‘lhberculous pyomyositis in a renal transplant recipient R. Indudhara, Department
S. K. Singh, M. Minz, R.V. S. Yadav, K. S. Chugh* of Surgery (Transplantation
Education and Research,
Chandigarh,
Unit) and *Department
of Nephrology,
Postgraduate
lnstitute of Medical
India
S U M MA R Y. Infections are a major cause of morbidity and mortality in renal transplant recipients. Although these patients are susceptible to many types of infection, soft tissue infections are rare. We report a case of tnbercnlons pyomyositis involving the left erector spinae muscle but with no other manifestations of tuberculosis. The diagnosis was suspected from the CT scan appearance and confirmed by microscopy and culture of the pus. Surgical incision and drainage, together with antituberculosis therapy, cured the infection. The relevant literature is briefly reviewed.
l? . L’infection est nne cause majeure de morbidite et de mortalite cbez les recevenrs de transplantation renale. MalgrC la snsceptibilite de ces snjets a plusieurs types d’infection, l’infection des tissns mons est rare. Est d&it ici un cas de pyomyosite tnbercnlense atteignant le muscle spinal Crectenr gauche sans antre manifestation de tnbercnlose. Le diagnostic a CtCsonpqonne lors de la tomodensitometrie, et confirm6 par microscopic et culture dn pus. L’incision chirnrgicale et le drainage, ainsi qn’une therapie antitubercnlense, ont gneri l’infection. La litteratnre correspondante est revue brievement. R l?S U M
R ES I! M E N .
Las infecciones son nna de las cansas principales de morbilidad y mortalidad en 10s pacientes qne han recibido nn transplante renal. Annqne estos pacientes son snsceptibles a diversos tipos de infection, son raras las infecciones de 10s tejidos blandos. Se presenta nn case de piomiositis qne compromete el mnscnlo erector espinal ieqnierdo, sin otras manifestaciones de tuberculosis. El diagnostico presnntivo se hizo a partir de las imagenes de la tomodensitometria computarizada y fne confirmado por microscopia y cnltivo de1 pus. La incision qnirurgica y drenaje, jnnto con nna terapia antituberculosa cnraron la infection. Se hate una breve revision de la literatura a este respecto.
INTRODUCTION
We present a case of tuberculous occurring 7 years after a live related transplantation.
Despite significant improvements in immunosuppression and other aspects of kidney transplantation, infections continue to be a major cause of morbidity and mortality in transplant recipients.’ Most of these infections are caused by common pathogens although opportunistic infections are not rare. Despite being susceptible to many types of infection, spontaneous cellulitis, soft tissue infections and osteomyelitis are rare in these patients, accounting for only 3% of infections in one large series.2 Reactivation of tuberculosis often occurs in the tropics and most cases involve the lung although lymph node, soft tissue and miliary forms of tuberculosis also occur.’ Pyogenic infection of skeletal muscle is very rare,4 as is tuberculous pyomyositis in the general population.5%6
pyomyositis donor renal
CASE REPORT A 32-year-old man who had received a live related donor (LRD) renal allotransplant 7 years previously and had been on regular follow-up presented with a low grade fever, a cough with scanty sputum and backache of 3 months duration. On admission he was pale, anicteric and had no features of fluid overload. Chest examination revealed scattered bilateral fine crepitations but the chest radiograph was normal. The abdomen appeared normal. Examination of the spine revealed tenderness over the left paraspinal muscles in the thoracic and lumbar regions. There was no restriction of spinal movements. Investigations revealed a haemoglobin of 70 g/l, WBC 8600/cmm with a normal differential, ESR 46 mm in 1h.
Correspondence to: Dr R. Indudhara, Department of Surgery .(Transplantation Unit). Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. 239
240
Tubercle and Lung Disease
Fig. 1XT scan showing a hypodense spinae muscle.
lesion within the left erector
blood urea 13.3 mmol/l and serum creatinine 354 pmol/l. Cultures of sputum, urine and blood were negative for bacteria, including acid-fast bacilli, and fungi. His cough subsided after an empirical course of antibiotics and he had no fever during a period of observation in hospital for 10 days. However, he continued to complain of backache localized to the thoracic and lumbar regions. A plain radiograph of the spine was normal but computerized tomography (CT) revealed a hypodense lesion inside the left erector spinae muscle (Figs 1 and 2). The spine and intra-abdominal viscera appeared normal. Needle aspiration of the hypodense lesion revealed pus. The lesion was incised under general anaesthesia and about 300 ml of thick, creamy, non-foul smelling pus was drained. The wound was left open for secondary healing. Routine bacterial (aerobic and anaerobic) and fungal cultures of the pus yielded no growth but microscopy revealed numerous acid-fast bacilli (> 10 per oil immersion field) and Mycobacterium tuberculosis grew on culture. The patient was started on isoniazid, rifampicin and pyrazinamide and, in addition, he continued receiving prednisolone and azathioprine. The open wound healed completely in 6 weeks and there was no functional disability. At 6 months the patient was well with a serum creatinine of around 370 l.tmol/l.
DISCUSSION Pyomyositis is a pyogenic infection of skeletal muscle, with a predilection for the large muscles which are normally resistant to bacterial invasion.4 Though often called tropical pyomyositis due to its frequent occurrence in tropical and subtropical regions, it has been reported in both Europe and North America.7-9 Staphylococcus aureus is the most frequent causative organism (90%); others include Escherichia coli, Streptococcus pyogenes and other streptococci.7-9 Granulomatous myositis due to tuberculosis, other mycobacteria, sarcoidosis, syphilis or
Fig. Z-Magnified
CT scan showing more clearly the hypodense within the left erector spinae muscle.
lesion
parasites is rare.536It has been suggested that some cases are due to a primary virus infection with secondary bacterial invasion. ‘O.’’ Possible predisposing factors for pyomyositis include trauma, nutritional deficiencies and, perhaps, a tropical climate.’ The clinical presentation depends on the extent of the underlying inflammation and is divisible into 3 stages: the invasive stage, the suppurative stage and the late stage.5 In the late stage the patient is usually very ill with septicaemia. True necrosis and gangrene are unusual in pyomyositis and this distinguishes it from the more serious condition of necrotizing myositis (akin to necrotizing fasciitis caused by clostridia, streptococci, Aeromonas hydrophila and Serratia marcescens).‘2 Necrotizing pyomyositis is more likely to occur when the patient is immunosuppressed or has an underlying condition such as diabetes. Pyomyositis usually affects a single large muscle although multiple muscle involvement occurs in 1243% of cases ’ and a higher incidence, up to 60%, is reported from temperate climates.’ The most commonly affected muscles are those of the thighs and calves and the gluteal, paraspinal, psoas, latissimus dorsi, pectoral, deltoid, anterior abdominal and chest muscles. Diagnosis is based on local signs and symptoms of inflammation (less marked in the early stages) and systemic toxicity. Computerized tomography is of value for the localization of the lesion and to differentiate it from haematoma, cellulitis, osteomyelitis and malignancy. Computerized tomography was diagnostic in the case reported here. Needle aspiration confirms the diagnosis. Gallium 67 scanning is also useful for diagnosing pyomyositis and for locating occult abscesses.g Treatment consists of appropriate parenteral antibiotics and drainage of the abscess by aspiration or open drainage. A high index of suspicion is required for rare pathogens, particularly in immunosuppressed patients. Accordingly, pus should be examined for a wide range of opportunistic organisms. The prognosis is excellent when pyomyositis is
Tuberculous
diagnosed early and treated appropriately. Surprisingly little, if any, functional disability persists after successful drainage, even when the abscesses are very large. The reason for the lack of disability is unknown: regeneration of skeletal muscle is unlikely. The reported mortality of pyomyositis is in the range of 1.5-10%.7*” The presence of necrosis and gangrene carries a poor prognosis, particularly in immunosuppressed patients.”
References 1. Cohen J, Hopkin J, Kurtz J. Infectious complications after renal transplantation. In: Morris PJ, ed. Kidney transplantation, 3rd ed. Philadelphia: Saunders, 1988: pp 533-573. 2. Peterson P K, Ferguson R, Fryd D S, Balfour H H, Rynasiewicz J, Simmons R L. Infectious diseases in hospital&d renal transplant recipients: a prospective study of a complex and evolving problem. Medicine 1982; 61: 360-37 1.
pyomyositis
241
3. Yadav R V S, Indudhara R, Minz M et al. Tuberculosis in renal transplant recipients. Indian J Surg 1991 (in press). 4. Smith I M, Vicjkers A B. The natural history of 338 treated and untreated patients with Stu~hylococcus septicaemia. Lancet 1960; 1: 1318-1322. 5. Rosai J. Skeletal muscle. In: Rosai J, ed. Ackerman’s surgical pathology vol. 2,6th cd. St Louis: Mosby, 1981: p 1629. 6. Carpenter S, Karpati G. Pathology of skeletal muscle. Edinburgh Churchill Livingstone, 1984: p 5 19. 7. Chiedozi L C. Pyomyositis: review of 205 cases in 112 patients. Am J Surg 1979; 137: 255-259. 8. Geelhoed G W, Gray H, Alavi A, et al. Pyomyositis - tropical and nontropical. N Engl J Med 197 1; 284: 853-854. 9. Gibson R K, Rosenthal S J, Lukert B P. Pyomyositis - increasing recognition in temperate climates. Am J Med 1984; 77: 768-772. 10. Taylor J F, Templeton A C, Henderson B H. Pyomyositis: a clinicopathological study. East Afr Med J 1969; 47: l-7. 11. Anand S V, Evans K T. Pyomyositis Br J Surg 1964; 5 I : 917-920. 12. Pascual J, Liano F, Rivera M, Carillo R, Grtuno J. Necrotising myositis secondary to Serruria marcescenr in a renal allograft recipient. Nephron 1990; 55: 329-33 I.
S. K. Singh, M. Minz, R.V. S. Yadav, K. S. Chugh* of Surgery (Transplantation
Education and Research,
Chandigarh,
Unit) and *Department
of Nephrology,
Postgraduate
lnstitute of Medical
India
S U M MA R Y. Infections are a major cause of morbidity and mortality in renal transplant recipients. Although these patients are susceptible to many types of infection, soft tissue infections are rare. We report a case of tnbercnlons pyomyositis involving the left erector spinae muscle but with no other manifestations of tuberculosis. The diagnosis was suspected from the CT scan appearance and confirmed by microscopy and culture of the pus. Surgical incision and drainage, together with antituberculosis therapy, cured the infection. The relevant literature is briefly reviewed.
l? . L’infection est nne cause majeure de morbidite et de mortalite cbez les recevenrs de transplantation renale. MalgrC la snsceptibilite de ces snjets a plusieurs types d’infection, l’infection des tissns mons est rare. Est d&it ici un cas de pyomyosite tnbercnlense atteignant le muscle spinal Crectenr gauche sans antre manifestation de tnbercnlose. Le diagnostic a CtCsonpqonne lors de la tomodensitometrie, et confirm6 par microscopic et culture dn pus. L’incision chirnrgicale et le drainage, ainsi qn’une therapie antitubercnlense, ont gneri l’infection. La litteratnre correspondante est revue brievement. R l?S U M
R ES I! M E N .
Las infecciones son nna de las cansas principales de morbilidad y mortalidad en 10s pacientes qne han recibido nn transplante renal. Annqne estos pacientes son snsceptibles a diversos tipos de infection, son raras las infecciones de 10s tejidos blandos. Se presenta nn case de piomiositis qne compromete el mnscnlo erector espinal ieqnierdo, sin otras manifestaciones de tuberculosis. El diagnostico presnntivo se hizo a partir de las imagenes de la tomodensitometria computarizada y fne confirmado por microscopia y cnltivo de1 pus. La incision qnirurgica y drenaje, jnnto con nna terapia antituberculosa cnraron la infection. Se hate una breve revision de la literatura a este respecto.
INTRODUCTION
We present a case of tuberculous occurring 7 years after a live related transplantation.
Despite significant improvements in immunosuppression and other aspects of kidney transplantation, infections continue to be a major cause of morbidity and mortality in transplant recipients.’ Most of these infections are caused by common pathogens although opportunistic infections are not rare. Despite being susceptible to many types of infection, spontaneous cellulitis, soft tissue infections and osteomyelitis are rare in these patients, accounting for only 3% of infections in one large series.2 Reactivation of tuberculosis often occurs in the tropics and most cases involve the lung although lymph node, soft tissue and miliary forms of tuberculosis also occur.’ Pyogenic infection of skeletal muscle is very rare,4 as is tuberculous pyomyositis in the general population.5%6
pyomyositis donor renal
CASE REPORT A 32-year-old man who had received a live related donor (LRD) renal allotransplant 7 years previously and had been on regular follow-up presented with a low grade fever, a cough with scanty sputum and backache of 3 months duration. On admission he was pale, anicteric and had no features of fluid overload. Chest examination revealed scattered bilateral fine crepitations but the chest radiograph was normal. The abdomen appeared normal. Examination of the spine revealed tenderness over the left paraspinal muscles in the thoracic and lumbar regions. There was no restriction of spinal movements. Investigations revealed a haemoglobin of 70 g/l, WBC 8600/cmm with a normal differential, ESR 46 mm in 1h.
Correspondence to: Dr R. Indudhara, Department of Surgery .(Transplantation Unit). Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. 239
240
Tubercle and Lung Disease
Fig. 1XT scan showing a hypodense spinae muscle.
lesion within the left erector
blood urea 13.3 mmol/l and serum creatinine 354 pmol/l. Cultures of sputum, urine and blood were negative for bacteria, including acid-fast bacilli, and fungi. His cough subsided after an empirical course of antibiotics and he had no fever during a period of observation in hospital for 10 days. However, he continued to complain of backache localized to the thoracic and lumbar regions. A plain radiograph of the spine was normal but computerized tomography (CT) revealed a hypodense lesion inside the left erector spinae muscle (Figs 1 and 2). The spine and intra-abdominal viscera appeared normal. Needle aspiration of the hypodense lesion revealed pus. The lesion was incised under general anaesthesia and about 300 ml of thick, creamy, non-foul smelling pus was drained. The wound was left open for secondary healing. Routine bacterial (aerobic and anaerobic) and fungal cultures of the pus yielded no growth but microscopy revealed numerous acid-fast bacilli (> 10 per oil immersion field) and Mycobacterium tuberculosis grew on culture. The patient was started on isoniazid, rifampicin and pyrazinamide and, in addition, he continued receiving prednisolone and azathioprine. The open wound healed completely in 6 weeks and there was no functional disability. At 6 months the patient was well with a serum creatinine of around 370 l.tmol/l.
DISCUSSION Pyomyositis is a pyogenic infection of skeletal muscle, with a predilection for the large muscles which are normally resistant to bacterial invasion.4 Though often called tropical pyomyositis due to its frequent occurrence in tropical and subtropical regions, it has been reported in both Europe and North America.7-9 Staphylococcus aureus is the most frequent causative organism (90%); others include Escherichia coli, Streptococcus pyogenes and other streptococci.7-9 Granulomatous myositis due to tuberculosis, other mycobacteria, sarcoidosis, syphilis or
Fig. Z-Magnified
CT scan showing more clearly the hypodense within the left erector spinae muscle.
lesion
parasites is rare.536It has been suggested that some cases are due to a primary virus infection with secondary bacterial invasion. ‘O.’’ Possible predisposing factors for pyomyositis include trauma, nutritional deficiencies and, perhaps, a tropical climate.’ The clinical presentation depends on the extent of the underlying inflammation and is divisible into 3 stages: the invasive stage, the suppurative stage and the late stage.5 In the late stage the patient is usually very ill with septicaemia. True necrosis and gangrene are unusual in pyomyositis and this distinguishes it from the more serious condition of necrotizing myositis (akin to necrotizing fasciitis caused by clostridia, streptococci, Aeromonas hydrophila and Serratia marcescens).‘2 Necrotizing pyomyositis is more likely to occur when the patient is immunosuppressed or has an underlying condition such as diabetes. Pyomyositis usually affects a single large muscle although multiple muscle involvement occurs in 1243% of cases ’ and a higher incidence, up to 60%, is reported from temperate climates.’ The most commonly affected muscles are those of the thighs and calves and the gluteal, paraspinal, psoas, latissimus dorsi, pectoral, deltoid, anterior abdominal and chest muscles. Diagnosis is based on local signs and symptoms of inflammation (less marked in the early stages) and systemic toxicity. Computerized tomography is of value for the localization of the lesion and to differentiate it from haematoma, cellulitis, osteomyelitis and malignancy. Computerized tomography was diagnostic in the case reported here. Needle aspiration confirms the diagnosis. Gallium 67 scanning is also useful for diagnosing pyomyositis and for locating occult abscesses.g Treatment consists of appropriate parenteral antibiotics and drainage of the abscess by aspiration or open drainage. A high index of suspicion is required for rare pathogens, particularly in immunosuppressed patients. Accordingly, pus should be examined for a wide range of opportunistic organisms. The prognosis is excellent when pyomyositis is
Tuberculous
diagnosed early and treated appropriately. Surprisingly little, if any, functional disability persists after successful drainage, even when the abscesses are very large. The reason for the lack of disability is unknown: regeneration of skeletal muscle is unlikely. The reported mortality of pyomyositis is in the range of 1.5-10%.7*” The presence of necrosis and gangrene carries a poor prognosis, particularly in immunosuppressed patients.”
References 1. Cohen J, Hopkin J, Kurtz J. Infectious complications after renal transplantation. In: Morris PJ, ed. Kidney transplantation, 3rd ed. Philadelphia: Saunders, 1988: pp 533-573. 2. Peterson P K, Ferguson R, Fryd D S, Balfour H H, Rynasiewicz J, Simmons R L. Infectious diseases in hospital&d renal transplant recipients: a prospective study of a complex and evolving problem. Medicine 1982; 61: 360-37 1.
pyomyositis
241
3. Yadav R V S, Indudhara R, Minz M et al. Tuberculosis in renal transplant recipients. Indian J Surg 1991 (in press). 4. Smith I M, Vicjkers A B. The natural history of 338 treated and untreated patients with Stu~hylococcus septicaemia. Lancet 1960; 1: 1318-1322. 5. Rosai J. Skeletal muscle. In: Rosai J, ed. Ackerman’s surgical pathology vol. 2,6th cd. St Louis: Mosby, 1981: p 1629. 6. Carpenter S, Karpati G. Pathology of skeletal muscle. Edinburgh Churchill Livingstone, 1984: p 5 19. 7. Chiedozi L C. Pyomyositis: review of 205 cases in 112 patients. Am J Surg 1979; 137: 255-259. 8. Geelhoed G W, Gray H, Alavi A, et al. Pyomyositis - tropical and nontropical. N Engl J Med 197 1; 284: 853-854. 9. Gibson R K, Rosenthal S J, Lukert B P. Pyomyositis - increasing recognition in temperate climates. Am J Med 1984; 77: 768-772. 10. Taylor J F, Templeton A C, Henderson B H. Pyomyositis: a clinicopathological study. East Afr Med J 1969; 47: l-7. 11. Anand S V, Evans K T. Pyomyositis Br J Surg 1964; 5 I : 917-920. 12. Pascual J, Liano F, Rivera M, Carillo R, Grtuno J. Necrotising myositis secondary to Serruria marcescenr in a renal allograft recipient. Nephron 1990; 55: 329-33 I.
