Piomiositis en niños: experiencia en un hospital pediátrico de referencia en Argentina / Pediatric pyomyositis: experience in a Pediatric Reference Center in Argentina

Resumen Introducción: La piomiositis es la infección del músculo esquelético, entidad poco frecuente en pediatría. Objetivo: Describir las características de 21 niños con piomiositis. Métodos: Estudio prospectivo-analítico de niños ingresados con diagnóstico de piomiositis entre mayo de 2016 y abril de 2017 en el Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina. Resultados: Tasa de hospitalización de 21,5/10.000 admisiones (IC 95% 4,65- 71,43). La mediana de edad fue de 5,4 años (rango 1,25-11,6). El 90,4% presentaba algún factor predisponente. La localización más frecuente fue en miembros inferiores. La proteína C reactiva (PCR) estuvo elevada en todos los pacientes, con una media de 124 mg/L (DS 96), siendo significativamente más elevada en los pacientes que tuvieron hemocultivos positivos 206 (DS 101) vs 98 (DS 81), (p = 0,02). Se obtuvo rescate microbiológico en 17 pacientes (80,9%): Staphylococcus aureus resistente a meticilina (SARM) (n: 15) y Streptococcus pyogenes (n: 2). Se presentó con bacteriemia 23,8% de los pacientes. El 81% requirió drenaje quirúrgico. Conclusión: Staphylococcus aureus RM adquirido en la comunidad (SARMAC) es el patógeno predominante. En la selección del tratamiento empírico adecuado debería tenerse en cuenta: el patrón de resistencia local y el valor de PCR.

Background: Pyomyositis is the infection of skeletal muscle, a rare pathology in children. Aim To describe the characteristics of pyomyositis in pediatric patients. Methods: Prospective analytical study of hospitalized children diagnosed with pyomyositis from May 2016 to April 2017 at the Ricardo Gutiérrez Children's Hospital, Buenos Aires, Argentina. Results: Twenty-one patients with pyomyositis were identified. Annual rate: 21.5/10,000 admissions (95% CI 4.65-71.43). The median age was 5.4 years (range 1.25-11.6). The lower limbs were the most affected site. C-reactive protein (CRP) was elevated in all patients, with a mean of 124 mg/L (SD 96), being significantly higher in patients with bacteremia: 206 (DS 101) vs 98 (DS 81), p = 0.02. Bacterial cultures were positive in 17/21 (80.9%): 15 methicillin-resistant Staphylococcus aureus (MRSA), and 2 Streptococcus pyogenes. Blood cultures were positive in 5 (23.8%). Conclusion: MRSA-community acquired is the predominant pathogen in our setting. In the selection of the appropriate empirical treatment, the local resistance pattern and the CRP value should be taken into account.

Tropical pyomyositis: diabetes facilitating the onset of an uncommon disease / Piomiosite tropical: diabetes facilitando o aparecimento de uma doença incomum

INTRODUCTION: Tropical pyomyositis is an infectious disease that affects skeletal muscle and may appear as a diffuse inflammation or a rapidly progressive myonecrotic process. The predisposition of this disease in diabetics is already mentioned in several studies. The pathogenesis is possibly related to changes in neutrophils and the reversal of the immune response pattern that occurs in situations such as parasitic diseases. Staphylococcus aureus is the most common microorganism, accounting for 90% of cases of tropical pyomyositis. The diagnosis is sometimes late because patients usually do not seek care by the first symptoms, and because it is a rare disease and physicians are not very familiar with it. CASE REPORT: A 42-year-old male patient with diabetes mellitus, hypothyroidism, anemia, thrombocytopenia, and hypoalbuminemia developed tropical pyomyositis with multiple muscle abscesses in quadriceps, soleus and anterior tibial, triceps and biceps brachialis and pronator round, requiring prolonged antibiotic therapy and surgical drainage. CONCLUSION: Pyomyositis is a little known disease and if not diagnosed early can be fatal.

INTRODUÇÃO: A piomiosite tropical é uma doença infecciosa que afeta o músculo esquelético, aparecendo como uma inflamação difusa ou um processo mionecrótico rapidamente progressivo. A predisposição desta enfermidade em diabéticos já é referida em vários estudos. A patogênese possivelmente está relacionada a alterações nos neutrófilos e na inversão do padrão de resposta imune que acontece em situações como parasitoses. Staphylococcus aureus é o microorganismo mais comum, representando 90% dos casos de piomiosite tropical. O diagnóstico pode ser tardio porque os pacientes geralmente não buscam cuidados com os primeiros sintomas e, por ser uma doença rara, pode surpreender um médico ainda não familiarizado com esta entidade clínica. RELATO DE CASO: Paciente do sexo masculino com 42 anos de idade com diabetes mellitus, hipotireoidismo, anemia, trombocitopenia e hipoalbuminemia que desenvolveu piomiosite tropical com múltiplos abscessos musculares em quadríceps, sóleo e tibial anterior, tríceps e bíceps braquial e pronador redondo, necessitando de antibioticoterapia prolongada e drenagem cirúrgica. CONCLUSÃO: A piomiosite não é uma doença bem conhecida e pode ser fatal se não for diagnosticada precocemente.

Piomiositis primaria: Revisión de 32 casos diagnosticados por ecografía / Primary pyomyositis. Review of 32 cases diagnosed by ultrasound

La piomiositis primaria es la infección bacteriana por vía hematógena del músculo estriado. Está relacionada con factores de riesgo como HIV/sida y otras enfermedades inmunodepresoras, pudiendo estar asociados a factores locales de estrés muscular. El agente etiológico más frecuente es Staphylococcus aureus. Su retardo diagnóstico puede ocasionar una evolución fatal. En esta serie se evaluaron 32 pacientes con piomiositis primaria diagnosticados por ecografía. El factor de riesgo más frecuente fue el HIV/sida (61%). Los factores locales se detectaron en 21 casos (66%): en primer lugar, la práctica de futbol. La forma monofocal se observó en 19 (59%) los músculos más frecuentemente afectados fueron cuádriceps, gemelos y psoas. Se obtuvieron muestras para estudio bacteriológico en 30 casos, 27 de material del absceso y 22 hemocultivos. En los 30 casos se aisló el agente etiológico. El Staphylococcus aureus representó el 83.3% (25 casos) y Escherichia coli, Nocardia spp., Streptococcus agalactiae, Micobacteria no tuberculosa y Pseudomonas aeruginosa fueron aislados en un caso cada uno. Recibieron tratamiento quirúrgico 17 pacientes, punciones aspirativas, 9; antibióticos solamente, 4. Presentaron buena evolución 28 de los 30 pacientes (93.3%), óbitos, 2 (6.6%); desconocida, 2. Este estudio concluyó que: ante la etiología diversa y cambiante de las piomiositis primarias es importante reconocer el agente involucrado y su sensibilidad antibiótica. La ecografía realiza la evaluación en tiempo real y puede ser utilizada como guía de punción facilitando el diagnóstico inmediato. Esto la diferencia de otras técnicas, transformándola en un método de primera línea para el estudio de esta enfermedad.

Primary pyomyositis is a bacterial infection of striated muscle which is acquired by hematogenous route. It is related to risk factors such as HIV/aids and other immuno suppressing diseases, and can be associated with local muscle stress factors. The most frequent etiology is Staphylococcus aureus. Its diagnostic delay may cause a fatal evolution. In this series 32 patients with primary pyomyositis diagnosed by ultrasound were evaluated. The most frequent risk factor was HIV/aids (61%). Local factors were detected in 21 (66%) cases: first, the practice of football. The monofocal form was observed in 19 (59%), the most commonly affected muscles were quadriceps, calves and psoas. Samples for bacteriological study were obtained in 30 cases, 22 blood culture and 27 abscess materials. In 30 cases the etiologic agent was isolated. Staphylococcus aureus accounted for 83.3% (25 cases) and Escherichia coli, Nocardia spp., Streptococcus agalactiae, nontuberculous mycobacteria, Pseudomonas aeruginosa were isolated in one case each. Seventeen patients received surgical treatment, aspirative punctures, 9; antibiotics alone, 4. Twenty eight (93.3%) patients had a good evolution; deaths, 2 (6.6%); unknown, 2. Main conclusions of this study were: due to the diverse and changing etiology of the primary pyomyositis it is important to recognize the etiological agent involved and their antibiotic susceptibility.The ultrasound performed the study in real time so it can be used to guide the puncture and to facilitate the immediate diagnosis. This makes the difference with other techniques and transforms it into a first-line method for the study of this disease.

Sonographic Findings of Common Musculoskeletal Diseases in Patients with Diabetes Mellitus

Diabetes mellitus (DM) can accompany many musculoskeletal (MSK) diseases. It is difficult to distinguish the DM-related MSK diseases based on clinical symptoms alone. Sonography is frequently used as a first imaging study for these MSK symptoms and is helpful to differentiate the various DM-related MSK diseases. This pictorial essay focuses on sonographic findings of various MSK diseases that can occur in diabetic patients.

Primary pyomyositis and disseminated septic pulmonary emboli: a reactivated staphylococcal infection?

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunecompetent woman, which was complicated with septic pulmonary emboli within 24 h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.

Presentación atípica de piomiositis tropical difusa de psoas por Staphylococcus aureus meticilino resistente / Atypical presentation of diffuse tropical pyomiositis of the psoas due to methicillin resistant Staphylococcus aureus

La piomiositis tropical difusa primaria es una enfermedad de presentación infrecuente en nuestro medio, con pocos casos asociados a Staphylococcus aureus meticilino resistente, adquirido en la comunidad (MRSA-AC). Se presenta el caso de un paciente de 70 años, con tratamiento irregular para diabetes mellitus tipo 2, que fue hospitalizado por presentar un cuadro de diez días de evolución, con dolor lumbar irradiado a miembro inferior izquierdo, fiebre y flexión forzada de la cadera derecha por dolor a la movilización. El diagnóstico de piomiositis difusa de ambos psoas se realizó con resonancia magnética. Del cultivo de una colección paravertebral posterior se aisló Staphylococcus aureus resistente a oxacilina, penicilina y dicloxacilina.

Diffuse tropical primary pyomyositis is an infrequent entity in our country, with few cases associated to communityacquired Methicillin- resistant Staphylococcus aureus. There are no reported cases of Community-Acquired Methicillin- Resistant Staphylococcus aureus (CA- MRSA) in Peru. We present the case of a 70 year old male with a previous diagnosis of type 2 diabetes mellitus, receiving irregular treatment, who was admitted to the hospital with a history of 10 days of low back pain radiating to the left leg, fever and forced flexion of the right hip due to pain during movement. The diagnosis of diffuse pyomyositis of both psoas muscles was performed with MRI and culture of a posterior paravertebral collection, from which Staphylococcus aureus resistant to oxacillin, penicillin and dicloxacillin was isolated.

Pyomyositis of extraocular muscle: Case series and review of the literature.

Pyomyositis is a primary acute bacterial infection usually caused by Staphylococcus aureus. Any skeletal muscle can be involved, but the thigh and trunk muscles are commonly affected. Only three cases of extraocular muscle (EOM) pyomyositis have been reported. We herein present four cases of isolated EOM pyomyositis. Three of our cases presented with acute onset of proptosis, pain, swelling and redness. One patient presented with mass in the inferior orbit for 4 months. One patient had central retinal artery occlusion on presentation. None of them had marked systemic symptoms. Computed tomography scan of all patients showed a typical hypodense rim enhancing lesion of the muscle involved. Three patients were started on intravenous antibiotics immediately on diagnosis and the pus was drained externally. Two patients underwent exploratory orbitotomy. In conclusion, it should be considered in any patient presenting with acute onset of orbital inflammation. Management consists of incision and drainage coupled with antibiotic therapy.

Rheumatological manifestations in patients with melioidosis.

Melioidosis, an infection caused by the bacterium Burkholderia pseudomallei, has a wide range of clinical manifestations. Here, we describe rheumatological melioidosis (involving one or more of joint, bone or muscle), and compare features and outcome with patients without rheumatological involvement. A retrospective study of patients with culture-confirmed melioidosis admitted to Sappasithiprasong Hospital, Ubon Ratchathani during 2002 and 2005 identified 679 patients with melioidosis, of whom 98 (14.4%) had rheumatological melioidosis involving joint (n=52), bone (n = 5), or muscle (n = 12), or a combination of these (n=29). Females were over-represented in the rheumatological group, and diabetes and thalassemia were independent risk factors for rheumatological involvement (OR; 2.49 and 9.56, respectively). Patients with rheumatological involvement had a more chronic course, as reflected by a longer fever clearance time (13 vs 7 days, p = 0.06) and hospitalization (22 vs 14 days, p < 0.001), but lower mortality (28% vs 44%, p = 0.005). Patients with signs and symptoms of septic arthritis for longer than 2 weeks were more likely to have extensive infection of adjacent bone and muscle, particularly in diabetic patients. Surgical intervention was associated with a survival benefit, bur not a shortening of the course of infection.

Piomiositis: presentación de 17 casos en niños y adultos / Pyomyositis: Report of seventeen cases

Background: Pyomyositis is a bacterial infection of skeletal muscle. Although more commonly seen in the tropics, it is increasingly recognized in temperate regions. The age distribution for patients with so called "tropical" or "temperate" pyomyositis differs. Most cases of tropical pyomyositis are seen in otherwise healthy patients and mainly in children, while the majority of cases of temperate pyomyositis occur in inmunocompromised adults. Aim: To report a series of patients with pyomyositis. Material and Methods: Retrospective review of clinical records of patients admitted to our hospital with pyomyositis during the period 1996-2001. Results: Seventeen patients were identified, aged from 5 to 86 years old, nine (53%) males. Staphylococcus aureus (13 cases, 76%) was the most common infecting organism. Eleven patients (65%) had a history of previous trauma. All patients were immunocompetent. Six patients underwent surgical drainage. Six patients (35%) presented complications and of those, one died. Conclusions: All patients of this series were immunocompetent. Pyomyositis is a serious and life threatening disease but curable. An early treatment is the key to a better prognosis.