A Case of Pyomyositis

Prof.Dr.P.Vijayaraghavan’s unit.Dr.A.Vijayalakshmi.

A CASE OF PYOMYOSITIS

Mr.Vijayakumar. 36years. Admitted with complaints of fever for 15 days.Generalized body pain for 10 days.Tiredness and fatiguability for 10 days.History of present illness

A known case of IDDM, secondary to chronic calculus pancreatitis on insulin therapy for the past 2 ½ yrs.

Was admitted with fever 15 days, intermittent, no chills and rigor.

No vomiting, headache, throat pain, cough with expectoration, pain abdomen and burning micturition.

Past history. No h/o T.B., Asthma ,Epilepsy and Hypertension.

Personal history.Consuming alcohol for 20 years,

Smoking cigarettes, married, Has two children.

Family history.Nil relevant.

GENERAL EXAMINATIONConscious, Oriented. Febrile.NO cyanosis, clubbing, icterus, No

generalized lymphadenopathy. Bed sores present in the sacral region.Pulse :98/min.BP:100/70mm of Hg.

Cardiovascular examinationS1,S2 heard. No murmur.Respiratory examinationNormal vesicular breath sounds heard.Abdomen examinationSoft, no organomegaly.Central nervous system examinationNo focal neurological deficit.

INVESTIGATIONSCBC: Hb-10 gm PCV- 33%WBC:22000/cu.mm.DC:- P87% E4% L9%Sugar 406mg urea 44mg

creatinine 0.4mgLFTTotal bilirubin 1.6mg/dlDirect 1.2AST39 ALT22

CGT68

SAP 388Total protein 5.3 Alb 2

Globulin 2.3ElectrolytesNa 134 K3.99 Cl 84.4HIV, HBsAg,AntiHCV are negative.Urine routine normal.Fever profile negative except Blood

culture sensitivity.

Blood culture sensitivity: Staphylococcus aureus grown in culture.

Peripheral smear; Microcytic hypochromic anemia. With

leucocytosis with neutrophilia.Serum CPK 33u/lCardiac evaluation Normal LV function. No regional valve motion abnormality.Pus culture sensitivity: Staphylococcus

aureus grown in culture.

Problems;1.IDDM.2.Bed sores. 3.Multiple abscess in the muscles.Probable diagnosis: Tropical

pyomyositis due to Staphylococcus aureus. .

TREATMENTIncision and drainage of the abscess done

followed thatPatient was given one course of inj.cloxacillin 500

mg I.V. 3 times.After pus culture and blood culture sensitivity

results Inj. Vancomycin 1G 12th hourly started and was

given for 2 weeks .Patient was better .He was able to walk and was

given fresh blood transfusion to improve his general condition.

Patient was discharged at request as he want to continue his treatment nearby Govt. hospital to his home.

DIFERENTIAL DIAGNOSIS FOR MULTIPLE ABSCESS

1.Streptococcal septicemia.2.Anaerobic bacterial infections.3.Staphylococcus aureus infections.4.Cat scratch disease.5.Metastatic staph .aureus abscess

syndrome.6.Tuberculosis.7.Pneumonia.8.Melioidosis.9.Glanders disease.

10.Histoplasmosis.11.Tularemia, Plaque(bubonic).12.MRSA Staph.aureus.13.Wegeners granulamatosis.14.Congenital (job syndrome).15.Hidradenitis suppurativa.

DISCUSSIONStaphylococcus aureus infection is part of normal

human flora .25 to 50% healthy persons may be persistently colonized .

The rate of colonization increased among Insulin dependent diabetics,HIV infected patients,Patients undergoing hemodialysis, and individual with skin damage.

This organism is known for its capacity to induce abscess formation at sites of both local and metastatic infections.

This organism may be introduced into tissue as a result of minor abrasions, administration of medication such as insulin or establishment of I.V. access with catheters.

This organism causes skin and soft tissue infections.

It causes pyomyositis presents as fever, pain overlying the involved muscles,and swelling.

Pyomyositis :Staph .aureus is responsible for 95% cases

in tropical areas.Leukocytosis and hypoalbuminemia is

common.

The pyomyositis occurs in three stages.1.First stage :Fever, anorexia, erythema, pain,

tenderness.2.Second stage:Abscess, Arthritis.3.Third stage:Toxic shock syndrome.

Diagnosis:CBC show leukocytosis.Hypoalbuminemia.Sometimes elevated CPK enzyme.U.S.G.Show muscular heterogeneity and purulent

collection.C.T . Heterogenous attenuation and fluid

collection with ring enhancement.

M.R.I. is the definite modality to assess pyomyositis and to determine localization and extent.

TREATMENT OF STPHYLOCOCCUS INFECTIONSFor penicillin sensitive staph. Penicillin is the drug of choice.Penicillin G (4mU 4th hourly).Penicillin resistant cases are treated with Oxacillin, Nafcillin.Dose-2G 4th hourly.First generation cephalosporins can be given.Cefazolin 2g

8th hourly.The carbapenem has excellent activity against methicillin

sensitive strains. Merpenem dose-0.5 to2g(10 to 40 mg/kg) I.V. 8th hourly. Faropenem dose-200 to 300 mg oral 3 times. Imepenem dose-0.5 g I.V. 6th hourly.(max.4gm/day).Vancomycin is the drug of choice for methicillin resistant

strains.

For vancomycin resistant strains chloramphenical,linezolid,minocyclin,quinupristin/dalfopristin,Trimethoprime-sulfamethoxazole can be given.

Flouroquinolones also given for methicillin sensitive strains.(cipro 4oomg 12th hourly,levoflox 5oomg OD).

Among the newer antistaph .agents quinupristin and dalfopristin has bactericidal activities. Can be used for serious staph infections.

7.5mg/kg every 8 to 12 hours.

Linezolid bacteriostatic can be used for skin and soft tissue infections.But its use is restricted to prevent emergence of resistence.

Linezolid dose-600mg BD oral.Tigecyclin a broad spectrum minocyclin

analogue has bacteriostatic activity for soft tissue infections and for abdominal infections.

So the choice of empirical treatment depends on susceptibility data for the local geographic area.

However Vancomycin 1gm 12th hourly(in combination with an aminoglycoside or rifampicin for serious infection ) is the drug of choice for both community as well as hospital acquired Staph. Infections.

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