"Tropical Pyomyositis" A
Diagnostic
Peter
Problem in
Temperate Climates
Echeverria, MD, M. Clay Vaughn, MD
Pyomyositis is a common disease in tropical countries, but is believed to be rare in temperate climates. Two children who had never left the northeastern part of the United States developed single intramuscular abscesses. Pyomyositis may be more common in temperate climates than has previously been appreciated.
plained of mild discomfort in the right leg, he
was
well within 24 hours. He had been
playing in a sandbox on a farm with other children, two of whom were subsequently treated with cloxacillin sodium monohy¬ drate (Tegopen) for lymphangitis. Three-and-a-half weeks prior to admis¬ sion, he developed a macular rash and a temperature of 39 C (102.2 F), and
was
aspirin. Four days later he began limping on his left leg and was ad¬ mitted to a hospital with a left hip flexion contracture. A tentative diagnosis of Legg-Calvé-Perthes disease was made, but bilateral arthrograms were normal. He was discharged with a persistent lowgrade fever and an erythrocyte sedimenta¬ tion rate (ESR) of 34 mm/hr. He was treated with aspirin for two subsequent weeks without improvement in his condi¬ tion, and was then referred to the Chil¬ dren's Hospital Medical Center. On admission, he was not in acute dis¬ treated with
Bacterial myositis tropical
is well recog¬ nized in countries. It is included in the differential diagnosis of patients with muscle tenderness, swelling, or limitation of motion.13 Three children with this disease who had recently immigrated have been described.4 One child who had never traveled abroad was found to have extensive intermuscular and intra¬ muscular suppuration.5 Recently, two children who had never left the north¬ eastern part of the United States were admitted to the Children's Hos¬ pital Medical Center, Boston, and each was found to have a single intra¬ muscular pyogenic abscess. Failure to recognize this clinical entity resulted in the resection of the rectus femoris in one child. These children are de¬ scribed to call attention to this entity in the differential diagnosis of muscle disease in children in temperate cli¬ mates.
REPORT OF CASES Case 1.—A boy, 5 years 11 months old, in good health until early July, five weeks prior to admission, when he fell and abraded his right knee. Forty-eight hours later, his mother noticed "red streaks" ex¬ tending up his right thigh, but did not seek medical care. Although he initially comwas
Received for publication Aug 9,1974; accepted Nov 26. From the Division of Infectious Diseases, Department of Medicine (Dr. Echeverria), and the Department of Orthopedics (Dr. Vaughn), Children's Hospital Medical Center, Boston. Reprint requests to Division of Infectious Diseases, Children's Hospital Medical Center, 300 Longwood Ave, Boston, MA 02115 (Dr. Ech-
everria).
a temperature of 38.4 C (101.2 F). He had a bilateral antalgic gait; bilateral, nontender inguinal adenopathy;
Fig 1.—Transection of rectus femoris muscle (case 1).
tress, but had
40° left hip contracture; and full range of motion of the right hip. Flexion of his right knee over 120° produced spasm in the an¬ terior part of the thigh. There was a 10 x 6cm mass palpable in the anterior part of the right thigh that was slightly tender, mobile, and firm. There was no erythema, induration, fluctuance, or skin abrasion. The white blood cell (WBC) count was 12,300/cu mm with 76% polymorphonuclear leukocytes (PMNs), 3% band forms, 11% lymphocytes, 2% eosinophils, 2% atypical lymphocytes, and 6% monocytes. The hematocrit value was 32%, ESR was 56 mm/hr, and corrected sedimentation rate (CSR) was 31 mm/hr. A stool examination failed to disclose any ova and parasites. A complement-fixation test for Trichinella was negative. Roentgenograms of the a
right leg demonstrated a soft tissue swell¬ ing. A tentative diagnosis of a rhabdomyosarcoma was made. The right thigh was explored and showed a muscle mass that was gray, firm, and infiltrating, and lim¬
ited to the rectus femoris. The rectus fe¬ moris was resected in its entirety to avoid "spillage" of malignant cells. The mass was transected and found to contain 5 ml of purulent material (Fig 1 and 2). A Gram
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Fig 2.—Close-up of transection of rectus femoris. Purulent material is intramuscu¬ lar. stain of this material disclosed numerous PMNs and Gram-positive cocci in clusters. A culture subsequently yielded Staphylococcus aureus. The patient received oxacillin sodium intravenously, 300 mg/kg/day for ten days, and made an uneventful re¬ covery. Case 2.-A girl, age 3 years 9 months, was in good health until early September, 17 days prior to admission, when she fell and struck her left leg. She complained of tenderness and was seen in the emergency room seven days later. She was afebrile, and the anterior side of her left thigh was tender and swollen. A roentgenogram of the left leg showed a soft tissue swelling, and she was treated with bed rest and warm soaks with the impression she had a quadriceps contusion. The child returned to the emergency room ten days later com¬ plaining of increasing left thigh ten¬ derness. The left thigh was swollen, indurated, tender, and 6 cm larger in cir¬ cumference than the right. Tender en¬ larged nodes were palpable in the left side of the groin, but there was no evidence of
lymphangitis.
The temperature was 39 C (102.2 F), and the WBC count was 23,600/cu mm with 70% PMNs, 6% band forms, 16% lympho¬ cytes, and 8% monocytes. The hematocrit value was 29%, ESR was 64 mm/hr, CSR was 34 mm/hr, the hemoglobin electrophcresis was normal. Aspiration of the in¬ durated area produced 10 ml of purulent material. A Gram stain showed numerous PMNs and Gram-positive cocci in clusters. Incision and drainage, performed under general anesthesia, produced 15 ml of loculated material within the rectus femoris. A culture of this material yielded S aureus. A single blood culture yielded S albus, which was considered to be a contaminant. The patient received oxacillin parenterally, 300 mg/kg/day for one week, and dicloxacillin sodium monohydrate orally, 25 mg/kg/day for another week. She made an uneventful recovery, and had no evidence of muscle dysfunction one month later.
COMMENT
Although pyomyositis is common in the indigenous population as well as among Europeans living in tropical countries,3-6·' primary muscle ab¬ scesses are seldom reported in the United States. Ninety-five percent of the cases of pyomyositis are caused by S aureus, while streptococci, S epidermidis, and Pasteurella are occa¬ sionally implicated. Four of five cases of pyomyositis due to group A strep¬ tococci were rapidly fatal.8 The pathogenesis of pyomyositis has never been adequately explained. Predisposing factors that have been considered include trauma,3·6-9 vibrios
infection,10·11 parasitic infection,2 arbovirus infection,6 and hemoglobinop-
athies.2 Anand and Evans2 made a differentiation between intramuscu¬ lar and intermuscular abscesses. They were able to identify Dracunculus medinensis in eight of ten patients with intermuscular abscesses. Filariasis has also been associated with pyomyositis but a direct causal rela¬ tionship has not been shown.4-12 Forty percent of pyomyositis cases have been associated with multiple ab¬ scesses in some series,9·1213 raising the possibility that myositis is preceded by a bacteremia. However, less than 5% of patients with pyogenic myositis
have positive blood cultures,4 and pyogenic myositis is rare in S aureus bacteremia.1416 Miyake17 was able to pro¬ duce pyomyositis in rabbits injected with sublethal doses of S aureus by damaging striated muscle. Pyomyositis occurs at all ages.1 Characteristically, the onset is subacute, and ill-defined muscle pain pre¬ cedes fever by several days to weeks. The commonest sites of involvement are the quadriceps and trunk muscles. The abscesses develop deep within striated muscle so that erythema, heat, and localized pain may not be striking. The initial swelling has been described as "hard," "woody," and "elastic," and may not appear fluctuant until after several weeks.13 Occasionally, there is muscle pain and swelling without systemic signs of in¬ fection, as with the first patient de¬ scribed. The WBC count and ESR are usually elevated. Despite evidence of muscle destruction, serum levels of aldolase, creatine phosphokinase, serum glutamic oxaloacetic transaminase, lactic dehydrogenase, and creatine not elevated.3 Since the lesion is an abscess, surgi¬ cal drainage and treatment with an¬ tibiotics are required. Two patients previously described remained febrile despite appropriate therapy with an¬ tibiotics until all the abscesses had been drained.4 Persistent fever after an abscess has been drained should alert the physician to search for addi¬ tional muscle abscesses. Since the ma¬ jority of organisms isolated from pyomyositis are S awrews-resistant to penicillin, initial treatment with a ßlactamase-resistant penicillin is rec¬ ommended.7 Residual deformities are are
rare.2·3
Adams et al believe that pyomyo¬ sitis is exceedingly rare in temperate climates.18 The two children we de¬ scribed had no history of foreign travel. The child who had been play¬ ing in the sandbox may have been ex¬ posed to Toxocara, but parasitic infec¬ tion was never proved in either child. Both children had prolonged histories of muscular pain; one child was
acutely
ill when the
diagnosis
was
made, but the other child had only a flexion contracture of the opposite
hip. This experience indicates that pyomyositis should be considered in the differential diagnosis of any child with localized muscle pain of un¬ known
cause.
Nonproprietary
Name and
Trademarks of
Drug
Dicloxacillin sodium monohydrate-Z>î/îiapen, Pathocil, Veracillin.
References CV, Master S: Pyomyositis tropicans East Afr Med J 45:463-471, 1968. 2. Anand SV, Evans KT: Pyomyositis. Br J Surg 51:917-920, 1964. 3. Robin GC: Tropical myositis in Malaya. J Trop Med Hyg 64:288-291, 1961. 4. Levin MJ, Gardner P, Waldvogel FA: "Tropical" pyomyositis: An unusual infection due to Staphylococcus aureus. N Engl J Med 284:196-198, 1971. 5. Altrocchi PH: Spontaneous bacterial myositis. JAMA 217:819-820, 1971. 6. Marcus RT, Foster WD: Observations on the clinical features, aetiology and geographical distribution of pyomyositis in east Africa. East Afr Med J 45:167-176, 1968. 7. Foster WD: The bacteriology of tropical pyomyositis in Uganda. J Hyg 63:517-524, 1965. 8. Barrett AM, Gresham GA: Acute streptococcal myositis. Lancet 1:347-351, 1958. 1. Horn
in
Uganda.
9. Chacha PB: Muscle abscesses in children. Clin Orthop 70:174-180, 1970. 10. Manson-Bahr PH: Manson's Tropical Disease, ed 14. London, Cassel & Co, 1954, pp 693\x=req-\ 695. 11. Meyer-May J, Vaurel M: La spirochestose ictero-hemorragique: Est-elle responsible de certaines myosites tropicales? Bull Soc Pathol Exot 29:257-263, 1936. 12. Burkitt RT: Tropical pyomyositis. J Trop Med Hyg 50:71-75, 1947. 13. Traquair RN: Pyomyositis. J Trop Med Hyg 50:81-89, 1947. 14. Faber V, Jessen O, Rosendal K, et al: Staphylococcal bacteremia: Clinical and bacteriological observations in 201 cases. Br Med J 3:1832-1836, 1960. 15. Cluff LE, Reynolds RC, Page DL, et al: Staphylococcal bacteremia and altered host resistance. Ann Intern Med 69:859-873, 1968. 16. Smith IM, Vickers AB: Natural history of treated and untreated staphylococcal septicemia. Lancet 1:1318-1322, 1960. 17. Miyake H: Beitrage zur Kenntis der sogenannten myositis Infectiosa. Mitt Grenzgeb Med Chir 13:155-198, 1904. 18. Adams RD, Denny-Brown D, Pearson CM: Diseases of Muscle: A Study in Pathology, ed 2. New York, Harper & Bros, 1962, pp 386-387.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Pittsburgh User on 06/03/2015
Diagnostic
Peter
Problem in
Temperate Climates
Echeverria, MD, M. Clay Vaughn, MD
Pyomyositis is a common disease in tropical countries, but is believed to be rare in temperate climates. Two children who had never left the northeastern part of the United States developed single intramuscular abscesses. Pyomyositis may be more common in temperate climates than has previously been appreciated.
plained of mild discomfort in the right leg, he
was
well within 24 hours. He had been
playing in a sandbox on a farm with other children, two of whom were subsequently treated with cloxacillin sodium monohy¬ drate (Tegopen) for lymphangitis. Three-and-a-half weeks prior to admis¬ sion, he developed a macular rash and a temperature of 39 C (102.2 F), and
was
aspirin. Four days later he began limping on his left leg and was ad¬ mitted to a hospital with a left hip flexion contracture. A tentative diagnosis of Legg-Calvé-Perthes disease was made, but bilateral arthrograms were normal. He was discharged with a persistent lowgrade fever and an erythrocyte sedimenta¬ tion rate (ESR) of 34 mm/hr. He was treated with aspirin for two subsequent weeks without improvement in his condi¬ tion, and was then referred to the Chil¬ dren's Hospital Medical Center. On admission, he was not in acute dis¬ treated with
Bacterial myositis tropical
is well recog¬ nized in countries. It is included in the differential diagnosis of patients with muscle tenderness, swelling, or limitation of motion.13 Three children with this disease who had recently immigrated have been described.4 One child who had never traveled abroad was found to have extensive intermuscular and intra¬ muscular suppuration.5 Recently, two children who had never left the north¬ eastern part of the United States were admitted to the Children's Hos¬ pital Medical Center, Boston, and each was found to have a single intra¬ muscular pyogenic abscess. Failure to recognize this clinical entity resulted in the resection of the rectus femoris in one child. These children are de¬ scribed to call attention to this entity in the differential diagnosis of muscle disease in children in temperate cli¬ mates.
REPORT OF CASES Case 1.—A boy, 5 years 11 months old, in good health until early July, five weeks prior to admission, when he fell and abraded his right knee. Forty-eight hours later, his mother noticed "red streaks" ex¬ tending up his right thigh, but did not seek medical care. Although he initially comwas
Received for publication Aug 9,1974; accepted Nov 26. From the Division of Infectious Diseases, Department of Medicine (Dr. Echeverria), and the Department of Orthopedics (Dr. Vaughn), Children's Hospital Medical Center, Boston. Reprint requests to Division of Infectious Diseases, Children's Hospital Medical Center, 300 Longwood Ave, Boston, MA 02115 (Dr. Ech-
everria).
a temperature of 38.4 C (101.2 F). He had a bilateral antalgic gait; bilateral, nontender inguinal adenopathy;
Fig 1.—Transection of rectus femoris muscle (case 1).
tress, but had
40° left hip contracture; and full range of motion of the right hip. Flexion of his right knee over 120° produced spasm in the an¬ terior part of the thigh. There was a 10 x 6cm mass palpable in the anterior part of the right thigh that was slightly tender, mobile, and firm. There was no erythema, induration, fluctuance, or skin abrasion. The white blood cell (WBC) count was 12,300/cu mm with 76% polymorphonuclear leukocytes (PMNs), 3% band forms, 11% lymphocytes, 2% eosinophils, 2% atypical lymphocytes, and 6% monocytes. The hematocrit value was 32%, ESR was 56 mm/hr, and corrected sedimentation rate (CSR) was 31 mm/hr. A stool examination failed to disclose any ova and parasites. A complement-fixation test for Trichinella was negative. Roentgenograms of the a
right leg demonstrated a soft tissue swell¬ ing. A tentative diagnosis of a rhabdomyosarcoma was made. The right thigh was explored and showed a muscle mass that was gray, firm, and infiltrating, and lim¬
ited to the rectus femoris. The rectus fe¬ moris was resected in its entirety to avoid "spillage" of malignant cells. The mass was transected and found to contain 5 ml of purulent material (Fig 1 and 2). A Gram
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Fig 2.—Close-up of transection of rectus femoris. Purulent material is intramuscu¬ lar. stain of this material disclosed numerous PMNs and Gram-positive cocci in clusters. A culture subsequently yielded Staphylococcus aureus. The patient received oxacillin sodium intravenously, 300 mg/kg/day for ten days, and made an uneventful re¬ covery. Case 2.-A girl, age 3 years 9 months, was in good health until early September, 17 days prior to admission, when she fell and struck her left leg. She complained of tenderness and was seen in the emergency room seven days later. She was afebrile, and the anterior side of her left thigh was tender and swollen. A roentgenogram of the left leg showed a soft tissue swelling, and she was treated with bed rest and warm soaks with the impression she had a quadriceps contusion. The child returned to the emergency room ten days later com¬ plaining of increasing left thigh ten¬ derness. The left thigh was swollen, indurated, tender, and 6 cm larger in cir¬ cumference than the right. Tender en¬ larged nodes were palpable in the left side of the groin, but there was no evidence of
lymphangitis.
The temperature was 39 C (102.2 F), and the WBC count was 23,600/cu mm with 70% PMNs, 6% band forms, 16% lympho¬ cytes, and 8% monocytes. The hematocrit value was 29%, ESR was 64 mm/hr, CSR was 34 mm/hr, the hemoglobin electrophcresis was normal. Aspiration of the in¬ durated area produced 10 ml of purulent material. A Gram stain showed numerous PMNs and Gram-positive cocci in clusters. Incision and drainage, performed under general anesthesia, produced 15 ml of loculated material within the rectus femoris. A culture of this material yielded S aureus. A single blood culture yielded S albus, which was considered to be a contaminant. The patient received oxacillin parenterally, 300 mg/kg/day for one week, and dicloxacillin sodium monohydrate orally, 25 mg/kg/day for another week. She made an uneventful recovery, and had no evidence of muscle dysfunction one month later.
COMMENT
Although pyomyositis is common in the indigenous population as well as among Europeans living in tropical countries,3-6·' primary muscle ab¬ scesses are seldom reported in the United States. Ninety-five percent of the cases of pyomyositis are caused by S aureus, while streptococci, S epidermidis, and Pasteurella are occa¬ sionally implicated. Four of five cases of pyomyositis due to group A strep¬ tococci were rapidly fatal.8 The pathogenesis of pyomyositis has never been adequately explained. Predisposing factors that have been considered include trauma,3·6-9 vibrios
infection,10·11 parasitic infection,2 arbovirus infection,6 and hemoglobinop-
athies.2 Anand and Evans2 made a differentiation between intramuscu¬ lar and intermuscular abscesses. They were able to identify Dracunculus medinensis in eight of ten patients with intermuscular abscesses. Filariasis has also been associated with pyomyositis but a direct causal rela¬ tionship has not been shown.4-12 Forty percent of pyomyositis cases have been associated with multiple ab¬ scesses in some series,9·1213 raising the possibility that myositis is preceded by a bacteremia. However, less than 5% of patients with pyogenic myositis
have positive blood cultures,4 and pyogenic myositis is rare in S aureus bacteremia.1416 Miyake17 was able to pro¬ duce pyomyositis in rabbits injected with sublethal doses of S aureus by damaging striated muscle. Pyomyositis occurs at all ages.1 Characteristically, the onset is subacute, and ill-defined muscle pain pre¬ cedes fever by several days to weeks. The commonest sites of involvement are the quadriceps and trunk muscles. The abscesses develop deep within striated muscle so that erythema, heat, and localized pain may not be striking. The initial swelling has been described as "hard," "woody," and "elastic," and may not appear fluctuant until after several weeks.13 Occasionally, there is muscle pain and swelling without systemic signs of in¬ fection, as with the first patient de¬ scribed. The WBC count and ESR are usually elevated. Despite evidence of muscle destruction, serum levels of aldolase, creatine phosphokinase, serum glutamic oxaloacetic transaminase, lactic dehydrogenase, and creatine not elevated.3 Since the lesion is an abscess, surgi¬ cal drainage and treatment with an¬ tibiotics are required. Two patients previously described remained febrile despite appropriate therapy with an¬ tibiotics until all the abscesses had been drained.4 Persistent fever after an abscess has been drained should alert the physician to search for addi¬ tional muscle abscesses. Since the ma¬ jority of organisms isolated from pyomyositis are S awrews-resistant to penicillin, initial treatment with a ßlactamase-resistant penicillin is rec¬ ommended.7 Residual deformities are are
rare.2·3
Adams et al believe that pyomyo¬ sitis is exceedingly rare in temperate climates.18 The two children we de¬ scribed had no history of foreign travel. The child who had been play¬ ing in the sandbox may have been ex¬ posed to Toxocara, but parasitic infec¬ tion was never proved in either child. Both children had prolonged histories of muscular pain; one child was
acutely
ill when the
diagnosis
was
made, but the other child had only a flexion contracture of the opposite
hip. This experience indicates that pyomyositis should be considered in the differential diagnosis of any child with localized muscle pain of un¬ known
cause.
Nonproprietary
Name and
Trademarks of
Drug
Dicloxacillin sodium monohydrate-Z>î/îiapen, Pathocil, Veracillin.
References CV, Master S: Pyomyositis tropicans East Afr Med J 45:463-471, 1968. 2. Anand SV, Evans KT: Pyomyositis. Br J Surg 51:917-920, 1964. 3. Robin GC: Tropical myositis in Malaya. J Trop Med Hyg 64:288-291, 1961. 4. Levin MJ, Gardner P, Waldvogel FA: "Tropical" pyomyositis: An unusual infection due to Staphylococcus aureus. N Engl J Med 284:196-198, 1971. 5. Altrocchi PH: Spontaneous bacterial myositis. JAMA 217:819-820, 1971. 6. Marcus RT, Foster WD: Observations on the clinical features, aetiology and geographical distribution of pyomyositis in east Africa. East Afr Med J 45:167-176, 1968. 7. Foster WD: The bacteriology of tropical pyomyositis in Uganda. J Hyg 63:517-524, 1965. 8. Barrett AM, Gresham GA: Acute streptococcal myositis. Lancet 1:347-351, 1958. 1. Horn
in
Uganda.
9. Chacha PB: Muscle abscesses in children. Clin Orthop 70:174-180, 1970. 10. Manson-Bahr PH: Manson's Tropical Disease, ed 14. London, Cassel & Co, 1954, pp 693\x=req-\ 695. 11. Meyer-May J, Vaurel M: La spirochestose ictero-hemorragique: Est-elle responsible de certaines myosites tropicales? Bull Soc Pathol Exot 29:257-263, 1936. 12. Burkitt RT: Tropical pyomyositis. J Trop Med Hyg 50:71-75, 1947. 13. Traquair RN: Pyomyositis. J Trop Med Hyg 50:81-89, 1947. 14. Faber V, Jessen O, Rosendal K, et al: Staphylococcal bacteremia: Clinical and bacteriological observations in 201 cases. Br Med J 3:1832-1836, 1960. 15. Cluff LE, Reynolds RC, Page DL, et al: Staphylococcal bacteremia and altered host resistance. Ann Intern Med 69:859-873, 1968. 16. Smith IM, Vickers AB: Natural history of treated and untreated staphylococcal septicemia. Lancet 1:1318-1322, 1960. 17. Miyake H: Beitrage zur Kenntis der sogenannten myositis Infectiosa. Mitt Grenzgeb Med Chir 13:155-198, 1904. 18. Adams RD, Denny-Brown D, Pearson CM: Diseases of Muscle: A Study in Pathology, ed 2. New York, Harper & Bros, 1962, pp 386-387.
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