Internal obturator muscle abscess caused by Klebsiella pneumoniae

Invasive Hypervirulent Klebsiella pneumoniae Syndrome Originating from an Anorectal Abscess as Opposed to a Pyogenic Liver Abscess

An immunocompetent 49-year-old man presented with swelling and pain in the lower region of his left leg that had lasted for 4 weeks. The diagnosis was severe pyomyositis and osteomyelitis in the lower left leg caused by hypervirulent Klebsiella pneumoniae (hvKP) along with multiple metastatic infections in the kidneys, lungs, and brain originating from an anorectal abscess. A virulence-gene analysis revealed that the isolated K. pneumoniae harbored rmpA, entB, ybtS, kfu, iutA, mrkD, and allS-virulence genes and belonged to the K1 capsular serotype. After repeated abscess drainage procedures, intravenous ceftriaxone was administered for more than 10 weeks, and the patient's infection was controlled. We focused on the clinical features of hvKP originating from an anorectal abscess without a pyogenic liver abscess. We suggest that hvKP be considered a causative pathogen of pyomyositis and osteomyelitis resulting in multiple metastatic infections in an immunocompetent patient, and more information on the unexpected multiple metastatic infections should be obtained from a virulence analysis of K. pneumoniae.

Obturator internus and externus muscle abscess caused by methicillin-resistant Staphylococcus aureus in a 6-year-old boy: A case report

Obturator abscess is a rare condition in children which usually occurs commonly in tropical countries. Because of its rarity, vague symptomatology and a lack of focus about this condition, the diagnosis of obturator abscess is commonly delayed or missed. Hence, physicians should be familiar with this condition and have a high index of suspicion when a patient presents with fever, pain in the thigh, hip or abdomen and a limp on the affected side which are considered as the classic clinical triad of obturator abscess. Herein, we present a 6-year-old previously healthy Russian boy who was on holiday in Sri Lanka. He presented on the third day of the fever associated with pain in the right thigh and abdomen. This is the first reported case of an obturator externus muscle abscess due to methicillin-resistant Staphylococcus aureus in a European boy visiting a tropical country.

Combined approach for intrapelvic abscess drainage among adults

Obturator internus muscle (OIM) and adductor brevis (AB) abscess occurs rarely in adults. This condition mainly affects children experiencing trauma. This paper presents and discusses a unique case of OIM and AB abscess in an adult male that was treated operatively with a combined surgical approach (modified Stoppa and Smith-Peterson) after multiple failed drainage procedures.

Case

A 23-year-old male underwent reduction and fixation of his right tibiae shaft fracture with an intramedullary nail. After several referrals to the emergency room due to recurrent symptoms of fever and groin pain, he was finally admitted and diagnosed with OIM and AB abscess and fulminant MRSA sepsis. The operative treatment was performed by addressing the abscess with an unusual combined surgical approach (Smith-Peterson and modified Stoppa) for abscess drainage.

Methods

Using PubMed, Google scholar and Hadassah Hebrew University search engines, we conducted a literature search using the following keywords: ‘pyomyositis’, ‘obturator abscess’, ‘pelvic abscess’, and ‘pelvic osteomyelitis among children and adults’. Twenty case studies were found (14 children and 6 adults). No cases of combined OIM and AB abscess were found and only one OIM case was reported with methicillin-resistant Staphylococcus (MRSA).

Obturator internus muscle abscess caused by methicillin-resistant Staphylococcus aureus in an adult: A case report

INTRODUCTION

Obturator internus muscle (OIM) abscess is a rare condition, usually affecting children after trauma or muscular effort. Blood cultures always yield positive findings, with Staphylococcus aureus being the most common culprit. There are few reports in adults.

PRESENTATION OF CASE

We report a case of OIM abscess in an adult. A 24-year-old male was admitted to our hospital because of right hip pain and fever. He was diagnosed with OIM abscess, and methicillin-resistant Staphylococcus aureus (MRSA) was detected on bacterial examination. The patient was successfully treated with a surgical drainage procedure and antibiotics.

DISCUSSION

There are only five reported cases of OIM abscess in adults. The patient had no history of recent hip trauma, but had intractable acronyx of the right great toe, which was being treated for 2 years. MRSA was also detected from cultures of samples obtained from the toe. A toe infection can lead to bacteremia.

CONCLUSION

In conclusion, we report the first case of OIM abscess in an adult caused by MRSA. Surgical drainage, debridement, and systemic antibiotic treatment were administered, resulting in a successful outcome.

Pyomyositis in a patient with systemic lupus erythaematosus and a review of the literature

Pyomyositis (PM) is a common masquerading disease that is frequently misdiagnosed. A concurrent state of immunodeficiency is observed in up to 75% of tropical PM cases. PM in systemic lupus erythaematosus (SLE) is a relatively rare disease. I report a case of PM that was caused byKlebsiella pneumoniaein a patient with SLE who presented with leg pain, fever and a lupus flare-up. The patient was correctly diagnosed using a CT scan. Immediate surgical drainage was performed, and empirical antibiotics were administered. The patient was discharged while in a recovering condition. The clinical features, the results of radiographic investigations and the management of PM in SLE are synopsised in this article to underscore the importance of considering this relatively rare disease during differential diagnosis in patients with SLE with muscle pain with or without fever. I also emphasise the need to exclude mycobacterial infection in patients with SLE with PM.

Primary obturator-muscle pyomyositis in immunocompetent children

PURPOSE

Primary pyomyositis in immunocompetent children in non-tropical regions (countries with temperate climates) is very uncommon. It is rarely found in the intrapelvic muscles, and even more rarely in the obturator muscles. We try to draw attention to the potential occurrence in these conditions.

METHODS

Five new cases of primary obturator-muscle pyomyositis in immunocompetent children aged between 6 and 11 years in a temperate climate are presented. They present with symptoms as follows: fever, pain (thigh, abdominal, inguinal, and/or hip pain), and limp. Three of them had no hip movement limitation. All of them had tenderness in the perineum zone.

RESULTS

Laboratory tests may reveal high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) counts, but depend on the length of diagnostic delay. The evolution time oscillated from 1 to 5 days. Fever and limp disappearance depends on the evolution time previous to the onset of the antibiotics administration. In 4 out of 5 patients, Staphylococcus aureus was present in the blood cultures. In all cases of obturator-muscle pyomyositis, diagnosis was confirmed using computed tomography (CT) scan (one) and/or magnetic resonance imaging (MRI) (four).

CONCLUSIONS

Obturator-muscle pyomyositis is aimed at emphasizing the diagnostic difficulties associated with the condition, due to its deep location and to the fact that the disease presents with multiple manifestations that may initially cause confusion, since they mimic other conditions occurring in the abdomen, hip (septic arthritis, osteomyelitis), spine, etc. The diagnosis is only confirmed using CT scan and/or MRI. In the five patients with antibiotics treatment, the condition resolves without sequelae, even at long-term follow-up.

Increased oxacillin resistance in thigh pyomyositis in diabetic patients

Thigh abscesses due to pyomyositis are uncommon. To guide empiric antibiotic therapy in diabetics we determined the rate of such infections due to oxacillin-resistant Staphylococcus aureus and Gram-negative organism infections, and whether the occurrence of oxacillin-resistant pathogens increased during the study period. We retrospectively reviewed 39 adult patients with diabetes mellitus treated for a deep thigh abscess. There were 29 men and 10 women; their mean age was 45 years. Comorbidities were present in 15 patients. S. aureus was the most common pathogen, present in 82% (32/39) of our patients. Gram-negative organisms were cultured in 14% (6/39) of patients and anaerobes in 10% (4/39). The infection was polymicrobial in 12 of 39 patients (31%). Oxacillin-resistant S. aureus comprised 25% (8/32) of infections due to S. aureus. Oxacillin-resistance increased during the last 3 years of this study from one of 18 S. aureus isolates from 1994 to 2004 to seven of 14 isolates from 2004 to 2006. In diabetic patients with thigh pyomyositis, empiric antibiotic therapy should provide broad spectrum coverage for oxacillin-resistant S. aureus, Gram-negative, as well as anaerobic organisms.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.