Mr. Vijayakumar, a 36-year-old man with IDDM and chronic pancreatitis, was admitted with fever, body pain, and fatigue for 10-15 days. He was found to have pyomyositis with multiple muscle abscesses caused by Staphylococcus aureus. He underwent incision and drainage of the abscesses followed by treatment with cloxacillin then vancomycin. He improved with treatment and was discharged upon request to continue treatment nearer to his home.

1. Prof.Dr.P.Vijayaraghavan’s unit . Dr.A.Vijayalakshmi. A CASE OF PYOMYOSITIS

2. 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 .

3. 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 .

4. GENERAL EXAMINATION Conscious, Oriented. Febrile. NO cyanosis, clubbing, icterus, No generalized lymphadenopathy. Bed sores present in the sacral region. Pulse :98/min. BP:100/70mm of Hg.

5. Cardiovascular examination S1,S2 heard. No murmur. Respiratory examination Normal vesicular breath sounds heard. Abdomen examination Soft, no organomegaly. Central nervous system examination No focal neurological deficit .

6. INVESTIGATIONS CBC: Hb-10 gm PCV- 33% WBC:22000/cu.mm. DC:- P87% E4% L9% Sugar 406mg urea 44mg creatinine 0.4mg LFT Total bilirubin 1.6mg/dl Direct 1.2 AST39 ALT22 CGT68

7. SAP 388 Total protein 5.3 Alb 2 Globulin 2.3 Electrolytes Na 134 K3.99 Cl 84.4 HIV, HBsAg,AntiHCV are negative. Urine routine normal. Fever profile negative except Blood culture sensitivity.

8. Blood culture sensitivity: Staphylococcus aureus grown in culture. Peripheral smear; Microcytic hypochromic anemia. With leucocytosis with neutrophilia. Serum CPK 33u/l Cardiac evaluation Normal LV function. No regional valve motion abnormality. Pus culture sensitivity: Staphylococcus aureus grown in culture .

9. Problems; 1.IDDM. 2.Bed sores. 3.Multiple abscess in the muscles. Probable diagnosis: Tropical pyomyositis due to Staphylococcus aureus . .

15. TREATMENT Incision and drainage of the abscess done followed that Patient was given one course of inj.cloxacillin 500 mg I.V. 3 times. After pus culture and blood culture sensitivity results Inj. Vancomycin 1G 12 th 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 .

16. 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 .

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

18. DISCUSSION Staphylococcus 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 .

19. 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.

20. 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 .

21. 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.

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

23. TREATMENT OF STPHYLOCOCCUS INFECTIONS For penicillin sensitive staph. Penicillin is the drug of choice. Penicillin G (4mU 4 th hourly). Penicillin resistant cases are treated with Oxacillin, Nafcillin. Dose-2G 4 th hourly. First generation cephalosporins can be given.Cefazolin 2g 8 th hourly. The carbapenem has excellent activity against methicillin sensitive strains. Merpenem dose-0.5 to2g(10 to 40 mg/kg) I.V. 8 th hourly. Faropenem dose-200 to 300 mg oral 3 times. Imepenem dose-0.5 g I.V. 6 th hourly.(max.4gm/day). Vancomycin is the drug of choice for methicillin resistant strains .

24. For vancomycin resistant strains chloramphenical,linezolid,minocyclin,quinupristin/dalfopristin,Trimethoprime-sulfamethoxazole can be given. Flouroquinolones also given for methicillin sensitive strains.(cipro 4oomg 12 th 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.

25. 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 .

26. However Vancomycin 1gm 12 th 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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