A 17-year-old male presented with difficulty breathing and swelling of the right leg for 6-7 days following a fall. Examination revealed respiratory distress and induration of the right thigh. Imaging showed a fluid collection in the right thigh muscle consistent with pyomyositis. He was diagnosed with pyomyositis, bilateral pneumonia, and sepsis. Incision and drainage of the thigh collection was performed and antibiotics were started. The patient developed complications including ankylosis of the right hip joint. He was discharged after 35 days with ongoing physiotherapy.

1. DR FREDA DODD-GLOVER
PS 3
LEG SWELLING and
DIFFICULTY BREATHING – a
differential diagnosis

2. › NAME: B.D
› AGE: 17 years
› PC: Inability to walk – 6/7
Difficulty breathing – 3/7
HISTORY

3. HISTORY OF PC
› A student at a Technical Senior High School . Well until 6/7
prior to presentation. Sustained a fall, landing on his right hip,
while it was raining.
› Reported to Mamprobi Polyclinic a day later(01/06/17) and
diagnosed as case of musculoskeletal pain to rule out fracture
of the right femur.
HISTORY

4. - X rays of the Right femur requested
- Referred to Korle Bu Teaching Hospital (KBTH) for further
management on 01/06/17
› Presented to the Surgical, Medical Emergency(SME) on the
06/06/17
HISTORY

5. › 3/7 prior to presentation started experiencing sudden onset
difficulty in breathing
› Brought into ER at KBTH (4 days after reporting to referring
centre)
HISTORY

6. ON DIRECT QUESTIONING:
POSITIVES:
› First episode of such difficulty breathing, palpitations
› Cough (productive yellowish sputum – 3/7)
› Contact with chronic cough person( in boarding house)
› Drenching night sweats
› Leg pain and swelling (right leg), unable to bear weight
HISTORY

7. ON DIRECT QUESTIONING
NEGATIVES:
› Weight loss
› Haemoptysis
› Orthopnoea, chest pain, dizziness, easy fatiguablility
› Abdominal distension
› Early morning facial puffiness , oliguria
HISTORY

8. PAST MEDICAL HISTORY
› No Asthma , Sickle Cell Disease, DM or hypertension.
› Not previously diagnosed or treated for TB
› No history of malignancy
› No previous medical or surgical admissions
› No blood transfusions
HISTORY

9. DRUG HISTORY:
› IM Diclofenac 75mg stat
› Oral Amoxicillin-clavalunic acid 1g bd
› Oral paracetamol 1g tds
› Oral vitamin c
› No history of herbal medication use
HISTORY

10. FAMILY HISTORY:
› Nil of significance
SOCIAL HISTORY:
› Second year boarding student at Koforidua Secondary
Technical.
› No history of alcohol use or smoking.
› Denied use of illicit drugs in any form (oral, inhaled or injected)
HISTORY

11. 17 year old male.
Presented 6/7 after a fall with right thigh pain and swelling and
3/7 sudden onset difficulty breathing associated with a
productive cough
SUMMARY

12. › Young male, acutely ill-looking
› In respiratory distress. SPO2 – 91% on RA. 97% on INO2 at
6L/min
› Not pale nor jaundiced. Afebrile. Hydration satisfactory
› No digital clubbing, no pedal oedema, no peripheral
lymphadenopathy.
EXAMINATION

13. CARDIOVASCULAR:
› P: 100bpm, rgv. Apex 5LICS MCL
› HS I and II present, normal. No murmurs
› BP: 96/ 54mmHg
› JVP not raised
EXAMINATION

14. RESPIRATORY:
› RR- 44cpm, Flaring alar nasi, Intercostal recession, subcostal
recession
› Trachea central
› Chest expansion equal all lung zones
› TVF reduced right lower zone anteriorly
› Percussion stony-dull right lower zone anteriorly;
› Dull in left lateral, middle and lower zones posteriorly with
crackles.
› Vocal resonance reduced right lower zone anteriorly
EXAMINATION

15. ABDOMEN:
› Flat, moved with respiration
› Mild epigastric tenderness
› Generalised guarding.
› No rebound tenderness
› Liver span 10cm. No spleen or kidneys palpable
› No shifting dullness
› Bowel sound present and normal
EXAMINATION

16. CNS:
› Conscious, alert, communicating but in pain.
› Moved all limbs. Tone and reflexes normal
› Power in 5/5 in all limbs except the Right lower limb of 4/5
MSK (lower limbs)
› 10 cm below ASIS Rt thigh = 44.5 cm (Indurated post. Warm)
Lt thigh = 41.0 cm
› No puncture wounds, abrasions or lacerations
› No shortening of the right leg
EXAMINATION

17. Xray Right femur:
› No evidence of fracture or acute osteomyelitis
EXAMINATION

18. 1. Bilateral lobar pneumonia with right pleural effusion
2.? Pulmonary embolism 20
- ? Fat embolism post trauma
- ? DVT
3. ? Pyomyositis
DIFFERENTIAL DIAGNOSIS

19. WELL’S SCORE
0
0
1.5
0
0
0
0
1.5

20. › FBC, BUE & Cr, LFTs, LDH, Clotting profile, serum D-dimer
› Sputum for AFBs and C/S
› Chest X-ray
› Venous doppler USG Right leg
› Abdominopelvic USG
› SC enoxaparin 40mg od
› PO paracetamol 1g tds
› IV Ceftriaxone 2g od
› Admit to the ward
INVESTIGATIONS

21. DAY 2:
› Dyspnoeic, palpitations , fever, cola-like urine
› Normal urine volume.
ON EXAMINATION
› Moderately pale , jaundiced.
› Tachycardic.
› In respiratory distress requiring intranasal oxygen
PROGRESS

22. INVESTIGATIONS - RESULTS
VENOUS DOPPLER USG RT LEG
› No DVT seen
› There is fluid collection with internal echoes and debris
noted in the posterior compartment of the Right thigh,
within the muscles .
(Right thigh collection suggestive of pyomyositis)
INR - 1.4

23. PROGRESS

24. INVESTIGATION RESULTS
› FBC LFT URINALYSIS
Hb 8.6
MCV 82.1 fl (70 - 86)
MCH 28.0 pg (27 – 30)
PLT 58 X109
(150-400)
WBC 26.03 X 109 (2.5-
8.5)
N 83.6%
L 9.1%
M 6.8%
E 0.2%
B 0.3%
Tot Bili 47.9 umol/l (3-22)
Indirect 5.6 umol/l (0-19)
Direct 42.2 umol/l (<10)
AST 85 u/l (15-46)
ALT 45 u/l (13-69)
ALP 132 u/l (38-126)
GGT 235 (12-58)
Tot
Protein
65 g/l (65-82)
Albumin 29 g/l (35-50)
Protein Negative
Glucose Negative
Bilirubin Negative
Bile pigment Not
prominent
Urobilin Not
prominent
Urobilinogen Increased
leucocyte Negative
Nitrite Negative
Pus cells 1
Bacteria Not seen
RETIC. COUNT - 0.15% ESR - 116 BF for MPs - Negative

25. OTHER LAB RESULTS:
› D-dimer: 0.54 ug/dl (0.1-0.5)
› Retroscreen: Non-reactive
› HBsAg: Non-reactive
› HCV: Non-reactive
› G6PD: Normal
PROGRESS

26. Diagnoses revised to :
› 1. Bilateral lobar pneumonia with right pleural effusion
› 2. Pyomyositis of the right thigh
› 3. Sepsis with intravascular haemolysis 2o pyomyositis/pneumonia
› Surgical consult sought for I&D of pyomyositis
› PO tramadol 50 mg tds added on for analgesia
› IV Clindamycin 300mg q8hrs started
› To transfuse 2 units CRCs
PROGRESS

27. PROGRESS
I&D done

28. DAY 3
› Incision and Drainage of pyomyositis done
› 500mls of seropurulent exudate evacuated
› Samples sent for Gram stain, C/S, AFBs and Gene Xpert
DAY 5, on return from I&D,
› Found to be dyspnoeic, tachypnoeic, SPO2- 87% on room air
› Percussion note dull lung bases, reduced breath sound intensity,
scattered crackles
› Missed 2 doses of IV antibiotics, spiking temperatures, RDT +ve
› FBC , Chest X-ray and Physiotherapy consult requested.
PROGRESS

29. PROGRESS
07/06/17 12/06/17
Hb 8.6 4.3
MCV 82.1 fl (70 - 86) 84.4
MCH 28.0 pg (27 – 30) 28.7
PLT 58 X109
(150-400) 871X109
WBC 26.03 X 109 (2.5-8.5) 23.21X109
N 83.6% 69.3
L 9.1% 17.8
M 6.8% 7.5
E 0.2% 4.9
B 0.3% 0.5

30. PROGRESS
RDT Positive
ACT started
transfused

31. DAY 10
› Temperatures still spiking after completing anti-malarials.
› c/o : Pleuritic chest pains
› Tachypnoeic (28cpm), percussion note dull in lung bases,
vesicular BS, Coarse crackles bilaterally.
› Wound site clean and dry
› Purulent Exudate C/S: Staphylococcus aureus isolated
sensitive to : Cloxacillin
Erythromycin
Resistant to : Penicillin
PROGRESS

32. PROGRESS

33. DAY 12
› Fullness observed in the Right iliac region. Power still maximum
3/5 in right lower limb. Passive physiotherapy.
Repeat right thigh ultrasound and Abdominopelvic USG:
› Normal USG of abdomen and pelvis
› No sonographic evidence of psoas abscess seen.
› Oedematous muscle right thigh in keeping with inflamed muscles
› Normal Doppler USG of the right lower limb
› IV Clindamycin switched to IV Cloxacillin 500mg q6hrs (2/7 now)
PROGRESS

34. Day 19
› Orthopaedic Surgeon’s review o/a persistent fullness in RIF region,
pain and inability to mobilise.
› Tender right femur and hip joint. Stiff Rt hip joint, non-fluctuant
› Pelvic Xray : markedly reduced Joint space Rt hip
Differential diagnoses:
› 1. ?Post-septic arthritic ankyloses
› 2. ?Severe chondrolysis post septic arthritis
PLAN
› For skin traction of right lower limb now, x-rays
› ROM exercises when pain subsides
PROGRESS

35. PROGRESS

36. DAY 30:
› Received 4 days of skin traction to Right lower limb.
› Temperature peaks settling down.
› 20 days IV Cloxacillin. Switched to oral
› Repeat chest x-ray requested
› Transfused 2 more units of blood o/a Hb 6.6g/dl.
PROGRESS

37. PROGRESS

38. PROGRESS

39. PROGRESS
07/06/17 12/06/17 27/06/17 05/07/2017
Hb 8.6 4.3 6.6 10.5
MCV 82.1 fl (70 - 86) 84.4 84.3
MCH 28.0 pg (27 – 30) 28.7 28.1
PLT 58 X109
(150-400) 871 X 109 456 X 109 382 X109
WBC 26.03 X 109 (2.5-8.5) 23.21 X 109 10.28 X 109 6.06 X 109
N 83.6% 69.3 65.3
L 9.1% 17.8 24.4
M 6.8% 7.5 7.4
E 0.2% 4.9 1.8
B 0.3% 0.5 1.1

40. PROGRESS

41. PROGRESS

42. › Discharged home on Day 35
› Skin traction removed
› Mobilizing with zimmer frame
› Physiotherapy continued
› To complete total 6/52 flucloxacillin course
› Oral tramadol and diclofenac prn
› Follow-up with orthopaedic surgeons on account of severe
chondrolysis of right hip joint
PROGRESS

43. FINAL DIAGNOSIS
› Pyomyositis with Staphyloccus aureus sepsis complicated by
post septic arthritis chondrolysis of the right hip joint.
PROGRESS

44. › Patient not seen for follow-up at either medical nor
orthopaedic clinics
› Patient still unable to mobilise without aids despite
physiotherapy
› Father believes condition is spiritual and wants to seek spiritual
help
› Counselled on condition . Agreed to bring patient for
orthopaedic review
› Plans to change secondary School to one in Accra
FOLLOW-UP

45. LITERATURE REVIEW
PYOMYOSITIS

46. › Introduction
› Epidemiology
› Microbiology
› Clinical manifestations
› Differential diagnoses
› Investigation
› treatment
OUTLINE

47. WHAT IS PYOMYOSITIS?
› A purulent infection of skeletal muscle.
› Arises from haematogenous spread, usually with
abscess formation.
› Single muscle group (usually)
› 1885 – Scriba; 1971- Levin
INTRODUCTION

48. › Pyomyositis is classically an infection of the tropics
› Recognized in temperate climates with increasing
frequency.
› Tropical pyomyositis occurs in two age groups: children
(ages 2 to 5) and adults (ages 20 to 45)
› Majority of temperate pyomyositis cases occurs in adults.
› Males more commonly affected than females. (5:3)
EPIDEMIOLOGY

49. Tropical pyomyositis (myositis tropicans) -
› otherwise healthy individuals without underlying
comorbidities.
Temperate pyomyositis (infectious myositis) -
› immunocompromised or have other serious underlying
conditions.
EPIDEMIOLOGY

50. EPIDEMIOLOGY

51. EPIDEMIOLOGY

52. › Incidence in Uganda : 1/1000 1
› 13% of deaths in emergency room in Nigeria 1
› 1 – 2% of surgery hospitalization 4
› 1. Adesunkanmi et al. A five year analysis of death in accident and emergency room of a
semi-urban hospital. West Afr J Med. 2002;21:99-104
› 4. Shepherd JJ. Tropical myositis :is it an entity and what is its cause? Lancet 1983; 26:
1240-1242
EPIDEMIOLOGY

53. › Immunodeficiency
› Trauma (25-50%)
› injection drug use
› concurrent infection
› malnutrition
PREDISPOSING FACTORS

54. › Staphyloccocus aureus
› Group A streptococci
› Pneumococci
› Gram-negative enteric bacilli
› Mycobacteria
› Polymicrobial infection **
MICROBIOLOGY

55. › Fever
› Pain
› Cramping localized to a single muscle group.
› most often in the lower extremity
› However, any muscle group can be involved
› Multifocal infection - more than one muscle group in up to
20 percent of cases .
CLINICAL MANIFESTATION

56. STAGE 1: EARLY INVASIVE
› Cramping local muscle pain, swelling, and low-grade fever.
› Mild leucocytosis
› A deep abscess may not be discretely palpable,+/- "woody"
texture on palpation.
› Fluctuation is not present, aspiration of the muscle - no yield
› Only 2 percent of patients present at this stage
3 CLINICAL STAGES

57. STAGE 2: SUPPURATIVE
› 10 to 21 days after the initial onset of symptoms.
› Fever, exquisite muscle tenderness, and oedema.
› A frank abscess may be clinically apparent.
› Aspiration of the affected muscle typically yields pus
› Marked leucocytosis
› More than 90 percent of the patients present at this stage.
3 CLINICAL STAGES

58. STAGE 3: TOXIC
› The affected muscle is fluctuant.
› Complications of S. aureus bacteraemia such as
septic shock,
endocarditis,
septic emboli,
pneumonia,
pericarditis,
septic arthritis, brain abscess, and acute renal failure can occur
** Rhabdomyolysis
3 CLINICAL STAGES

59. › Variable.
› Most present with stage 2 or 3 disease, some experience a
more indolent course
› Delayed diagnosis - multiple muscle groups involved -
prolonged therapy.
› Recurrent infection - immunocompromised individuals.
› Mortality as high as 10 percent in one retrospective cohort
study***
› ***Sharma A, Kumar S, Wanchu A et al. Clinical characteristics and predictors of
mortality in 67 patients with primary pyomyositis: a study from India ; Clin Rheumatol
2010 ; 29:45
CLINICAL COURSE

60. › muscle strain
› Contusion
› Hematoma
› Cellulitis
› Deep vein thrombosis
› Osteomyelitis
› septic arthritis
› Neoplasm
DIFFERENTIAL DIAGNOSIS

61. Pyomyositis MUST BE distinguished from:
› clostridial myonecrosis
› necrotizing fasciitis
› spontaneous gangrenous myositis,
› diabetic muscle infarction
› other forms of myositis
DIFFERENTIAL DIAGNOSIS

62. › History
› Physical Examination
› Investigations:
– Blood workup
– Imaging
– Cultures
DIAGNOSIS

63. LAB WORKUP
› Leucocytosis with left shift
› Elevated inflammatory markers (erythrocyte sedimentation rate
and C-reactive protein).
› Eosinophilia should raise suspicion for a concomitant parasitic
infection
› Creatine kinase levels are often normal
INVESTIGATIONS

64. CULTURES
› Bacteriologic diagnosis
› Diagnostic drainage prior to antibiotic therapy
› Positive yield - 10 % of tropical cases; 35% of temperate cases
› Systemic toxicity - two sets of blood cultures
› Presence of bacteraemia - clinical assessment for signs and
symptoms of infective endocarditis
INVESTIGATIONS

65. IMAGING
› Most useful tool for diagnosing pyomyositis
› Defining the site(s) of infection
› ruling out other conditions
› Magnetic resonance imaging (MRI) is the optimal imaging
technique.
› Highly sensitive for muscle inflammation, prior to the formation
of a frank abscess
› can demonstrate the extent of involvement in the tissues.
INVESTIGATIONS

66. Computed tomography (CT) :
› detects muscle swelling
› well-delineated areas of fluid attenuation that display rim
enhancement with contrast.
› CT-guided drainage of purulent material.
Ultrasonography :
› useful diagnostic and therapeutic tool,
› during the purulent stage of infection.
› diffuse muscle hyperechogenicity +/- localized
hypoechogenicity and diffuse hyperemia
IMAGING

67. › Stage 1 pyomyositis - antibiotics alone
› Stage 2 or 3 pyomyositis - antibiotics and drainage for
definitive management
TREATMENT

68. ANTIBIOTICS
› Immunocompetent individuals - initial empiric parenteral
antibiotic therapy directed against staphylococci, including
methicillin-resistant S. aureus (MRSA) and streptococci
› Immunocompromised individuals - broad antibiotic
coverage for gram-positive, gram-negative, and anaerobic
organisms.
TREATMENT

69. › Duration: tailored to clinical and radiographic improvement.
› Three to four weeks of parenteral therapy is usually sufficient.
› Extensive, multifocal, or poorly drained infection: longer
courses of therapy.
› Sequelae of bacteraemia (such as endocarditis or osteomyelitis) :
adjusted based on the nature of infection at these other sites.
› Mycobacteria isolates: nature and duration of treatment
tailored to the microbiologic isolate.
TREATMENT

70. DRAINAGE
› Percutaneous drainage: CT/ USG –guided
› Surgical intervention: In deep infections or extensive
muscle involvement with significant necrosis
TREATMENT

71. › Associated with stage 3 /toxic pyomyositis
› Treatment depends on the type of complication.
septic shock,
endocarditis,
septic emboli,
pneumonia,
pericarditis,
septic arthritis,
brain abscess, and acute renal failure
MANAGEMENT OF COMPLICATIONS

72. DEFINITION: Joint space narrowing to <3mm**
› A rare condition of unknown aetiology.
› Characterized by progressive destruction of the hyaline cartilage
that covers the femoral head and acetabulum.
› Idiopathic
› Secondary
› ** Koroula RJ, Jebaraj I, David KS. Idiopathic chondrolysis of the hip: medium to long
term results. AZN Journal of Surgery. 2005 Sep;75(9);750-3
CHONDROLYSIS of the HIP JOINT

73. SECONDARY CAUSES
› Prolonged immobilization
› Neoplasias
› Legg-Calvé-Perthes disease (avascular necrosis of the femoral
head)
› Trauma
› Septic arthritis
› Juvenile idiopathic arthritis (JIA)
› Stickler syndrome
› Slipped upper femoral epiphysis.
CHONDROLYSIS OF THE HIP JOINT

74. PRESENTATION
› Severe pain in the hip, knee or the entire lower limb
› Mobility limitation
› Claudication
› Shortening of the limb might result
CHONDROLYSIS OF THE HIP JOINT

75. CHONDROLYSIS OF THE HIP JOINT

76. TREATMENT
Pain control and preservation of the joint mobility
› physical therapy
› continuous use of a passive motion machine
› Protected weight bearing
› Nonsteroidal anti-inflammatory Drugs
› Skin traction
› Surgery
CHONDROLYSIS OF THE HIP JOINT

77. CLINICAL COURSE
› Progression to end stage arthritis
› Spontaneous fusion
› Completely heal.
CHONDROLYSIS OF THE HIP JOINT

78. › Pyomyositis can occur following trauma
› It is usually not a recurrent infection except in
immunocompromised persons.
› Indolent infections not diagnosed and treated early can lead to
infection in multiple muscle groups.
› In toxic patients, sequelae of bacteraemia – endocarditis, septic
arthritis etc must be sought and managed promptly
› Mortality as high as 10%. Morbidity can affect quality of life.
TAKE HOME MESSAGE

79. › Uptodate
› Medscape
› SA Orthopaedic Journal
› Scientific Research; Surgical science 2014
› AZN Journal of Surgery 2005
REFERENCES

80. › PS3 TEAM
› Patient B.D
› Other healthcare workers who assisted in care
of this patient
› God Almighty
ACKNOWLEDGEMENT