Pneumococcal pyomyositis: report of 2 cases and review of the literature

Invasive pneumococcal disease serotype 23B1 causing multifocal septic arthritis, myositis and retroperitoneal abscess

We describe a case of a previously healthy unvaccinated man in his 70s who developed penicillin-susceptible bacteraemic invasive pneumococcal disease due to non-vaccine serotype 23B with the unusual manifestations of multifocal myositis, intramuscular abscesses, polyarticular septic arthritis and synovitis. Blood cultures drawn prior to antibiotic therapy and culture of iliopsoas collection were helpful in making the diagnosis. At follow-up, he had persistent hip pain attributed to avascular necrosis of the head of femur, a possible late complication of his pyomyositis.

Streptococcal pyomyositis in asplenia and underlying connective tissue disease

Pyomyositis is an infection of skeletal muscles, commonly affecting deep longitudinal muscles of the lower extremities. Primary pyomyositis is uncommon in the United States. Staphylococcus aureus is the most common cause of pyomyositis, but Streptococcus pneumoniae is the most common cause of life-threatening bacterial infection in asplenic patients. Most cases of S. pneumoniae pyomyositis occur in immunocompromised patients. We describe a 31-year-old man with S. pneumoniae pyomyositis whose diagnosis and hospital course were complicated by an immunocompromised state from asplenia and an underlying connective tissue disease, Stickler syndrome. Underlying connective tissue diseases such as systemic lupus erythematosus and polymyositis can predispose patients to infection, but susceptibility with Stickler syndrome is less known. While pyomyositis is only seen in up to 0.2% of US hospital admissions, it remains a pertinent differential for patients with asplenia and connective tissue disease.

Trismus originating from rare fungal myositis in pterygoid muscles: A case report

BACKGROUND

Trismus is a common problem with various causes. Any abnormal conditions of relevant anatomic structures that disturb the free movement of the jaw might provoke trismus. Trismus has a detrimental effect on the quality of life. The outcome of this abnormality is critically dependent on timely diagnosis and treatment, and it is difficult to identify the true origin in some cases. We present a rare case of trismus due to fungal myositis in the pterygoid muscle, excluding any other possible pathogenesis.

CASE SUMMARY

The patient presented with a 2-mo history of restricted mouth opening. Computed tomography showed obvious enlargement of the left pterygoid muscles. Furthermore, the patient had trismus without obvious predisposing causes. The primary diagnosis was pterygoid myosarcoma. Consequently, lesionectomy of the left pterygoid muscle was performed. Intraoperative frozen biopsy implied the possibility of an uncommon infection. Postoperative pathologic examination confirmed myositis and necrosis in the pterygoid muscle. Fungi were detected in both muscle tissue and surrounding necrotic tissue. The patient recovered well with antifungal therapy and mouth opening exercises. The rarity of fungal myositis may be responsible for the misdiagnosis. Although the origin of pathogenic fungi is still unknown, we believe that both hematogenous spread and local invasion could be the most likely sources. To the best of our knowledge, this is the first case in the literature that reported fungal myositis in pterygoid muscles as the only reason that results in trismus.

CONCLUSION

Surgeons should remain vigilant to the possibility of trismus originating from fungal myositis.

[Inflammatory myopathy following acute meningoccemia in a properdin-deficient patient: A case report]

INTRODUCTION

Myalgia is a classical sign in invasive meningococcal diseases (IMD), but severe and persistent myalgia following an IMD have never been reported to date.

CASE REPORT

A 20-year-old man presented with purpura fulminans and meningitis caused by Neisseria meningitidis serogroup Y, revealing properdin deficiency. Although meningitis symptoms improved after antibiotherapy, initial myalgia of the lower limbs increased, associated with mild rhabdomyolysis. Magnetic resonance imaging (MRI) revealed an increased STIR (Short TI inversion recovery) signal of both quadriceps muscles, without abscess. After exclusion of other causes of myopathy, a post-infectious myositis was diagnosed. A four-week course of corticosteroids led to dramatic improvement.

CONCLUSION

Post-infectious inflammatory myopathy should be suspected in case of severe and persistent myalgia associated with rhabdomyolysis following an IMD, after exclusion of pyomyositis especially. A short course of corticosteroids seems to be effective.

Osteoarticular Infections Caused by Streptococcus pneumoniae in Children in the Post-Pneumococcal Conjugate Vaccine Era

BACKGROUND

Pneumococcal osteoarticular infections (OAIs) are an uncommon manifestation of invasive pneumococcal disease (IPD). We describe the demographic characteristics, hospitalization rate, serotype distribution and antibiotic susceptibility of children with pneumococcal OAI over a 16-year period.

METHODS

We identified patients ≤18 years old with pneumococcal OAI at 8 children's hospitals in the United States (2000-2015). Pneumococcal isolates were collected prospectively. Serotyping and antibiotic susceptibility were performed in a central laboratory.

RESULTS

We identified 97 (3.3%) patients with pneumococcal OAI out of 2943 patients with IPD. Over 60% of the children were <2 years old. Septic arthritis (56.7%, 55/97) was the most common pneumococcal OAI, followed by osteomyelitis (25.8%, 25/97) and septic arthritis with concomitant osteomyelitis (17.5%, 17/97). Hospitalization for pneumococcal OAI overall decreased from 6.8 [95% confidence interval (CI): 5.2-8.6] to 4.4 (95% CI: 3.0-6.3) per 100,000 admissions from 2000-2009 to 2010-2015 (-35%, P = 0.05). Hospitalization for pneumococcal OAI caused by PCV13 serotypes decreased from 4.6 (95% CI: 3.4-6.2) to 0.9 (95% CI: 0.3-1.9) per 100,000 admissions from 2000-2009 to 2010-2015 (-87%, P < 0.0001). Overall, 12% of isolates had a penicillin minimal inhibitory concentration> 2 µg/mL, 3% a ceftriaxone minimal inhibitory concentration> 1 µg/mL and 15% were clindamycin resistant; these proportions remained unchanged after the introduction of PCV13. Serotypes 19A and 35B were responsible for penicillin and ceftriaxone nonsusceptible isolates in 2010-2015.

CONCLUSIONS

Pneumococcal OAI represents 3% of all IPD, affecting mainly healthy infants and young children. Hospitalization for pneumococcal OAI caused by PCV13 serotypes dramatically decreased (-87%) after the introduction of PCV13.

Pyomyositis caused by Streptococcus pneumoniae after allogeneic hematopoietic stem cell transplantation

Pyomyositis is classified into two main types: tropical and non-tropical. Non-tropical pyomyositis occurs among various immunocompromised patients, and Staphylococcus aureus has been reported as the most common pathogen. Pyomyositis caused by Streptococcus pneumoniae is uncommon, and has not been previously reported after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Here, we report a unique case with pyomyositis caused by S. pneumoniae in the bilateral erector spinae muscles 34 months after allo-HSCT. The patient had an initial clinical response following the administration of intravenous benzylpenicillin potassium for 4 weeks. Although S. pneumoniae bacteremia is a rare bacterial infection after HSCT, the possibility of pyomyositis must be considered when a recipient develops S. pneumoniae bacteremia. Accurate diagnosis and the selection of appropriate antibiotics are necessary for the treatment of pyomyositis.

Pneumococcal Pyomyositis of the Neck Muscles

High fever, severe neck pain and neck stiffness can result from meningitis. We report a case of pneumococcal pyomyositis of the neck muscles. A 72-year-old man developed high fever and severe neck pain. His chief complaint mimicked bacterial meningitis. Although his condition was initially suspected to be bacterial meningitis, his cerebrospinal fluid did not show pleocytosis. MRI showed areas of high intensity in the posterior deep neck muscles on short tau inversion recovery (STIR) sequences and gadolinium-enhanced T1-weighted images. Pneumococcal myositis should therefore be included in the differential diagnosis of severe neck pain with fever.

Staphylococcus aureus endocarditis and pyomyositis: Rare complications of rotavirus gastroenteritis

Rotavirus may cause life-threatening complications in untreated patients during the course of gastroenteritis. Electrolyte imbalance, bacteremia and sepsis are the most common complications of rotavirus gastroenteritis (RG). It is believed that translocation of intestinal microorganisms as a result of intestinal epithelium dysfunction is the underlying mechanism of bacteremia in RG. Although Gram-negative bacteremia has been noted as a complication in RG, Staphylococcus aureus bacteremia and endocarditis have not been reported previously. A 22-month-old boy was admitted with complaints of fever, diarrhea and dehydration. He was diagnosed with RG complicated with S. aureus bacteremia, pyomyositis and endocarditis. We call attention to these complications in patients with prolonged or late-onset fever during RG as rare complications of the disease.

[Invasive pneumococcal disease of serotype 6C with skin and soft tissue infections in an immunocompetent adult]

We report herein on a rare case of deep-soft tissue infection due to invasive pneumococcal disease (IPD). A 77-year-old woman was admitted to our hospital with progressive pain in the right upper arm and the distal leg associated with swelling. We diagnosed the condition as multiple instances of cellulitis that were initially treated with ceftriaxone and clindamycin. Penicillin-susceptible Streptococcus pneumoniae (PSSP) was isolated from blood cultures on admission. Although inflammatory marker levels improved following susceptive antibiotic therapy (ampicillin), multiple abscesses, septic arthritis and osteomyelitis were detected with image testing. The antibiotic was then changed to meropenem and arthroscopic surgery was performed for the right shoulder; the patient's clinical symptoms improved. Since pneumococcal infection including skin and soft tissue infection (SSTI) often causes blood stream invasion or metastatic suppurative complications, metastatic lesions or multiple abscesses should be taken care of.