D Belekar, R Verma, A Sangvikar
infection, myositis, pyomyositis, tropical
D Belekar, R Verma, A Sangvikar. A Rare Case of Tropical Myositis. The Internet Journal of Surgery. 2008 Volume 19 Number 2.
Pyomyositis is a primary infection of skeletal muscles usually caused by staphylococcus aureus. This infectious disease is endemic in tropical areas and sporadic in temperate climates. It mainly affects immunocompromised patients like patients with AIDS, leukemia, and diabetes mellitus, etc. The incidence of pyomyositis is increasing worldwide with rise in prevalence of patients infected with HIV virus. The disease is neglected initially due to nonspecific clinical features. Further evolution of disease is usually associated with fever, septic shock and inflammatory involvement of large muscles of the lower extremity. The diagnosis of the responsible agent is established by blood culture and surgical or radio-guided puncture. Treatment includes antibiotics and surgical drainage. Our case showed such a typical presentation of myositis without any pus formation, which responded to standard treatment. We would like to report such a rare case at our institute.
A 30-year-old Hindu male patient residing in Mumbai was admitted for pain in his left thigh for 3 days which was not relieved by standard analgesics. He was admitted in the ICU in a private hospital in view of unrecordable blood pressure. He was treated in that hospital in view of deep venous thrombosis and was then referred to our institute for management of falling blood pressure.
There was no history of any trauma to his left thigh or any fever or any injection given in the left buttock or thigh prior to this. There was also no history of prolonged immobilization. The patient had no other complaints except severe agonizing pain in his left thigh and buttock, which was increasing.
On examination, the patient was a little drowsy but was well oriented in time, place and person. He had no fever. He had tachycardia of 96 beats/min. and a recordable blood pressure. The patient was tachypnoic and abdominal examination was within normal limits.
On local examination, his left thigh was more edematous than the right one and there were no features of redness/tense compartment suggestive of DVT/abscess. The patient’s resuscitation started immediately after his arrival at our institute and he was put on dopamine and adrenaline drip to restore his blood pressure. A broad-spectrum antibiotic was administered along with pain analgesia without any sedatives. He was catherised and his CVP was monitored via jugular access.
After vigorous resuscitation for 48 hours, the patient became hemodynamically slightly better with a blood pressure of more than 70 systolic. Simultaneously an ultrasound was done of thigh, abdomen and pelvis to rule out any abscess or deep venous thrombosis, but it was normal. There was no sign of compartment syndrome, either. The clinical senario was extremely confusing and was not fitting into any standard criteria.
After 48 hours (on the 3rd day), a small incision was made over his left thigh after checking his coagulation profile which was within normal limits. It was done for ~5cm under local anesthesia and the findings were very rare. There was only edematous fluid within without muscle edema and no pus pocket. The patient was relieved of his pain and his blood pressure became 110 systolic after 24 hours.
Edema fluid was sent for routine microscopy and culture sensitivity but it showed no organisms. A diagnosis of tropical myositis with superficial necrotizing gangrene of skin was made after review of the literarure.
The patient required repeated wound debridement. After the wound became healthy, the patient underwent SSG under spinal anesthesia. Graft take was 85% on 1st wound check. The patient was discharged after two weeks when the wound was well covered with graft. Now, after 2 years, the patient is totally disease-free, asymptomatic and settled completely.
Pyomyositis, both in the tropics and in non-tropical countries, is strikingly associated with immunocompromised status like HIV infection, leukemia or diabetes mellitus. The prevalence of myositis is increasing with rise in patients infected with HIV. It is especially high with patients with CD4 count of <150/cc.
Our case showed all features of classical myositis without any pus formation (that is pyomyositis). Simple myositis causing a severe shock is quite rare. In our case, after stabilizing the patient and controlling local infection, the wound was ready for split-thickness skin graft (SSG). We followed standard measures of “wound cover”.
Dr. Dnyanesh M. Belekar, Associate Professor of Surgery, Department of General Surgery, K J Somaiya Medical College, Sion, Mumbai - 22. Contact - +91-9820055482. E-mail – email@example.com