Pyomyositis in patients who have the human immunodeficiency virus. Case report and review of the literature

Staphylococcus aureus-Associated Musculoskeletal Infections

Musculoskeletal infections caused by Staphylococcus aureus are among the most difficult-to-treat infections. S. aureus osteomyelitis is associated with a tremendous disease burden through potential for long-term relapses and functional deficits. Although considerable advances have been achieved in diagnosis and treatment of osteomyelitis, the management remains challenging and impact on quality of life is still enormous. S. aureus acute arthritis is relatively seldom in general population, but the incidence is considerably higher in patients with predisposing conditions, particularly those with rheumatoid arthritis. Rapidly destructive course with high mortality and disability rates makes urgent diagnosis and treatment of acute arthritis essential. S. aureus pyomyositis is a common disease in tropical countries, but it is very seldom in temperate regions. Nevertheless, the cases have been increasingly reported also in non-tropical countries, and the physicians should be able to timely recognize this uncommon condition and initiate appropriate treatment. The optimal management of S. aureus-associated musculoskeletal infections requires a strong interdisciplinary collaboration between all involved specialists.

High Prevalence of Malnutrition among the Above Thirteen with Primary Pyomyositis in Northern Uganda

Aim

To determine the prevalence of malnutrition and its association with primary pyomyositis among patients and controls who were age and sex matched.

Study Design and Setting

A case-control study was conducted at Gulu Regional, Lacor, Kalongo, Kitgum and St. Joseph’s Hospitals in Northern Uganda.

Study Duration

Study was conducted from September 2011 to November 2013.

Methods

Primary pyomyositis patients were consecutively recruited to these Hospitals and were age and sex-matched with controls selected during the same period. History, physical examinations, Body Mass Index (BMI), blood samples for haematology, biochemistry, clinical chemistry and muscle biopsy for histology were obtained. Those that did not meet the inclusion criteria were excluded. The study was approved by the Ethics and Review Committee of Gulu University Medical School.

Results

During the study period, 63 patients and 63 controls were recruited; 29 females and 34 males. Among primary pyomyositis patients, 59 (93.7%) had malnutrition while there were 2 in the control group, giving a prevalence of 3.2%.The matched analysis produced an aOR of 449.875 with a 95% CI (79.382, 2549.540; p<0.001) for malnutrition. Among the cases, 16 (25.4%) fulfilled the Clinical Case Definition (CCD) for AIDS, compared to 2 (3.2%) among the controls. The adjusted Odds ratio for the difference in fulfilling the CCD for AIDS between cases and controls was statistically significant aOR of 10.383 with a 95% CI (2.275, 47.397; p<0.001).

Conclusion

Primary pyomyositis is a common health problem in Northern Uganda. It is evident that malnutrition is the most common risk factor in Primary pyomyositis especially among the above thirteen year olds in Northern Uganda.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

A 31-year-old female with fever and back pain

Primary pyomyositis is a suppurative infection of striated muscle, the diagnosis of which is overlooked or delayed due to its rarity and vague clinical presentation. Though rare in the United States and temperate zones, pyomyositis is more frequently reported from tropical countries. The exact pathogenesis of pyomyositis is uncertain in most cases. The disease progresses through three stages with characteristic features and require a high index of suspicion to institute stage-wise treatment. Newer imaging methods, particularly magnetic resonance imaging, have facilitated the accurate diagnosis of the infection and of the extent of involvement. Early recognition with appropriate antibiotics in the pre-suppurative stage and prompt surgical intervention in the late stages form the corner stone of treatment. Delay in diagnosis can result in increased morbidity and mortality, especially in diabetics and immunocompromised state. Here, we report a case of primary paraspinal pyomyositis in a middle-aged female and emphasize the importance of early diagnosis and treatment.

Imaging of musculoskeletal soft tissue infections

Prompt and appropriate imaging work-up of the various musculoskeletal soft tissue infections aids early diagnosis and treatment and decreases the risk of complications resulting from misdiagnosis or delayed diagnosis. The signs and symptoms of musculoskeletal soft tissue infections can be nonspecific, making it clinically difficult to distinguish between disease processes and the extent of disease. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of soft tissue infections. Computed tomography (CT), ultrasound, radiography and nuclear medicine studies are considered ancillary. This manuscript illustrates representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. The imaging approach described in the manuscript is based on relevant literature and authors' personal experience and everyday practice.

Primary pyomyositis of the paraspinal muscles: a case report and literature review

A case of non-tropical pyomyositis in a healthy, adolescent, 13-year-old boy, affecting the paraspinal muscles is presented. Computerised axial tomography scan (CT scan) of the spine provided valuable information on the nature, extent of the disease and helped to plan successful surgical management. None of the reported cases of such severity of paraspinal pyomyositis had involvement of quadratus lumborum muscle or compression on retroperitoneal organ as in our case.

Timed Gait test: normative data for the assessment of the AIDS dementia complex

The Timed Gait test is a standardized procedure assessing motor dysfunction of lower extremities and gait abnormalities associated with AIDS dementia complex. Heretofore, interpretations of Timed Gait results have been hampered by the lack of normative data. We provide results on this test derived from 1,549 subjects (HIV-seronegatives (HIV-) and seropositives (HIV+) classified according to ADC stage). Timed Gait was found to be a useful screening and assessment tool for evaluating ADC and correlated with clinical ADC staging as well as more extensive structured neurological and neuropsychological evaluations. Analysis of covariance results (with age and education as covariates) revealed symptomatic HIV+(SX) and AIDS groups having significantly slower Timed Gait scores than those in the HIV- and asymptomatic HIV+(ASX) groups. The SX group obtained significantly slower timed gait scores than those in the AIDS group. There was a significant increase in Timed Gait scores with each increase in dementia staging with the HIV- subjects having the fastest mean Timed Gait scores and the HIV+ dementia stage 2+ having the slowest. These normative data should prove useful in both recognition of ADC and treatment response. Given its minimal training requirements, the Timed Gait would have utility in resource limited settings.

MR Imaging of Hip Infection and Inflammation

With its superior anatomical resolution and high sensitivity in depicting pathological processes of the joint, bone marrow and surrounding soft tissue structures, MR imaging is the ideal modality for demonstrating the manifestations and sequelae of the infective and inflammatory conditions common to the hip. Though the imaging features of these conditions may overlap, combining the clinical history and results and other imaging modalities yields a higher degree of specificity, ultimately enhancing the confidence of the radiological interpretation.

Nontropical Pyomyositis in an Immunocompetent Host

Pyomyositis is a primary infection of the striated muscle. We describe the clinical and imaging features of 2 cases with nontropical pyomyositis in immunocompetent hosts. Staphylococcus aureus was the causative agent; the treatment included antibiotics and either computed tomography or magnetic resonance-guided percutaneous needle drainage, avoiding open drainage. This treatment modality was successful with complete recovery of movement. Because of the rarity of pyomyositis in temperate climates, the common lack of specific signs or symptoms, and the frequent negative blood cultures, considerable delay precedes the diagnosis. Fever, elevated erythrocyte sedimentation rate, and muscle stiffness are diagnostic clues. Increased awareness, especially in immunocompetent hosts, should lead to earlier diagnosis and treatment with improved outcomes. Diagnosis and treatment can be reached at the same time in some cases by image-guided percutaneous drainage.

Bacterial pyomyositis in the United States

The incidence of reported bacterial pyomyositis is increasing in the United States, especially among immunocompromised persons. This review summarizes all reported cases of pyomyositis among human immunodeficiency virus (HIV)-infected persons worldwide and HIV-negative persons in the United States since 1981. During the era of combination antiretroviral therapy, bacterial pyomyositis among HIV-infected persons typically occurred in those with end-stage acquired immunodeficiency syndrome. Among non-HIV-infected patients, about half have a serious underlying medical problem, most commonly diabetes mellitus, malignancy, or a rheumatologic condition. These patients are more likely to have a gram-negative infection, a normal white blood cell count, multifocal involvement, or higher mortality than those without an underlying medical condition. The characteristics of cases in temperate areas are similar to tropical cases, except that the former occurs more often in immunocompromised persons; this may change with the HIV epidemic in tropical regions.

Bacterial pyomyositis

Bacterial pyomyositis has been defined as a subacute, deep bacterial infection of the soft tissues. The entity was originally described only in tropical climates, but it is increasing in incidence in temperate climates, such as in the United States. This is mainly attributed to the presence of immunocompromising states such as HIV/AIDS or liver disease. The etiology of pyomyositis remains a mystery, but its characteristics are well-described. If untreated, the disease process progresses through three distinct stages. The first stage is defined by vague complaints, muscle pain, and a low-grade fever. The second stage presents as worsening pain, swelling, fever, and actual abscess formation in the muscle. If the patient remains untreated, pyomyositis progresses to the third stage, which includes septicemia and possible septic shock. Large muscles around the pelvis are most commonly affected, and Staphylococcus aureus is the bacteria seen in most documented cases. To make a timely diagnosis and prevent serious sequelae, physical examination, laboratory results, imaging studies, and a high clinical suspicion must all be combined. Magnetic resonance imaging is the diagnostic study of choice, but it may be inconclusive early in the disease process. Definitive diagnosis must be made with aspiration or surgical drainage. Once diagnosed, treatment consists of appropriate intravenous antibiotics and possible surgical intervention. A full recovery is expected if appropriate treatment is initiated early in the process.

Tropical pyomyositis (myositis tropicans): current perspective

Tropical pyomyositis, a disease often seen in tropical countries, is characterised by suppuration within skeletal muscles, manifesting as single or multiple abscesses. The most common organism implicated is Staphylococcus aureus. In 20%-50% of cases there is a history of trauma to the affected muscles. Commonly involved muscles are quadriceps, glutei, pectoralis major, serratus anterior, biceps, iliopsoas, gastrocnemius, abdominal and spinal muscles. Early diagnosis is often missed because of lack of specific signs, unfamiliarity with the disease, atypical manifestations, and a wide range of differential diagnosis. Diagnostic techniques like ultrasound and computed tomography/magnetic resonance imaging are very useful in diagnosis. The diagnosis is confirmed either by biopsy or aspiration of pus from the affected muscles. The initial antibiotic of choice is cloxacillin. Incision and drainage are important components of management. Treatment for Gram negative or anaerobic organisms should be instituted, whenever indicated. Physicians should become more familiar with this potentially life threatening but curable infective disease entity.

Musculoskeletal manifestations of human immunodeficiency virus infection

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) are common and are sometimes the initial presentation of the disease. Knowledge of the conditions affecting muscle, bone, and joints in HIV-infected patients is essential for successful management. Myopathies may be caused by pyogenic infection (eg, pyomyositis), idiopathic inflammation (eg, polymyositis), or drug effect (eg, AZT myopathy). Characteristic skeletal infections, such as tuberculosis and bacillary angiomatosis, require a high index of suspicion for accurate diagnosis. Neoplastic processes, such as non-Hodgkin's lymphoma and Kaposi's sarcoma, occur more frequently as the immune system deteriorates. Inflammatory and reactive arthropathies are more prevalent in HIV-positive than HIV-negative individuals and include Reiter's syndrome, psoriatic arthritis, HIV-associated arthritis, painful articular syndrome, acute symmetric polyarthritis, and hypertrophic osteoarthropathy. Patients with atypical musculoskeletal complaints and a suspected history of exposure should be tested for HIV.

Magnetic resonance imaging of congenital, inflammatory, and infectious soft-tissue lesions in children

Magnetic resonance imaging has the advantages of multiplanar capability and high degree of tissue differentiation. It is useful for assessing the extent of soft-tissue abnormalities, such as vascular malformations, inflammatory and infectious processes, muscle disorders, and limb hypertrophy. Magnetic resonance imaging is sensitive to the presence of water and edema and is a good indicator for early diagnosis of inflammation and its level of activity. Fat-saturation techniques, including T2-weighted sequences and inversion recovery imaging, optimize diagnostic accuracy. T1-weighted images are good at defining the distribution and proportion of fat in the body, so they are useful in evaluating syndromes of the limbs, including vascular malformations, as well as lipoatrophy-lipodystrophy conditions. Magnetic resonance imaging provides guidance for efficient tissue biopsy. It allows comprehensive pretherapeutic assessment of soft-tissue vascular anomalies. It constitutes a good modality for following up the natural history of soft-tissue disorders during childhood.

Imaging of musculoskeletal infections

Imaging studies play a critical role in the diagnosis and management of musculoskeletal infections in children. Conventional radiography is usually the first imaging study performed with other imaging modalities as needed. Ultrasound is helpful in detecting joint effusions and fluid collections in the soft tissue and subperiosteal regions, and may guide localization for aspiration or drainage. CT can demonstrate osseous and soft tissue abnormalities and is ideal for detecting gas in soft tissues. Nuclear scintigraphy and MR imaging are valuable because of their high sensitivity. Scintigraphy is particularly useful in identifying multifocal involvement, which is an important consideration in neonatal osteomyelitis and CRMO. MR imaging provides accurate information on both the soft tissues and bones and is our imaging study of choice for evaluating the local extent of musculoskeletal infections.

Unusual case of septic arthritis of the hip: spread from adjacent adductor pyomyositis

Distinguishing intracapsular and extracapsular hip infections may be clinically difficult. Because of this difficulty in diagnosis, the spread of an extracapsular infection into the hip joint may be missed and lead to significant joint destruction. The case of a patient who suffered from the spread of adductor pyomyositis to the hip joint is reported. The delay in diagnosis of an intracapsular hip infection led to significant intra-articular destruction and ultimately necessitated a Girdlestone resection arthroplasty. The patient's hip function was salvaged with a total hip arthroplasty. The presence of an extracapsular hip infection should mandate serial physical examinations and aggressive evaluation to rule out intracapsular spread. A delay in diagnosis of an intracapsular hip infection can lead to catastrophic results.

MRI of tuberculous pyomyositis

PURPOSE

The purpose of this article is to describe the findings of MRI in tuberculous pyomyositis (PM).

METHOD

The MR images of four proven cases of tuberculous PM were retrospectively reviewed and analyzed with clinical and laboratory findings. The location, signal intensity on T1- and T2-weighted spin echo images, presence of abscess, signal intensity of peripheral rim, patterns of contrast enhancement, and associated findings were evaluated.

RESULTS

On MR images, all cases demonstrated low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in a single muscle. Abscess was seen in all cases. Peripheral rim showed subtle hyperintensity on T1-weighted images and hypointensity on T2-weighted images. After gadolinium infusion, peripheral rim enhancement was observed in all cases. Cellulitis was associated in one case. The patients clinically presented with a palpable mass of long duration.

CONCLUSION

Tuberculous PM shows characteristic findings of a well demarcated abscess with rim enhancement at MRI and can be distinguished from other soft tissue masses.

Upper-extremity infections in patients seropositive for human immunodeficiency virus

The records of 74 human immunodeficiency virus (HIV)-seropositive patients who were treated for upper-extremity infections were retrospectively reviewed. Intravenous drug use was the most common risk factor for HIV infection as well as the most common cause of the infection necessitating admission. These patients were admitted a total of 97 times for the treatment of 89 different infections and underwent 120 surgical procedures. Twenty-six infections (29%) required more than 1 operation, and 11 (12%) resulted in amputation. Twenty-seven patients who met criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS) were found to be no more likely than their HIV-seropositive counterparts to be readmitted for the same diagnosis, to be treated for more than 1 infection, or to require more than 1 operation or amputation to eradicate their infection. Patients with AIDS were significantly more likely to present with spontaneous onset of infection in the absence of penetrating injury than were those who were HIV seropositive.

A case of muscle abscess presenting to an accident and emergency department

A case is reported of a patient with acute primary muscle abscess who presented to the accident and emergency department with hip pain. Pyomyositis must be considered as a cause of muscle pain especially around the hip. A brief discussion of the diagnosis and management of pyomyositis is also presented.

Infectious myositis. A tropical disease steals out of its zone

Infectious myositis is an acute infection of skeletal muscle that is increasing in prevalence with the increased incidence of HIV disease. Typical presentation is asymmetric swelling of an isolated muscle, with exquisite pain and fever. Results of laboratory studies are usually nonspecific, but magnetic resonance imaging of the affected area suggests the diagnosis. Muscle biopsy and direct identification of the pathogen on tissue culture are required, because the list of potential pathogens is long. With prompt treatment, most patients achieve complete resolution and return to their preinfection level of health.

Bacterial infections: pyomyositis

Staphylococcal pyomyositis is an important and common condition in many areas in the tropics. The cause is probably multifactorial and includes damage to the skeletal muscle in the presence of staphylococcal bacteraemia, with or without depressed immunity. In Africa, there are indications of an increased prevalence in association with HIV infection in young adults in whom multiple and recurrent abscesses are common. Long bone osteomyelitis is an important differential diagnosis in these patients. Timely surgical drainage and antibiotics leads to resolution. Delayed diagnosis is associated with disseminated disease and septic cardiorespiratory complications.