Point-of-care ultrasound in diagnosing pyomyositis: a report of three cases

Point-of-Care Ultrasound Diagnosis of Early Pyomyositis in a Pediatric Patient: A Case Report

ABSTRACT

Skin and soft tissue infections are common in the pediatric emergency department. Because pyomyositis occurs deep to the fascial plane, it is often difficult to appreciate on physical examination. The utility of point-of-care ultrasound for identifying pyomyositis is of great value to the pediatric emergency physician as this diagnosis has a different expected clinical course and requires different management than other skin and soft tissue infections. This case report describes a child who presented to the pediatric emergency department with leg pain and redness, initially concerning for an abscess based on clinical findings. Point-of-care ultrasound diagnosed early pyomyositis, prompting early involvement of the pediatric surgical service and urgent computed tomography imaging, which confirmed the diagnosis.

Point-of-Care Ultrasound Identifies Pyomyositis Secondary to Intramuscular Testosterone Injection: Report of Two Cases

BACKGROUND

Intramuscular (i.m.) injections are a commonly utilized route for medication delivery. Intramuscular-associated soft tissue infections are rare and can include pyomyositis and i.m. abscess. Intramuscular testosterone injections have not been previously implicated in causing pyomyositis. Point-of-care ultrasound is an important bedside tool that can identify pyomyositis and differentiate this infection from more common entities such as cellulitis.

CASE REPORTS

We present two cases of i.m. testosterone-associated pyomyositis. In both cases, the physical examination features were consistent with simple cellulitis. However, point-of-care ultrasound evaluation revealed changes consistent with pyomyositis in each case. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although uncommon, i.m. injections such as testosterone carry a risk of soft tissue infection. As demonstrated in the above cases, ultrasound can be helpful in making the differentiation between simple cellulitis and pyomyositis. The emergency physician should be cognizant of this complication of therapeutic i.m. injections, as well as the diagnostic efficacy of point-of-care ultrasound in evaluating the extent and location of the soft tissue infection.

The Utility of Musculoskeletal Ultrasonography in Diagnosing Pyomyositis: A Comparison With Surgically and Conservatively Treated Cases

Objective:

The study aimed to determine the accuracy of sonography in diagnosing pyomyositis.

Methods:

A retrospective review of pyomyositis cases in a government hospital between January 1, 2016 and June 30, 2019 was done. All cases underwent a sonogram for the indication of pyomyositis. Positive purulence for surgical cases and improved laboratory parameters for conservative cases were confirmatory for pyomyositis. Comparison with sonographic results using a 2 × 2 contingency table was done to determine sensitivity and specificity.

Results:

A total of 122 cases were included. The sonographic results corresponded with 95% of surgical cases and 89% of conservative cases. A lack of false and true negatives for surgical cases resulted in a sensitivity of 100% (95% confidence interval [CI] = 93%–100%) and a specificity of 0% (95% CI = 0%–71%). In conservative cases, sonography had a sensitivity of 92% (95% CI = 82%–97%) and a specificity of 0% (95% CI = 0%–84%) due to a lack of true negatives.

Conclusion:

Sonography is not limited to primarily as a screening tool but a capable diagnostic imaging choice for pyomyositis, particularly in low-resource settings. The results show the strength of sonography, particularly in the suppurative stage of pyomyositis. [Box: see text]

Emergency physician-performed bedside ultrasound of pyomyositis

Point-of-care ultrasound (POCUS) is an indispensable tool for emergency physicians in the rapid bedside diagnosis of skin and soft tissue infections. The utility of POCUS for the differentiation of cellulitis and subcutaneous abscess is well established; however, there is a paucity of studies highlighting POCUS as a first-line imaging approach for pyomyositis, an uncommon skeletal muscle infection and/or intramuscular abscess formation requiring emergent diagnosis. This report describes a case in which emergency physician-performed POCUS led to the early detection and timely management of pyomyositis in the emergency department.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Sonographic appearance of pyomyositis of the sternocleidomastoid muscle: A case report

Pyomyositis in the neck has rarely been described. We present the sonographic findings in a case of pyomyositis of the sternocleidomastoid muscle. A 62-year-old man with poorly controlled diabetes presented with an induration of the neck and fever. On gray-scale sonography, a part of the sternocleidomastoid muscle appeared swollen and contained irregularly shaped hypoechoic areas. Power Doppler imaging showed increased vascularity in the muscle. Sonographic-guided aspiration confirmed abscesses in the sternocleidomastoid muscle. Surgical drainage was successfully performed along with antibiotic treatment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:520-523, 2017.

Secondary myopathy due to systemic diseases

Background

Some systemic diseases also affect the skeletal muscle to various degrees and with different manifestations. This review aimed at summarizing and discussing recent advances concerning the management of muscle disease in systemic diseases.

Method

Literature review by search of MEDLINE, and Current Contents with appropriate search terms.

Results

Secondary muscle disease occurs in infectious disease, endocrine disorders, metabolic disorders, immunological disease, vascular diseases, hematological disorders, and malignancies. Muscle manifestations in these categories include pathogen‐caused myositis, muscle infarction, rhabdomyolysis, myasthenia, immune‐mediated myositis, necrotising myopathy, or vasculitis‐associated myopathy. Muscle affection may concern only a single muscle, a group of muscles, or the entire musculature. Severity of muscle affection may be transient or permanent, may be a minor part of or may dominate the clinical picture, or may be mild or severe, requiring invasive measures including artificial ventilation if the respiratory muscles are additionally involved. Diagnostic work‐up is similar to that of primary myopathies by application of non‐invasive and invasive techniques. Treatment of muscle involvement in systemic diseases is based on elimination of the underlying cause and supportive measures. The prognosis is usually fair if the causative disorder is effectively treatable but can be fatal in single cases if the entire musculature including the respiratory muscles is involved, in case of infection, or in case of severe rhabdomyolysis.

Conclusion

Secondary muscle manifestations of systemic diseases must be addressed and appropriately managed. Prognosis of secondary muscle disease in systemic diseases is usually fair if the underlying condition is accessible to treatment.

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review

PURPOSE

To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis.

METHODS

Guidelines, expert opinion, and local institutional policies were reviewed.

RESULTS

Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described.

CONCLUSIONS

We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.

Neuromuscular ultrasound in the evaluation of inclusion body myositis

This case report illustrates the role of using neuromuscular ultrasound to diagnose inclusion body myositis (IBM) in a patient who was previously diagnosed with polymyositis. Emerging studies have demonstrated the accuracy of MRI in detecting the selective involvement of the flexor digitorum profundus muscle in those with IBM. However, there have been only few reports on the use of ultrasound in diagnosing this condition. Our case demonstrates the benefit of using this ultrasonographic approach, which is simple, clear, inexpensive, painless and radiation-free, and provides another modality to assist in the evaluation of this sometimes difficult to diagnose condition.

Primary Bacterial Gluteal Pyomyositis: A Rare Disease in Temperate Climates Presenting as Suspected Septic Arthritis of the Hip

BACKGROUND

In nations with temperate climates, primary polymyositis is a rare, life-threatening bacterial infection that can mimic various clinical diseases depending on the area involved, leading to delayed diagnosis and management.

CASE REPORT

We describe a young postpartum woman who presented to the emergency department with hip pain that was initially suspected to be caused by septic arthritis. However, hip arthrocentesis was negative, and a magnetic resonance imaging scan revealed extensive pyomyositis of the gluteal muscles. She underwent surgical debridement and was given parenteral antibiotics with good clinical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We emphasize that cases of pyomyositis in temperate countries are often diagnosed late and therefore delay life- and potentially limb-saving treatment. For patients who present with hip and thigh pain and clinical features of sepsis, pyomyositis should be considered in the differential diagnosis and an early magnetic resonance imaging scan should be performed to confirm the diagnosis and reduce the high morbidity and mortality associated with this emerging disease.

Imaging: seeing muscle in new ways

PURPOSE OF REVIEW

The idiopathic inflammatory myopathies are diseases that can be difficult to diagnose and evaluate, but diagnosis has been improved by modern imaging techniques. Advances in imaging continue to be made. Therefore, it is necessary to evaluate the implications of these advances for the diagnosis, understanding, and management of muscle diseases.

RECENT FINDINGS

There have been advances in imaging across multiple modalities. Several new radiotracers show an improved ability to focus on inflammation better than older agents. Magnetic resonance spectroscopy has shown the ability to diagnose several idiopathic inflammatory myopathy mimics. MRI reveals previously unknown areas of disease when used for full-body imaging. Ultrasound has the ability to differentiate inclusion body myositis from other myopathies.

SUMMARY

Currently, MRI and ultrasound offer the most information about these diseases in a given patient, and new advances in these fields have served to only make them more useful. New advances in nuclear imaging and magnetic resonance spectroscopy are showing that they have utility as well, and advances in these techniques may allow them to come to the forefront in evaluating difficult idiopathic inflammatory myopathy patients.

Ultrasound for the diagnosis of infectious diseases: Approach to the patient at point of care and at secondary level

Bedside ultrasound evaluation for infection can be performed promptly at the bedside, using simple equipment and without irradiation. Visualization of the foci often enables prompt antimicrobial therapy and even early ultrasound-guided procedure, facilitating earlier confirmation. These procedures are made safer using the real-time visual control that ultrasound provides. Future challenges for an infectious diseases specialist include gaining experience about the appropriate use of point-of-care ultrasound (POCUS). Ultrasonography training is required to ensure competent use of this technology.

Ultrasound-guided diagnosis and aspiration of subdeltoid abscess from heroin injection

A 49-year-old man presented to the emergency department (ED) with shoulder pain after intramuscular injection of heroin into his right deltoid muscle. Point-of-care (POC) ultrasound identified a subdeltoid abscess, and ultrasound-guided aspiration of the fluid collection was performed. The patient was admitted and improved on antibiotics and made a complete recovery. POC ultrasound and ultrasound-guided aspiration can assist in the diagnosis and treatment of deep musculoskeletal abscesses.