American Journal of Emergency Medicine 33 (2015) 306.e3–306.e4
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Temperate pyomyositis: a pain in the belly☆ Abstract Pyomyositis is a rare disease in temperate climates. This case is a unique presentation of pyomyositis of the rectus abdominal muscle mimicking an acute abdominal process. Most reported cases of pyomyositis are of extremity infections with Staphylococcus aureus. This report presents a case of polymicrobial pyomyositis from Haemophylus parainfluenza and Steptococcus viridians infection. Pyomyositis, commonly known as “pyomyositis tropicans” because of its high prevalence in tropical areas, has become more frequent in temperate climates [1,2]. It generally affects extremities, and Staphylococcus aureus is the most common pathogen. We present a rare case of abdominal wall involvement with first-time pathogen Haemophylus parainfluenza. A 46-year-old man presented to the emergency department (ED) with right-sided abdominal pain. The pain started 3 weeks prior upon twisting forcefully. His pain became acutely worse, accompanied by subjective fevers, chills, and diarrhea, days prior to presentation. Medical history included diabetes, hypertension, peripheral neuropathy, remote cholecystectomy, and remote foot abscess/cellulitis. He denied alcohol, illegal substances, and relevant family history. Daily medications were insulin, pregabalin, simvastatin, and hydroxyzine. Physical examination revealed an obese (body mass index, 35.8 kg/m2) man in mild distress. His temperature was 37°C; heart rate, 96 beats/min; blood pressure, 144/86 mm Hg; respiratory rate, 16 breaths/min; and oxygen saturation, 95% on room air. Further examination was unremarkable other than abdominal examination, which showed truncal obesity and old bruises on the left from insulin injections, normal bowel sounds, and severe tenderness in the right lower and upper quadrants with guarding but no rigidity or rebound tenderness. Laboratory studies were normal, except elevated aspartate transaminase (148 U/L), alanine aminotransferase (157 U/L), total bilirubin (1.7 mg/dL), direct bilirubin (1.9 mg/dL), glucose (258 mg/dL), and venous lactate (2.5 mmol/L). A computed tomographic scan of the abdomen with intravenous contrast revealed a focal 4.3-cm fluid collection containing gas in the right rectus abdominal muscle, extensive muscle thickening with surrounding inflammatory changes (Fig. 1), and hypoattenuating foci in the right rectus concerning for loculations or phlegmon. Radiographic findings were interpreted as abscess with myositis. Vancomycin, cefepime, and clindamycin were started. Bedside needle aspiration under ultrasound guidance (Fig. 2) resulted in only 3 cc of purulent material because of a thick abscess material. The patient was
☆ There were no sources of support for this project, and this report has not been previously presented or published in anyway. There was no institutional review board approval obtained. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
admitted to the surgical service and, on hospital day 3, underwent ultrasound guidance drainage of 40 cc of pus with placement of a pigtail drain; however, there was continued pain and incomplete resolution of the abscess. Surgical drainage was performed, and 2 malecot drains were placed. Wound cultures grew H parainfluenza and Steptococcus viridians, and blood cultures had no growth. The patient was discharged on hospital day 7 with 10-day course of oral amoxicillin-clavulanate and was followed up in outpatient surgical clinic where drains were removed. Seven days after drain removal (3 weeks after presentation), the patient represented to the ED with recurrent right-sided abdominal abscess. He was readmitted to the hospital and required multiple visits to the operating room with eventual wound vacuum-assisted closure placement. He was discharged on hospital day 25 but returned to the ED several months later with pyomyositis of his right gluteal muscle from S aureus infection, again requiring surgical intervention. Pyomyositis (an intramuscular abscess of the large skeletal muscle groups) is thought to be due to transient bacteremia in the setting of muscular injury. It is a rare disease because of the resistance of muscles to bacteremia, but in the United States, it is becoming more prevalent [2]. Temparate myositis appears to be a different clinical entity than tropical myositis. Temperate cases are more likely to occur in patients with underlying medical disease (75%) rather than healthy young individuals. Temperate disease is also associated with bacteremia (up to 35% compared to only 5% for tropical) and associated with an organism other than S aureus (90% in tropical cases, only 65%-75% in temperate) [1–5]. This case is the first to report H parainfluenza as a pathogen in pyomyositis. H parainfluenza is a gram-negative organism categorized primarily as oropharyngeal microflora [6]. S viridians is considered to be commensal flora of the oropharyngeal, urogenital, and gastrointestinal tracts that only generally causes disease only with underlying comorbidities [7]. There have been case reports in which this group was the etiologic agent of pyomyositis [8]. The diagnosis of pyomyositis may be difficult because of the deep skeletal muscle groups involved, which are not visually erythematous or tender. Extremity cases may be misdiagnosed as muscle hematoma, cellulitis, thrombophlebitis, osteomyelitis, or neoplasm. Abdominal wall infections may mimic visceral diseases rather than an extraperitoneal process. Treatment of pyomyositis consists of antibiotic therapy for early disease and combined with surgical drainage in more advanced illness. Initial antibiotic therapy needs to be broad as etiologic agents have been varied in temperate disease and may later be tailored to culture. The length of required therapy may be 3 to 4 weeks, but it can vary considerably depending on the host and clinical course [1]. It is possible that, with increasing immunocompromized patients, new bacteria will be associated with pyomyositis. Further epidemiologic and clinical data are needed to understand the pathogenesis of pyomyositis. This patient is exceedingly unusual, as he had 2 different
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J.R. Pare et al. / American Journal of Emergency Medicine 33 (2015) 306.e3–306.e4
Fig. 1. Three images from the computed tomographic scan are provided. Images A (level of the pelvis) and B (level of the aortic bifurcation) are coronal images demonstrating asymmetric thickening of the right rectus muscle in comparison to the left with surrounding intra-abdominalal and superficial fat stranding. Image B and C (sagittal image through the right rectus) demonstrate again muscular thickening with stranding, but also display air within the abscess.
cases of pyomyositis separated in a short time span with different organisms isolated. Best practice for pyomyositis includes drainage in conjunction with broad-spectrum antibiotics. Joseph R. Pare, MD Department of Emergency Medicine Boston Medical Center, Boston University School of Medicine Boston, MA Corresponding author. 464 Congress Avenue, Suite 260 New Haven, CT 06519 E-mail address: [email protected] Elissa M. Schechter-Perkins, MD, MPH Department of Emergency Medicine, Boston University School of Medicine, Boston, MA http://dx.doi.org/10.1016/j.ajem.2014.07.016
References [1] Crum N. Bacterial pyomyositis in the United States. Am J Med 2004;117(6):420–8. http://dx.doi.org/10.1016/j.amjmed.2004.03.031. [2] Small LN, Ross JJ. Tropical and temperate pyomyositis. Infect Dis Clin North Am 2005;19(4):981–9. http://dx.doi.org/10.1016/j.idc.2005.08.003. [3] Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J 2004;80(943):267–70. [4] Niamane R, Jalal O, Elghazi M, Hssaida R, Had A. Multifocal pyomyositis in an immunocompetent patient. Joint Bone Spine 2004;71(6):595–7. [5] Shepherd JJ. Tropical myositis: is it an entity and what is its cause? Lancet 1983;2(8361): 1240–2. http://dx.doi.org/10.1016/S0140-6736(83)91281-3. [6] Pollard A, Michael FS, Connor L, Nichols W, Cox A. Structural characterization of Haemophilus parainfluenzae lipooligosaccharide and elucidation of its role in adherence using an outer core mutant. 2008;917:906–17. http://dx.doi.org/10.1139/W08-082. [7] Doern CD, Burnham C-AD. It's not easy being green: the viridans group streptococci, with a focus on pediatric clinical manifestations. J Clin Microbiol 2010;48(11): 3829–35. [8] Woo PCY, Teng JLL, Lau SKP, Lum PNL, Leung K, Wong K, et al. Analysis of a Viridans group strain reveals a case of bacteremia due to Lancefield group G alpha-hemolytic Streptococcus dysgalactiae subsp. equisimilis in a patient with pyomyositis and reactive arthritis analysis of a Viridans group strain reveals a Ca; 2003. http://dx. doi.org/10.1128/JCM.41.2.613.
Fig. 2. Two images from the bedside ultrasound obtained prior to drainage are provided. Image A was obtained with a high frequency linear array probe. However, the abscess was larger than the probe, so in order to obtain a full image of the abscess, a curvilear probe was used (image B) given the size and depth of the abscess. On the right of each image, the white lines corresponds to 1 cm in distance.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Temperate pyomyositis: a pain in the belly☆ Abstract Pyomyositis is a rare disease in temperate climates. This case is a unique presentation of pyomyositis of the rectus abdominal muscle mimicking an acute abdominal process. Most reported cases of pyomyositis are of extremity infections with Staphylococcus aureus. This report presents a case of polymicrobial pyomyositis from Haemophylus parainfluenza and Steptococcus viridians infection. Pyomyositis, commonly known as “pyomyositis tropicans” because of its high prevalence in tropical areas, has become more frequent in temperate climates [1,2]. It generally affects extremities, and Staphylococcus aureus is the most common pathogen. We present a rare case of abdominal wall involvement with first-time pathogen Haemophylus parainfluenza. A 46-year-old man presented to the emergency department (ED) with right-sided abdominal pain. The pain started 3 weeks prior upon twisting forcefully. His pain became acutely worse, accompanied by subjective fevers, chills, and diarrhea, days prior to presentation. Medical history included diabetes, hypertension, peripheral neuropathy, remote cholecystectomy, and remote foot abscess/cellulitis. He denied alcohol, illegal substances, and relevant family history. Daily medications were insulin, pregabalin, simvastatin, and hydroxyzine. Physical examination revealed an obese (body mass index, 35.8 kg/m2) man in mild distress. His temperature was 37°C; heart rate, 96 beats/min; blood pressure, 144/86 mm Hg; respiratory rate, 16 breaths/min; and oxygen saturation, 95% on room air. Further examination was unremarkable other than abdominal examination, which showed truncal obesity and old bruises on the left from insulin injections, normal bowel sounds, and severe tenderness in the right lower and upper quadrants with guarding but no rigidity or rebound tenderness. Laboratory studies were normal, except elevated aspartate transaminase (148 U/L), alanine aminotransferase (157 U/L), total bilirubin (1.7 mg/dL), direct bilirubin (1.9 mg/dL), glucose (258 mg/dL), and venous lactate (2.5 mmol/L). A computed tomographic scan of the abdomen with intravenous contrast revealed a focal 4.3-cm fluid collection containing gas in the right rectus abdominal muscle, extensive muscle thickening with surrounding inflammatory changes (Fig. 1), and hypoattenuating foci in the right rectus concerning for loculations or phlegmon. Radiographic findings were interpreted as abscess with myositis. Vancomycin, cefepime, and clindamycin were started. Bedside needle aspiration under ultrasound guidance (Fig. 2) resulted in only 3 cc of purulent material because of a thick abscess material. The patient was
☆ There were no sources of support for this project, and this report has not been previously presented or published in anyway. There was no institutional review board approval obtained. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
admitted to the surgical service and, on hospital day 3, underwent ultrasound guidance drainage of 40 cc of pus with placement of a pigtail drain; however, there was continued pain and incomplete resolution of the abscess. Surgical drainage was performed, and 2 malecot drains were placed. Wound cultures grew H parainfluenza and Steptococcus viridians, and blood cultures had no growth. The patient was discharged on hospital day 7 with 10-day course of oral amoxicillin-clavulanate and was followed up in outpatient surgical clinic where drains were removed. Seven days after drain removal (3 weeks after presentation), the patient represented to the ED with recurrent right-sided abdominal abscess. He was readmitted to the hospital and required multiple visits to the operating room with eventual wound vacuum-assisted closure placement. He was discharged on hospital day 25 but returned to the ED several months later with pyomyositis of his right gluteal muscle from S aureus infection, again requiring surgical intervention. Pyomyositis (an intramuscular abscess of the large skeletal muscle groups) is thought to be due to transient bacteremia in the setting of muscular injury. It is a rare disease because of the resistance of muscles to bacteremia, but in the United States, it is becoming more prevalent [2]. Temparate myositis appears to be a different clinical entity than tropical myositis. Temperate cases are more likely to occur in patients with underlying medical disease (75%) rather than healthy young individuals. Temperate disease is also associated with bacteremia (up to 35% compared to only 5% for tropical) and associated with an organism other than S aureus (90% in tropical cases, only 65%-75% in temperate) [1–5]. This case is the first to report H parainfluenza as a pathogen in pyomyositis. H parainfluenza is a gram-negative organism categorized primarily as oropharyngeal microflora [6]. S viridians is considered to be commensal flora of the oropharyngeal, urogenital, and gastrointestinal tracts that only generally causes disease only with underlying comorbidities [7]. There have been case reports in which this group was the etiologic agent of pyomyositis [8]. The diagnosis of pyomyositis may be difficult because of the deep skeletal muscle groups involved, which are not visually erythematous or tender. Extremity cases may be misdiagnosed as muscle hematoma, cellulitis, thrombophlebitis, osteomyelitis, or neoplasm. Abdominal wall infections may mimic visceral diseases rather than an extraperitoneal process. Treatment of pyomyositis consists of antibiotic therapy for early disease and combined with surgical drainage in more advanced illness. Initial antibiotic therapy needs to be broad as etiologic agents have been varied in temperate disease and may later be tailored to culture. The length of required therapy may be 3 to 4 weeks, but it can vary considerably depending on the host and clinical course [1]. It is possible that, with increasing immunocompromized patients, new bacteria will be associated with pyomyositis. Further epidemiologic and clinical data are needed to understand the pathogenesis of pyomyositis. This patient is exceedingly unusual, as he had 2 different
306.e4
J.R. Pare et al. / American Journal of Emergency Medicine 33 (2015) 306.e3–306.e4
Fig. 1. Three images from the computed tomographic scan are provided. Images A (level of the pelvis) and B (level of the aortic bifurcation) are coronal images demonstrating asymmetric thickening of the right rectus muscle in comparison to the left with surrounding intra-abdominalal and superficial fat stranding. Image B and C (sagittal image through the right rectus) demonstrate again muscular thickening with stranding, but also display air within the abscess.
cases of pyomyositis separated in a short time span with different organisms isolated. Best practice for pyomyositis includes drainage in conjunction with broad-spectrum antibiotics. Joseph R. Pare, MD Department of Emergency Medicine Boston Medical Center, Boston University School of Medicine Boston, MA Corresponding author. 464 Congress Avenue, Suite 260 New Haven, CT 06519 E-mail address: [email protected] Elissa M. Schechter-Perkins, MD, MPH Department of Emergency Medicine, Boston University School of Medicine, Boston, MA http://dx.doi.org/10.1016/j.ajem.2014.07.016
References [1] Crum N. Bacterial pyomyositis in the United States. Am J Med 2004;117(6):420–8. http://dx.doi.org/10.1016/j.amjmed.2004.03.031. [2] Small LN, Ross JJ. Tropical and temperate pyomyositis. Infect Dis Clin North Am 2005;19(4):981–9. http://dx.doi.org/10.1016/j.idc.2005.08.003. [3] Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J 2004;80(943):267–70. [4] Niamane R, Jalal O, Elghazi M, Hssaida R, Had A. Multifocal pyomyositis in an immunocompetent patient. Joint Bone Spine 2004;71(6):595–7. [5] Shepherd JJ. Tropical myositis: is it an entity and what is its cause? Lancet 1983;2(8361): 1240–2. http://dx.doi.org/10.1016/S0140-6736(83)91281-3. [6] Pollard A, Michael FS, Connor L, Nichols W, Cox A. Structural characterization of Haemophilus parainfluenzae lipooligosaccharide and elucidation of its role in adherence using an outer core mutant. 2008;917:906–17. http://dx.doi.org/10.1139/W08-082. [7] Doern CD, Burnham C-AD. It's not easy being green: the viridans group streptococci, with a focus on pediatric clinical manifestations. J Clin Microbiol 2010;48(11): 3829–35. [8] Woo PCY, Teng JLL, Lau SKP, Lum PNL, Leung K, Wong K, et al. Analysis of a Viridans group strain reveals a case of bacteremia due to Lancefield group G alpha-hemolytic Streptococcus dysgalactiae subsp. equisimilis in a patient with pyomyositis and reactive arthritis analysis of a Viridans group strain reveals a Ca; 2003. http://dx. doi.org/10.1128/JCM.41.2.613.
Fig. 2. Two images from the bedside ultrasound obtained prior to drainage are provided. Image A was obtained with a high frequency linear array probe. However, the abscess was larger than the probe, so in order to obtain a full image of the abscess, a curvilear probe was used (image B) given the size and depth of the abscess. On the right of each image, the white lines corresponds to 1 cm in distance.
