Letters to the Editor
139
Staphylococcus aureus tropical pyomyositis induced Guillain-Barré syndrome Sir, Pyomyositis is a frequently encountered disease in the tropics but is rarely accurately and timely diagnosed. As it is a potentially fatal disease, its prompt treatment is essential. Patients present with systemic features of fever, malaise, arthralgias, myalgias, and anorexia. Many case reports mention about rare presentation as sciatica due to psoas or gluteal muscle pyomyositis or similar focal myalgias in upper limbs and facial muscles. [1] A 30-year-old female patient without any significant antecedent medical history presented with acute onset weakness of both upper limbs with forearm swelling. In next 4 h, patient developed bilateral lower limb weakness, with dysphagia, dysarthria, nasal regurgitation, and inability to close both eyes. Respiratory and bladder functions were preserved. Two weeks back, she had fever and a 2 cm pustule on the upper lip, which resolved spontaneously. On examination, vital parameters were normal. Right forearm revealed a 3 × 1 cm subcutaneous swelling. Neurological examination revealed bilateral lower-motor-neuron facial palsy, bilateral vagus nerve palsy, generalized areflexia, and limb power grade 2/5. Rest of the examination was normal. Her blood tests showed white blood cell (WBC) count-25400/mm3, with neutrophilic predominance (90%) and sedimentation rate-100 mm/1st h, CPK-NAC-1054 U/L. Rest investigations, including fasting blood sugar, electrolytes, human immunodeficiency virusenzyme-linked immunosorbent assay, liver and renal function tests, and urine porphyrins were normal. Nerve conduction study (NCV) showed demyelination. She improved with intravenous immunoglobulin for the first 2 days. However, on the 3rd day, she redeveloped high-grade fever, dyspnea, and mucopurulent expectoration. Her computed tomography chest revealed multiple discrete cavitatory nodules in both lungs. Pus aspirate from the right forearm swelling as well as sputum culture revealed Staphylococcus aureus. Blood culture, sputum fungal culture, serum ANA, c-ANCA, and p-ANCA were negative. Antibiotics were given as per sensitivity report after which patient became afebrile within 24 h. Cerebrospinal fluid analysis done in the 2nd week of illness showed 74 mg/ dL proteins and normal cells count and sugar. At the time of discharge, patient’s full neurological examination and WBC count had normalized. Repeat chest X-ray showed decrease in size and number of the opacities. Repeat NCV also showed gradual improvement in latency and conduction velocities on follow-up. There have been previous reports of staphylococcal endocarditis-induced Guillain-Barré Syndrome (GBS).[2-4] It has been proposed to be secondary to molecular mimicry,
autoantibody formation against myelin gangliosides. Here, our patient presented with Staphylococcal aureus tropical pyomyositis-induced upper limb onset GBS. Such a presentation has not been reported till date world over as per the literature search done by us. By this case report, we would like to propose that GBS may be caused by disseminated Staphylococcus aureus infection. Until the septic focus is eliminated, treatment with immunoglobulins would utmost be only transiently beneficial and an unnecessary costly affair. Thus for a patient presenting with GBS and fever or neutrophilia on investigation, a thorough search for an occult infective focus of myositis should be sought for. Amita Narendra Bhargava, Subhakaran Khichar, Gaurav Mansukhlal Kasundra, Bharat S. K. Bhushan Department of Neurology, Dr. Sampurnanand Medical College and Mahatma Gandhi Hospital, Jodhpur, Rajasthan, India For correspondence: Dr. Gaurav Mansukhlal Kasundra, 122, Subhash Nagar,
Pal Road, Jodhpur - 342 008, Rajasthan, India. E-mail: [email protected]
References 1. 2. 3. 4.
Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): Current perspective. Postgrad Med J 2004;80:267-70. Baravelli M, Rossi A, Picozzi A, Gavazzi A, Imperiale D, Dario P, et al. A case of Guillain-Barre syndrome following Staphylococcus aureus endocarditis. Int J Cardiol 2007;114:E53-5. Snijders TJ, Notermans NC. Progressive, ascending neurological impairement: A spinal epidural abscess that presents as GuillainBarre syndrome. Ned Tijdschr Geneeskd 2008;152:1436-9. Celik T, Iyisoy A, Celik M, Baysan O, Bek S, Dogru MT. A case of Guillain-Barre syndrome following prosthetic valve endocarditis. Int J Cardiol 2009;133:102-4. Access this article online Quick Response Code:
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DOI: 10.4103/0972-2327.128594
Annals of Indian Academy of Neurology, January-March 2014, Vol 17, Issue 1
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