|Year : 2016 | Volume
| Issue : 5 | Page : 657-660
Tropical pyomyositis: A report of two cases
Subhash Chawla1, Manish Bansal1, Lipika Chawla2
1 Department of General Surgery, Command Hospital (WC), Chandimandir, Panchkula, Haryana, India
2 Department of Medical Officer, Command Hospital (WC), Chandimandir, Panchkula, Haryana, India
|Date of Web Publication||13-Oct-2016|
Department of Surgery, Command Hospital (WC), Chandimandir, Panchkula - 134 107, Haryana
Source of Support: None, Conflict of Interest: None
Tropical pyomyositis, a disease often seen in tropical countries, is characterized by suppuration within skeletal muscles, manifesting as single or multiple abscesses. The most common organism implicated is Staphylococcus aureus. In 20-50% of cases there is a history of trauma to the affected muscles. Commonly involved muscles are quadriceps, glutei, pectoralis major, serratus anterior, biceps, iliopsoas, gastrocnemius, abdominal, and spinal muscles. Early diagnosis is often missed because of lack of specific signs, unfamiliarity with the disease, atypical manifestations, and a wide range of differential diagnosis. Diagnostic techniques such as ultrasound and computed tomography/magnetic resonance imaging are very useful in diagnosis. The diagnosis is confirmed either by biopsy or aspiration of pus from the affected muscles. The initial antibiotic of choice is cloxacillin. Incision and drainage are important components of management. Treatment for Gram-negative or anaerobic organisms should be instituted, whenever indicated. Physicians should become more familiar with this potentially life-threatening but curable infective disease entity.
Keywords: Immunodeficiency, Staphylococcus aureus, temperate, tropical pyomyositis
|How to cite this article:|
Chawla S, Bansal M, Chawla L. Tropical pyomyositis: A report of two cases. Med J DY Patil Univ 2016;9:657-60
| Introduction|| |
Tropical pyomyositis is a suppurative infectious disease of the skeletal muscle which is common in tropical countries. Unfamiliarity with the disease, atypical presentation and a wide range of masquerading conditions often result in a delay in diagnosis. We present two patients of tropical pyomyositis both thighs after intensive exercise, one presented to this center in septic shock with advanced renal injury and coagulopathy and other presented as a case of acute urticaria to skin center.
| Case Reports|| |
A 20-year-old recruit developed sudden onset severe pain both thighs after running battle physical efficiency test (BPET), which was not relieved with antibiotics/analgesics. Next day he developed induration both thighs, deranged liver, and renal function. I and D was done at a midzonal hospital, 20 ml serosaguineous fluid was drained and muscle found necrotic. Postoperative period was stormy due to septicemia and was put on inotropic support. Swab culture report Staphylococcus aureus sensitive to meropenem, imipenem, and vancomycin. Treated with injection meropenem, piptaz, and flagyl. Developed coagulopathy. International normalized ratio (INR) 6.0 on December 24, 2012 treated with fresh blood O-ve, dropped to 3.0, air evacuated to zonal hospital by heptr as a lying case. On examination, blood pressure (BP) 114/78 mm of Hg, pulse 88/min, SpO298%, central venous pressure (CVP) 10, Hb 9.7 g%, thin layer chromatography (TLC) 42,800/cmm differential leukocyte count (DLC) P 87, L13, blood urea 164 mg%, serum creatinine 5.5 mg% prothrombin time (PT)–control 14 test 30 INR 3.0.
At zonal hospital, he was treated with 4 units fresh frozen plasma (FFP), intravenous fluids, antibiotics and hemodialysis. Underwent extensive wound debridement [Figure 1], fasciotomy and excision of necrosed liquefied muscles both sides quadriceps, vastus medialis, gracilis, and hamstrings with drainage of 500 ml of chocolate colored foul smelling pus. Closure with drains both sides. He was air evacuated to tertiary care hospital as a case of pyomyonecrosis both thighs, septicemia with advanced kidney injury and coagulopathy.
At this hospital, he was treated with frequent wound debridements, FFP, laminodialysis and broad spectrum antibiotics including injection clindamycin 600 mg 8 hourly, injection meropenem 500 mg twice daily, injection tymentin 3.1 mg thrice daily, injection daptomycin 350 mg OD and injection fluconazole 200 mg OD. Underwent wound debridement, split skin grafting (SSG) placed at proximal 2/3rd of rt thigh antermedial aspect, posterior aspect of both thighs and secondary suturing of right thigh lateral, antero-medial and left thigh posterior wound done. Patient was sent on 4 weeks sick leave, he has now reported for review after period of convalescence. At present, asymptomatic. Locally all wounds on anterior and posterior aspect of thigh healed well [Figure 2] and [Figure 3]. SSG has taken up well. No functional deficit. X-ray both thighs-no evidence of osteomyelitis. Doppler study both lower limbs shows chronic sequelae to deep vein thrombosis (DVT) involving right distal superficial femoral vein and popliteal veins with partial recanalization. The patient is being observed under sheltered appointment.
|Figure 3: Healed operation scar and well taken SSG anterior aspect of both thighs|
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An 18-year-old recruit was admitted to skin center base hospital as a case of acute urticarial and was being managed with steroids, antihistaminics, and analgesics. The patient developed high-grade fever with pain, swelling and redness left thigh and was transferred to this hospital. On admission, general examination revealed BP 100/44 mm of Hg, pulse 120/min, SpO299%, CVP 10 Hb 9.5 g%, TLC 32,800/cmm DLC P 88, L12, blood urea 44 mg%, and serum creatinine 1.2 mg% PT–control 14 test 20 INR 2.0. Local examination revealed generalized swelling of left thigh and calf with localized tenderness. Color Doppler flow imaging left lower limb showed no evidence of acute DVT, myositis present. Emergency exploration done by longitudinal incisions on medial and posterior aspect of the thigh, 100 ml of pus drained and debridement of necrosed muscles of medial and posterior compartment done. The patient was treated with broad-spectrum antibiotics, analgesics and repeated dressings. Debridement was repeated on next day. Pus culture - S. aureus grown. Patient showed rapid improvement and was sent on 4 weeks sick leave. On review, all wounds healed well and there was no functional deficit. He is declared fit to join back his training.
| Discussion|| |
Tropical pyomyositis was first described by Scriba in 1885, as an endemic disease in the tropics. (90% of cases in tropical areas and 75% of cases in temperate countries). The most common organism implicated is S. aureus as was seen in both the patients. Transient bacteremia is the source of infection because there is no external injury or portal of entry that can usually be identified. Usually, a single group of muscle is affected, but in 12-40% of cases multiple groups are involved either sequentially or simultaneously. The disease is seen in all age groups, although young males are most susceptible. Maximum incidence is seen at 10-40 years of age with a male to female ratio of 1.5:1. Glutei, quadriceps, iliopsoas, gastrocnemius, pectoralis major, serratus anterior, biceps, abdominal, sternocleidomastoid, and spinal muscles are commonly involved. Both patients were young male recruits and had simultaneous involvement of multiple groups of thigh muscles. The pathogenesis is not clear, however, muscle trauma causes sequestration of elemental iron leading to predisposition for bacterial growth. The initiating event is perhaps bacteriological seeding during transient bacteremia against a backdrop of trauma or vigorous exercise to muscles, underlying viral or parasitic infections or nutritional deficiency. Trauma as in exercise or blunt injury may facilitate hematogenous access to the muscle and provide a critical bacterial nutritional requirement in the form of iron from myoglobin.
Formation of a small hematoma may provide a favorable site for the binding of staphylococci and other bacteria, and the surrounding damaged, and devitalized tissue might also impede the host immune response. Some researchers have proved that the T-cells in patients with tropical pyomyositis are not primed adequately against staphylococcus during the course of infection. Microscopically, there is an edematous separation of muscle fibers with interfiber infiltration by lymphocytes and plasma cells. The process is not diffuse but patchy myocytolysis with inflammatory infiltrate consisting of lymphocytes, and plasma cells are seen with areas of complete disintegration. This is followed by either a reparative process or complete degeneration with suppuration.
The abscesses are mostly solitary but in 12-40% cases, they may be multifocal. The disease goes through invasive and suppurative stages followed by a stage of complications. Some of the complications are septicemia, metastatic abscesses, nerve palsy, and compartment syndrome. Laboratory investigations may reveal anemia, leukocytosis (shift to the left), raised erythrocyte sedimentation rate, and acute phase reactants. Blood cultures may be positive varying from 5% to 10% in the tropics to 20-30% in temperate regions. Serum levels of muscle enzymes such as aldolase and creatine phosphokinase may be slightly raised. Ultrasound is a simple noninvasive tool for establishing pyomyositis in cases with visible swelling/tenderness. Computed tomography (CT) and magnetic resonance imaging are useful imaging techniques for early diagnosis. Gallium scintigraphy is an extremely sensitive modality for obscure cases.
The management is aggressive with specific parenteral antibiotics covering staphylococcus/other organisms depending on the culture reports along with surgical drainage if required., Treatment with appropriate antibiotics should be continued until systemic, and local signs of sepsis are controlled. The natural history is progressive suppuration with either spontaneous drainage and gradual resolution or eventual bacteremia and secondary infection leading to the fatal outcome. Mortality rate varies from 0.5% to 2% which can be further reduced by early and appropriate management.
| Conclusion|| |
Awareness of tropical pyomyositis is lacking. Common predisposing factors should be kept in mind. The immunosuppressive state is an important predisposing factor in the pathogenesis of pyomyositis. Aggressive treatment by open drainage and wide debridement should be carried out after confirming the presence of pus by ultrasound or CT guided needle aspiration. Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]