropriate diagnosis and treatment are often delayed due to its non-specific signs, leading to fatal consequences. Staphylococcus aureus, especially methicillin-susceptible S. aureus, is responsible for most TP cases. However, other bacteria (i.e. streptococci, Pseudomonas aeruginosa, Escherichia coli, Klebsiella spp., Candida spp., Mycobacterium spp.) have been reported. This narrative review provides an update on the epidemiology and clinical course of TP. A special focus is laid on the role of toxins (i.e. Panton-Valentine Leucocidin and α-toxin) in the pathogenesis of TP and their implication for the clinical management of infection.

La pyomyosite tropicale (TP) est une infection bactérienne potentiellement mortelle du muscle squelettique qui survient particulièrement chez les enfants, les jeunes adultes et les personnes immunodéprimées. Le diagnostic et le traitement appropriés sont souvent retardés en raison de ses signes non spécifiques, entraînant des conséquences fatales. Staphylococcus aureus, en particulier S. aureus sensible à la méthicilline, est responsable de la plupart des cas de TP. Cependant, d'autres bactéries (ex: streptocoques, Pseudomonas aeruginosa, Escherichia coli, Klebsiella spp., Candida spp., Mycobacterium spp.) ont été rapportées. Cette revue narrative fournit une mise à jour sur l'épidémiologie et l'évolution clinique du TP. Un accent particulier est mis sur le rôle des toxines (la Leukocidine de Panton-Valentine et l'α-toxine) dans la pathogenèse du TP et leur implication pour la prise en charge clinique de l'infection.

Psoitis and multiple venous thromboses caused by Panton Valentine Leukocidin-positive methicillin-sensitive Staphylococcus aureus in a 12-year-old girl: A case report.

Panton Valentine Leukocidin (PVL) is one of the many toxins produced by Staphylococcus aureus. In Japan, PVL-positive S. aureus strains are mainly methicillin-resistant S. aureus (MRSA). Data regarding PVL-positive methicillin-sensitive S. aureus (MSSA) are scarce. In this report, we describe a case of severe infection by PVL-positive MSSA. A 12-year-old healthy girl was admitted with high fever and pain in the lower back. Computed tomography revealed a diagnosis of psoitis and multiple venous thromboses. Blood cultures obtained after admission revealed infection with MSSA. Her fever continued despite adequate antibiotic therapy. On the fifth hospitalization day, she developed bladder dysfunction, and an abscess was noted near the third lumbar vertebra. She underwent an emergency operation and recovered. Bacterial analyses revealed that the causative MSSA was a PVL-producing single variant of ST8 (related to USA300clone), of sequence type 2149. PVL is known to cause platelet activation. This case demonstrates the need for detailed analyses of the causative strain of bacteria in cases of S. aureus infection with deep vein thrombosis, even in cases of known MSSA infection.

Concurrent methicillin-resistant Staphylococcus aureus septicemia and pyomyositis in a patient with dengue hemorrhagic fever: a case report.

BACKGROUND: Concurrent presence of dengue hemorrhagic fever (DHF), tropical pyomyositis and septicemia due to methicillin-resistant Staphylococcus aureus (MRSA) in a previously healthy person has never been reported. These three conditions even individually are potentially fatal. "Here we describe a case of a patient contracting dengue and developing DHF along with concurrent pyomyositis likely to be due to MRSA, leading to MRSA septicemia with abscesses formed by MRSA". CASE PRESENTATION: A 44-year old previously healthy Sinhalese man presented on day 3 of the illness with fever, headache, arthralgia and myalgia and watery loose stools. His pulse rate was 76/min, blood pressure was 110/80 mmHg, while cardiovascular, respiratory and abdomen examination findings were unremarkable. The test for the dengue NS1 antigen was positive on the same day. We have diagnosed dengue and started managing him symptomatically as per the current national guidelines. The patient developed DHF with bilateral pleural effusion and ascitis. On the day 5 he developed severe myalgia, tenderness and non pitting edema of lower limbs especially in the thighs. His creatine kinase levels were high and an ultrasound scan confirmed myositis of both thighs. We suspected myositis due to dengue but investigated for possible simultaneous sepsis as well. On day 9 his blood culture became positive for MRSA. Considering the sensitivity of the bacteria intravenous vancomycin and ciprofloxacin was administered for 21 days. He developed a small abscess at the site of the first intravenous access and a large one above the ankle on the left. On day 12 the latter was drained and the pus culture yielded MRSA sensitive to the same antibiotics. The rapid test for dengue IgM was negative initially but later a positive MAC-ELISA test entrenched dengue infection. After improvement he was sent home on day 33 of the illness. He has developed two other abscesses in the proximity of the drained one and they were drained on day 57. The patient recovered. CONCLUSIONS: When dengue patients develop symptoms and signs of myositis, prompt investigations for pyomyositis and the treatment can save lives.

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.

Pelvic pyomyositis in children: changing trends in occurrence and management.

AIMS: We present the largest series of paediatric pelvic pyomyositis from a temperate country, analyse the factors influencing long term prognosis and suggest a diagnostic protocol. MATERIALS AND METHOD: We included 41 patients diagnosed with primary paediatric pelvic pyomyositis between 1998 and 2016, in this study with a mean age of 7.5 years. Demographic, clinical, radiological and follow-up data were reviewed. Statistical analysis was performed to analyse the influence of early diagnosis and treatment on the final outcome. RESULTS: There was an increased occurrence of primary pelvic pyomyositis in the last two years. Of cases identified, 85% fulfilled Kocher's criteria for hip septic arthritis. The mean time to diagnosis was 2.8 ± 0.8 days. The most common muscle affected was obturator internus (65.85%) and multifocal involvement was common (46.34%). Early diagnosis and antibiotic treatment within seven days from the time of onset of symptoms was the only factor that influenced final outcome (p < 0.001). DISCUSSION AND CONCLUSION: Pyomyositis is no longer restricted to tropical countries. The time from onset of symptoms to start of antibiotic treatment influences the final outcome. Clinical examination and inflammatory markers have low specificity in distinguishing between pyomyositis, septic arthritis, osteomyelitis or other infections. MRI is more sensitive and can diagnose pyomyositis in its early stages. Every suspected case of septic arthritis of the hip should undergo an ultrasound. MRI scan may be performed if the ultrasound shows inconclusive evidence of an effusion. Early identification will facilitate early antibiotic treatment which will improve the final outcome. CLINICAL RELEVANCE: There is an increasing occurrence of this tropical disease in temperate countries. Early diagnosis with an MRI scan and early antibiotic use results in good outcomes.

Ceftazidime/Avibactam for Refractory Bacteremia, Vertebral Diskitis/Osteomyelitis with Pre-Vertebral Abscess and Bilateral Psoas Pyomyositis Secondary to Klebsiella Pneumoniae Carbapenemase-Producing Bacteria (KPC).

A 36-year-old man was admitted to the intensive care unit due to diabetic ketoacidosis and pneumonia requiring mechanical ventilation. Three weeks after admission, he developed a refractory bacteremia with Klebsiella pneumoniae carbapenemase-producing bacteria (KPC). He remained febrile and with bacteremia for six weeks despite therapy with polymyxin B, carbapenems, and amikacin. Imaging studies looking for deep-seated infection revealed vertebral L1-L2 diskitis and osteomyelitis with pre-vertebral abscess and bilateral psoas pyomyositis that were not amenable for drainage. In view of the refractory infection and the activity against KPC described in the literature, we decided to switch the patient to ceftazidime/avibactam. After six weeks of therapy, there was complete resolution of the infectious processes. We present an instance of clinical success with ceftazidime/avibactam for the treatment of refractory KPC bacteremia, vertebral diskitis and osteomyelitis with pre-vertebral abscess and bilateral psoas pyomyositis. This experience serves as reference to support treatment with ceftazidime/avibactam in similar complicated cases.