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A Case of Pyomyositis

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A Case of Pyomyositis

  1. 1. Prof.Dr.P.Vijayaraghavan’s unit . Dr.A.Vijayalakshmi. A CASE OF PYOMYOSITIS
  2. 2. <ul><li>Mr.Vijayakumar. 36years. </li></ul><ul><li>Admitted with complaints of fever for 15 days. </li></ul><ul><li>Generalized body pain for 10 days. </li></ul><ul><li>Tiredness and fatiguability for 10 days. </li></ul><ul><li>History of present illness </li></ul><ul><li>A known case of IDDM, secondary to chronic calculus pancreatitis on insulin therapy for the past 2 ½ yrs. </li></ul><ul><li>Was admitted with fever 15 days, intermittent, no chills and rigor. </li></ul><ul><li>No vomiting, headache, throat pain, cough with expectoration, pain abdomen and burning micturition . </li></ul>
  3. 3. <ul><li>Past history. </li></ul><ul><li> No h/o T.B., Asthma ,Epilepsy and Hypertension. </li></ul><ul><li>Personal history. </li></ul><ul><ul><li>Consuming alcohol for 20 years, Smoking cigarettes, married, Has two children. </li></ul></ul><ul><li>Family history. </li></ul><ul><ul><li>Nil relevant . </li></ul></ul>
  4. 4. GENERAL EXAMINATION <ul><li>Conscious, Oriented. </li></ul><ul><li>Febrile. </li></ul><ul><li>NO cyanosis, clubbing, icterus, No generalized lymphadenopathy. </li></ul><ul><li>Bed sores present in the sacral region. </li></ul><ul><li>Pulse :98/min. </li></ul><ul><li>BP:100/70mm of Hg. </li></ul>
  5. 5. <ul><li>Cardiovascular examination </li></ul><ul><li>S1,S2 heard. No murmur. </li></ul><ul><li>Respiratory examination </li></ul><ul><li>Normal vesicular breath sounds heard. </li></ul><ul><li>Abdomen examination </li></ul><ul><li>Soft, no organomegaly. </li></ul><ul><li>Central nervous system examination </li></ul><ul><li>No focal neurological deficit . </li></ul>
  6. 6. INVESTIGATIONS <ul><li>CBC: Hb-10 gm PCV- 33% </li></ul><ul><li>WBC:22000/cu.mm. </li></ul><ul><li>DC:- P87% E4% L9% </li></ul><ul><li>Sugar 406mg urea 44mg creatinine 0.4mg </li></ul><ul><li>LFT </li></ul><ul><li>Total bilirubin 1.6mg/dl </li></ul><ul><li>Direct 1.2 </li></ul><ul><li>AST39 ALT22 CGT68 </li></ul>
  7. 7. <ul><li>SAP 388 </li></ul><ul><li>Total protein 5.3 Alb 2 Globulin 2.3 </li></ul><ul><li>Electrolytes </li></ul><ul><li>Na 134 K3.99 Cl 84.4 </li></ul><ul><li>HIV, HBsAg,AntiHCV are negative. </li></ul><ul><li>Urine routine normal. </li></ul><ul><li>Fever profile negative except Blood culture sensitivity. </li></ul>
  8. 8. <ul><li>Blood culture sensitivity: Staphylococcus aureus grown in culture. </li></ul><ul><li>Peripheral smear; </li></ul><ul><li>Microcytic hypochromic anemia. With leucocytosis with neutrophilia. </li></ul><ul><li>Serum CPK 33u/l </li></ul><ul><li>Cardiac evaluation </li></ul><ul><li>Normal LV function. </li></ul><ul><li>No regional valve motion abnormality. </li></ul><ul><li>Pus culture sensitivity: Staphylococcus aureus grown in culture . </li></ul>
  9. 9. <ul><li>Problems; </li></ul><ul><li>1.IDDM. </li></ul><ul><li>2.Bed sores. </li></ul><ul><li>3.Multiple abscess in the muscles. </li></ul><ul><li>Probable diagnosis: Tropical pyomyositis due to Staphylococcus aureus . . </li></ul>
  10. 15. TREATMENT <ul><li>Incision and drainage of the abscess done followed that </li></ul><ul><li>Patient was given one course of inj.cloxacillin 500 mg I.V. 3 times. </li></ul><ul><li>After pus culture and blood culture sensitivity results </li></ul><ul><li>Inj. Vancomycin 1G 12 th hourly started and was given for 2 weeks . </li></ul><ul><li>Patient was better .He was able to walk and was given fresh blood transfusion to improve his general condition. </li></ul><ul><li>Patient was discharged at request as he want to continue his treatment nearby Govt. hospital to his home . </li></ul>
  11. 16. DIFERENTIAL DIAGNOSIS FOR MULTIPLE ABSCESS <ul><li>1.Streptococcal septicemia. </li></ul><ul><li>2.Anaerobic bacterial infections. </li></ul><ul><li>3.Staphylococcus aureus infections. </li></ul><ul><li>4.Cat scratch disease. </li></ul><ul><li>5.Metastatic staph .aureus abscess syndrome. </li></ul><ul><li>6.Tuberculosis. </li></ul><ul><li>7.Pneumonia. </li></ul><ul><li>8.Melioidosis. </li></ul><ul><li>9.Glanders disease . </li></ul>
  12. 17. <ul><li>10.Histoplasmosis. </li></ul><ul><li>11.Tularemia, Plaque(bubonic). </li></ul><ul><li>12.MRSA Staph.aureus. </li></ul><ul><li>13.Wegeners granulamatosis. </li></ul><ul><li>14.Congenital (job syndrome). </li></ul><ul><li>15.Hidradenitis suppurativa. </li></ul>
  13. 18. DISCUSSION <ul><li>Staphylococcus aureus infection is part of normal human flora .25 to 50% healthy persons may be persistently colonized . </li></ul><ul><li>The rate of colonization increased among Insulin dependent diabetics,HIV infected patients,Patients undergoing hemodialysis, and individual with skin damage. </li></ul><ul><li>This organism is known for its capacity to induce abscess formation at sites of both local and metastatic infections . </li></ul><ul><li>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 . </li></ul>
  14. 19. <ul><li>This organism causes skin and soft tissue infections. </li></ul><ul><li>It causes pyomyositis presents as fever, pain overlying the involved muscles,and swelling. </li></ul><ul><li>Pyomyositis : </li></ul><ul><li>Staph .aureus is responsible for 95% cases in tropical areas. </li></ul><ul><li>Leukocytosis and hypoalbuminemia is common. </li></ul>
  15. 20. <ul><li>The pyomyositis occurs in three stages. </li></ul><ul><li>1.First stage : </li></ul><ul><li>Fever, anorexia, erythema, pain, tenderness. </li></ul><ul><li>2.Second stage: </li></ul><ul><li>Abscess, Arthritis. </li></ul><ul><li>3.Third stage: </li></ul><ul><li>Toxic shock syndrome . </li></ul>
  16. 21. <ul><li>Diagnosis: </li></ul><ul><li>CBC show leukocytosis. </li></ul><ul><li>Hypoalbuminemia. </li></ul><ul><li>Sometimes elevated CPK enzyme. </li></ul><ul><li>U.S.G. </li></ul><ul><li>Show muscular heterogeneity and purulent collection. </li></ul><ul><li>C.T . </li></ul><ul><li>Heterogenous attenuation and fluid collection with ring enhancement. </li></ul>
  17. 22. <ul><li>M.R.I. is the definite modality to assess pyomyositis and to determine localization and extent. </li></ul>
  18. 23. TREATMENT OF STPHYLOCOCCUS INFECTIONS <ul><li>For penicillin sensitive staph. Penicillin is the drug of choice. </li></ul><ul><li>Penicillin G (4mU 4 th hourly). </li></ul><ul><li>Penicillin resistant cases are treated with Oxacillin, Nafcillin. </li></ul><ul><li>Dose-2G 4 th hourly. </li></ul><ul><li>First generation cephalosporins can be given.Cefazolin 2g 8 th hourly. </li></ul><ul><li>The carbapenem has excellent activity against methicillin sensitive strains. </li></ul><ul><li>Merpenem dose-0.5 to2g(10 to 40 mg/kg) I.V. 8 th hourly. </li></ul><ul><li>Faropenem dose-200 to 300 mg oral 3 times. </li></ul><ul><li>Imepenem dose-0.5 g I.V. 6 th hourly.(max.4gm/day). </li></ul><ul><li>Vancomycin is the drug of choice for methicillin resistant strains . </li></ul>
  19. 24. <ul><li>For vancomycin resistant strains chloramphenical,linezolid,minocyclin,quinupristin/dalfopristin,Trimethoprime-sulfamethoxazole can be given. </li></ul><ul><li>Flouroquinolones also given for methicillin sensitive strains.(cipro 4oomg 12 th hourly,levoflox 5oomg OD). </li></ul><ul><li>Among the newer antistaph .agents quinupristin and dalfopristin has bactericidal activities. Can be used for serious staph infections . </li></ul><ul><li>7.5mg/kg every 8 to 12 hours. </li></ul>
  20. 25. <ul><li>Linezolid bacteriostatic can be used for skin and soft tissue infections.But its use is restricted to prevent emergence of resistence. </li></ul><ul><li>Linezolid dose-600mg BD oral. </li></ul><ul><li>Tigecyclin a broad spectrum minocyclin analogue has bacteriostatic activity for soft tissue infections and for abdominal infections. </li></ul><ul><li>So the choice of empirical treatment depends on susceptibility data for the local geographic area . </li></ul>
  21. 26. <ul><li>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 . </li></ul>
  22. 27. <ul><li>Thank u </li></ul>THANK YOU

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