Streptococcal myositis

Necrotizing myositis case report and brief literature study

Necrotizing myositis is an extremely rare soft tissue infection, mainly caused by Group A Streptococci. Although its presentation is nonspecific and seems harmless, it quickly leads to death in almost all cases. Therefore, diagnosis and treatment of necrotizing myositis are considered as medical emergencies. The 27 years old patient we report benefited from early diagnosis and care. Necrotic tissues were surgically removed 24 hours after the appearance of the first clinical signs. Intravenous antibiotherapy as well as immunoglobulin therapy were also given on the first day. Starting from this clinical case, we present a brief explanation of the pathogenesis, the key clinical features and appropriate tools for diagnosis. Then, adequate antibiotherapy, role of immunoglobulin therapy and interest of hyperbaric oxygenotherapy will be discussed.

Bromine, bear-claw scratch fasciotomies, and the Eagle effect: management of group A streptococcal necrotising fasciitis and its association with trauma

Necrotising fasciitis is a rare, but potentially fatal, soft-tissue infection. Historical depictions of the disease have been described since classical times and were mainly recorded in wartime reports of battle injuries. Although several different species of bacteria can cause necrotising fasciitis, perhaps the most widely known is group A streptococcus (GAS). Infection control, early surgical debridement, and antibiotic therapy are now the central tenets of the clinical management of necrotising fasciitis; these treatment approaches all originate from those used in wars in the past 150 years. We review reports from the 19th century, early 20th century, and mid-20th century onwards to show how the management of necrotising fasciitis has progressed in parallel with prevailing scientific thought and medical practice. Historically, necrotising fasciitis has often, but not exclusively, been associated with penetrating trauma. However, along with a worldwide increase in invasive GAS disease, recent reports have cited cases of necrotising fasciitis following non-combat-related injuries or in the absence of antecedent events. We also investigate the specific association between GAS necrotising fasciitis and trauma. In the 21st century, molecular biology has improved our understanding of GAS pathogenesis, but has not yet affected attributable mortality.

Necrotizing streptococcal myositis of an extremity: a rare case report

Necrotizing myositis is a severe and very rare streptococcal soft tissue infection involving the superficial fascia and muscle. Its clinical symptoms are nonspecific until the appearance of a fulminant clinical course with soft tissue destruction and septic shock. A high mortality and morbidity rate has been reported in the few cases over the last century. Despite several attempts to better define the different entities causing this necrotizing soft tissue infection, no clear treatment has been outlined. We present the case of a 47-year-old woman who had an acute necrotizing myositis after a stab wound. The diagnosis of necrotizing myositis was only established after surgical treatment with a pathology report. We reviewed the literature to highlight the clinical difficulty of a preoperative diagnosis and surgical treatment.

Review of compartment syndrome due to group A streptococcal infection

PURPOSE

To present a case of nontraumatic compartment syndrome secondary to group A streptococcal infection and review the literature regarding this unusual clinical entity.

METHODS

Case reports of compartment syndrome due to group A streptococci in the English language literature were identified through a computer-generated search using MEDLINE 1950-2007. Reviews of the cited literature in pertinent articles were also undertaken to find additional cases. Cases with evidence of chronic infection or trauma were excluded; cases were included for analysis if enough demographic information was available to allow identification of individual patients.

RESULTS

Thirteen cases, including the current case of group A streptococcus, were identified. The average age was 34 years (range 2-76). The majority of patients (77%) were previously healthy with no significant medical history or evidence of immunosuppression. All patients presented with either fever, or hypotension, or white blood cells >10,000 cells/mm and 77% presented with at least 2 of these signs. All patients received prompt surgical intervention and antibiotic therapy with gram-positive activity. The mortality rate was 15%.

CONCLUSIONS

Nontraumatic acute compartment syndrome presenting with fever, or hypotension, or leukocytosis may be associated with infection such as group A streptococcus. Prompt surgical and antibiotic therapy was associated with a relatively low mortality rate. A high clinical index of suspicion should occur for the possibility of infection with an organism such as group A streptococcus in patients presenting with acute extremity pain and tense compartments without trauma and with signs of a systemic inflammatory response.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

Surviving streptococcal toxic shock syndrome: a case report

Streptococcal toxic shock syndrome and associated myositis caused by group A beta-hemolytic streptococcus pyogenes generally have a poor outcome despite aggressive operative treatment. Frequently the diagnosis is missed initially as the clinical features are non-specific. The progression to a toxic state is rapid and unless definitive treatment measures are initiated early, the end result can be catastrophic. We report a previously healthy patient who had features of toxic shock syndrome due to alpha haemolytic (viridans) streptococcus mitis which was treated successfully with antibiotics, aggressive intensive care support including the use of a 'sepsis care bundle', monitoring and continuous multidisciplinary review. Life and limb threatening emergencies due to streptococcus mitis in an immune-competent person are rare and to our knowledge, have not previously been described in the English scientific literature. Successful outcome is possible provided a high degree of suspicion is maintained and the patient is intensively monitored.

Infection and musculoskeletal conditions: Infectious myositis

Infectious myositis, an infection of the skeletal muscle(s), is uncommon. This clinical entity may be caused by viral, bacterial, fungal, and parasitic pathogens. Viral etiologies typically cause diffuse myalgias and/or myositis, whereas bacteria and fungi usually lead to a local myositis which may be associated with sites compromised by trauma or surgery and are more common among immunocompromised patients. Localized collections within the muscles are referred to as pyomyositis. Other pyogenic causes of myositis include gas gangrene, group A streptococcal myonecrosis, and other types of non-clostridial myonecrosis. Early recognition and treatment of these conditions are necessary as they may rapidly become life-threatening.

A 46-year-old man with excruciating shoulder pain

A 46-year-old man with no significant medical history presented to his local emergency department complaining of excruciating right shoulder pain. The patient was in his usual state of excellent health until 4 days prior, when right shoulder pain developed while he was using a chainsaw to cut wood. The next day, flu-like symptoms developed with fevers, chills, and headache. An MRI revealed that the right pectoralis major was torn from its attachment to the acromion. His shoulder pain intensified despite treatment with hydrocodone and acetaminophen, and the flu-like symptoms progressed over the next 2 days. Finally, on the day of hospital admission, he was weak and unable to arise out of bed. He was taken by family members to the local emergency department.

Streptococcal myositis: a lesson

Streptococcal myositis is a rare, often fatal, acute infection of the muscle, caused by an invasive group A beta-haemolytic streptococcus. It is characterised by muscle necrosis without abscess formation, and, in contrast to necrotising fasciitis, does not primarily affect the subcutaneous tissue or skin. A young adult male presented with streptococcal myositis initially affecting the rectus femoris muscle of his left thigh. The symptoms, signs and management are discussed. Particular emphasis is given to the benefits of emergency CT scans to diagnose and delineate the extent of the disease. These scans may need to be repeated if the disease progresses. The four cornerstones of management are: early diagnosis using emergency CT scans; high-dose intravenous antibiotics; early aggressive surgical debridement; and intensive fluid and nutritional support. Published by Elsevier Science Ltd. All rights reserved.

Necrotizing soft tissue infections

Necrotizing soft tissue infections are a group of highly lethal infections that typically occur after trauma or surgery. Many individual infectious entities have been described, but they all have similar pathophysiologies, clinical features, and treatment approaches. The essentials of successful treatment include early diagnosis, aggressive surgical debridement, antibiotics, and supportive intensive treatment unit care. The two commonest pitfalls in management are failure of early diagnosis and inadequate surgical debridement. These life-threatening infections are often mistaken for cellulitis or innocent wound infections, and this is responsible for diagnostic delay. Tissue gas is not a universal finding in necrotizing soft tissue infections. This misconception also contributes to diagnostic errors. Incision and drainage is an inappropriate surgical strategy for necrotizing soft tissue infections; excisional debridement is needed. Hyperbaric oxygen therapy may be useful, but it is not as important as aggressive surgical therapy. Despite advances in antibiotic therapy and intensive treatment unit medicine, the mortality of necrotizing soft tissue infections is still high. This article emphasizes common treatment principles for all of these infections, and reviews some of the more important individual necrotizing soft tissue infectious entities.

Pyomyositis due to non-haemolytic streptococci

We present a unique case of a multifocal non-tropical pyomyositis due to non-haemolytic streptococci in a 36-y-old woman. The initial infection was in an area of contused muscle in the left anterior thigh and spread to the contralateral femoral and gluteal musculature. There was a previous history of Staphylococcus aureus pyomyositis and colitis ulcerosa. The patient was treated successfully with surgical drainage and parenteral antibiotics.

A case of streptococcal myositis (misdiagnosed as hamstring injury)

Streptococcal myositis is a very rare bacterial infection of muscle with a high mortality. Diagnosis is difficult because of the paucity of clinical signs and symptoms at the onset. However, presentation of the disease appears to have changed over the last 50 years. A case of streptococcal myositis is presented (misdiagnosed as hamstring injury), which more closely reflects the current presentation of the disease. Some of the features that may help emergency clinicians to recognise the onset of the condition are highlighted.

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.