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CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 5  |  Page : 639-641  

Pancarditis in a patient with tropical pyomyositis due to Aeromonas infection


1 Department of Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital (University of Delhi), Dilshad Garden, New Delhi, India
2 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
3 Department of Radiology, Lady Harding Medical College, (University of Delhi), New Delhi, India

Date of Web Publication10-Sep-2015

Correspondence Address:
Nikhil Gupta
Department of Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital (University of Delhi), Dilshad Garden, New Delhi -110 095
India
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Source of Support: Nil., Conflict of Interest: None declared.


DOI: 10.4103/0975-2870.164960

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  Abstract 

Tropical pyomyositis is a suppurative disease of the skeletal muscles. The most common site of the infection being muscles of the thigh. Staphylococcus aureus is the most common organism isolated. Aeromonas is one of the rarest organisms described as the etiologic agent for this disease. Rarely, cardiac involvement in pyomyositis has been described in the form of myocarditis and pyopericardium. Pancarditis is a very rare event in the natural course of pyomyositis. To the best of our knowledge, there is a single case report in world literature regarding involvement of all the layers of the heart in pyomyositis. We report a case of a 30-year-old immunocompetent male who had pyomyositis and developed pancarditis, which was managed successfully with conservative management.

Keywords: Aeromonas, pancarditis, pyomyositis, Staphylococcus aureus


How to cite this article:
Gupta N, Chabbra P, Nair N, Tomar LR. Pancarditis in a patient with tropical pyomyositis due to Aeromonas infection. Med J DY Patil Univ 2015;8:639-41

How to cite this URL:
Gupta N, Chabbra P, Nair N, Tomar LR. Pancarditis in a patient with tropical pyomyositis due to Aeromonas infection. Med J DY Patil Univ [serial online] 2015 [cited 2017 Nov 23];8:639-41. Available from: http://www.mjdrdypu.org/text.asp?2015/8/5/639/164960


  Introduction Top


Pyomositis is a subacute and deep bacterial infection of skeletal muscle seen in the tropics.[1] It is a primary infection of skeletal muscle frequently complicated by abscess formation. Staphylococcus aureus is the most common organism implicated.[2] Other etiologic agents involved in the disease process include Pneumococcus, Hemophilus, Pseudomonas, Klebsiella and  Escherichia More Details. Aeromonas has been rarely described as the culprit agent in this disease especially in an immunocompetent agent. Second peculiarity seen in our case was the development of pancarditis that improved on conservative management alone. Hence, we report this rare and unique case.


  Case Report Top


A 30-year-old non-diabetic, non-smoker male came to the emergency room with complaints of high-grade fever with chills and rigor for 4 days and swelling over left thigh for 4 days. There was no history of trauma, but he reported recent travel to the coastal area. On examination, swelling was tense, tender and local temperature was raised. Patient was febrile with a temperature of 38.3°C. Patient had a pulse rate of 110/min and blood pressure of 120/76 mm Hg. HIV, hepatitis B surface antigen and anti-hepatitis C virus was negative. Total leukocyte count was raised (21,000/mm3 with predominant neutrophils). Renal function tests were within normal range (serum creatinine −0.9 mg/dl). Creatine kinase levels were normal. Chest X-ray (initial CXR) was normal. Patient was empirically started on injectable Clindamycin and Vancomycin. Swelling was aspirated, the aspirate was pus like. It was sent for culture sensitivity. Blood cultures were also sent. Cultures from the pus aspirated from the thigh and blood revealed growth of Aeromonas species, which was sensitive to Gentamicin and Imipinem. Antibiotics were changed. Vancomycin and Clindamycin was stopped, and patient was started on intravenous Imipinem. Patient became afebrile in 48 h, but 7 days after the treatment patient developed sudden onset left side chest pain and breathlessness. Examination revealed pericardial rub and bilateral basal crepitations. CXR showed cardiomegaly, and classical bottle shaped heart evident of pericardial effusion [Figure 1]. Electrocardiogram revealed low voltage complexes with sinus tachycardia. Cardiac enzymes were normal. ECHO was done, which showed pericardial effusion, severe mitral regurgitation (MR) and mild tricuspid regurgitation (TR) and global hypokinesia with ejection fraction of 30% [Figure 2]a and [Figure 2]b. Patient was also started on injection ceftriaxone. Patient improved in 7 days. Pericardial rub and crepitations disappeared. Patient was discharged on oral Faropenem after 14 days of antibiotics and was currently doing fine after 1 month of follow-up with an ejection fraction of 55% and no MR or TR on echocardiography.
Figure 1: Cardiomegaly

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Figure 2: ECHO showing pericardial effusion (a and b)

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  Discussion Top


Tropical pyomyositis is a disease primarily involving the skeletal muscles of the body. It is more common in patients who are immunosupressed like patients with HIV infection, patients on steroids or immunosupression, etc. S. aureus is the organism most commonly isolated from these patients.[2] However, this is not the scenario always. Gram-negative organisms have increasingly been isolated in these patients. However, such reports are very few in the literature. Metastatic abscesses, renal failure, severe sepsis with multiorgan dysfunction and shock are the recognized and known complications of pyomyositis.[3],[4] However, cardiac involvement in pyomyositis is frequently seen in the form of endocarditis, especially when S. aureus is the organism involved. However, pancarditis is a very rare complication of this suppurative disease seen very frequently in the tropics.

Aeromonas is a Gram-negative bacilli, very fond of contaminating food specially sea food and drinking water.[5] It is a very important cause of skin and soft tissue infections, especially in patients with burns and chronic liver disease. Aeromonas related pyomyositis is not very common, and there are very few reports in the literature regarding this. However, in all the reports either the patient was on immunosuppressant, or the patient had cirrhosis of the liver as a predisposing condition for infection with this organism. Kratzke and Golenbock, in his study, revealed that the patient of chronic liver disease developed hepatic abscess and bilateral calf pyomyositis.[6] However, our patient was immunocompetent and probably acquired this organism from the coastal area he recently visited.

Second unusual and unreported event which occurred in this patient was development of pancarditis even on antibiotics to which the organism was sensitive. Most of the cases where involvement of the heart has been describing, the organism isolated is S. aureus. Recently, pyopericardium with cardiac tamponade has been described in a patient with S. aureus related pyomyositis. Patient improved with pericardiocentesis and drainage of the pus along with antibiotics. In a report by Akhtar et al., a 10-year-old girl developed pericardial effusion and endocarditis as a complication of Staphylococcus pyomyositis.[7] She was managed with open heart surgical drainage and intravenous antibiotics.

Aeromonas causes a wide range of illnesses ranging from gastroenteritis, skin infection to aspiration pneumonia. Among the extraintestinal infections, soft tissue infections following water related injuries are the most common. Various media have been described to isolate Aeromonas speicies, but most commonly used ones include Ampicillin blood agar and alkaline peptone water. Various antimicrobial agents are used against this organism.


  Conclusion Top


This case is unique in the sense that the patient even though being immunocompetent developed Aeromonas infection. Second, patient developed pancarditis that is also very rare in pyomyositis that too with Aeromonas as the etiologic agent.

 
  References Top

1.
Kallen P, Nies KM, Louie JS, Keller M, Worthen N, Bayer AS. Tropical pyomyositis. Arthritis Rheum 1982;25:107-10.  Back to cited text no. 1
    
2.
Ozkan K, Unay K, Ugutmen E, Eren A, Eceviz E, Saygý B. Pyomyositis of tensor fascia lata: A case report. J Med Case Rep 2008;2:236.  Back to cited text no. 2
    
3.
Madziga AG, Na'aya UH, Gali BM. Pyomyositis in north-eastern Nigeria: A 10-year review. Niger J Surg Res 2004;6: 17-20.  Back to cited text no. 3
    
4.
Romeo S, Sunshine S. Pyomyositis in a 5-year-old child. Arch Fam Med 2000;9:653-6.  Back to cited text no. 4
    
5.
Martin-Carnahan A, Joseph SW. Aeromonas. In: Brenner DJ, Krieg NR, Staley JT, Garrity GM, editors. Bergey's Manual of Systematic Bacteriology. 2nd ed., Vol. 2. New York: Williams and Wilkins; 2005.  Back to cited text no. 5
    
6.
Kratzke RA, Golenbock DT. Pyomyositis and hepatic abscess in association with Aeromonas hydrophila sepsis. Am J Med 1987;83:347-9.  Back to cited text no. 6
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7.
Akhtar K, Sultan M, Akbar H, Ahmed W, Sadiq N, Saleem K, et al. Pancarditis: A rare complication of tropical pyomyositis. J Coll Physicians Surg Pak 2012;22:320-2.  Back to cited text no. 7
    


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Abstract
Introduction
Case Report
Discussion
Conclusion
Introduction
Case Report
Discussion
Conclusion
References
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