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| CASE REPORT |
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| Year : 2022 | Volume
: 15
| Issue : 1 | Page : 48-49 |
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Isolated tropical pyomyositis of first web space in a child
Ganesh Singh Dharmshaktu1, Tariq Akhtar Ansari1, Tanuja Pangtey2
1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India
| Date of Submission | 17-Jul-2021 |
| Date of Decision | 08-Aug-2021 |
| Date of Acceptance | 01-Nov-2021 |
| Date of Web Publication | 25-Mar-2022 |
Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/hmj.hmj_48_21
Introduction: Pyomyositis or tropical pyomyositis is a form of acute pyogenic infection affecting skeletal muscles. Despite being called tropical pyomyositis, these cases are frequently reported from both tropical and non-tropical regions. The most common causative organism is Staphylococcus aureus with anecdotal reports of a variety of muscles involved throughout the human body. The isolated and focal affliction of muscles is uncommon and more so in children. Case Report: We report a case of isolated pyomyositis involving inter-osseous muscles of the first web space of the left hand in a 5-year-old otherwise healthy male child. Conclusion: The good delineation of the lesion on magnetic resonance imaging was followed by aspiration of the abscess, leading to uneventful healing and good clinical outcome.
Keywords: Hand infection, pyomyositis, Staphylococcus aureus, tropical pyomyositis
How to cite this article:
Dharmshaktu GS, Ansari TA, Pangtey T. Isolated tropical pyomyositis of first web space in a child. Hamdan Med J 2022;15:48-9 |
| Introduction | |  |
Pyomyositis, also referred to as tropical pyomyositis or myositis tropicans, a primary acute pyogenic infection of striated muscles with resultant abscess formation in most cases. It is found in about 2.2%–4% of surgical cases in tropical countries but is also being reported from temperate zones.[1] The early diagnosis, the key to the optimal outcome, requires clinical suspicion coupled with judicious use of investigations to exclude differential diagnoses. Despite reported mortality in serious cases ranging from 1% to 23%, these cases may be managed conservatively.[2] The abscess drainage through percutaneous, image-guided or surgical means may also be required in selected cases.[3]
| Case Report | | |
A 5-year-old male child from Northern Indian Hilly Region presented with painful swelling of his left hand for the last 3 days. There was a history of minor injury during a school sports activity 5 days back, leading to pain and hard tender swelling over the dorsal hand. The swelling was localized to the first web space region on palpation with increased temperature of overlying skin [Figure 1]. Finger movement and distal neurovascular status were intact. The child was otherwise healthy with no other localized or systemic comorbidities. As the radiograph revealed no underlying bony abnormalities, the magnetic resonance imaging (MRI) was done which showed a well-defined hyper-intense area within the first dorsal inter-osseous muscle without any bony affliction, suggestive of a focal abscess formation [Figure 1]b and [Figure 1]c. A provisional diagnosis of pyomyositis was made followed by ultrasound-guided aspiration, resulting in frank pus evacuation of about 6 mL. The sample was sent for Gram stain, acid-fast bacillus staining and fungal culture along with drug sensitivity. The blood reports showed leucocytosis, neutrophilia along with increased C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels corroborating with the acute infectious process. The culture showed the presence of Staphylococcus aureus sensitive to third-generation cephalosporin. Injectable cefuroxime 500 mg thrice a day for 5 days was followed by an oral tablet of 250 mg twice a day for 3 weeks. There was marked clinical improvement evident by decreased pain and swelling following this therapy. Active hand movements were encouraged all through the treatment, and pain medications were used on a need basis. The child improved clinically with laboratory parameters such as CRP and ESR at normal levels. He was performing activities of daily living in the follow-up of 3 months with no recurrence. | Figure 1: The clinical image showing the left hand with swelling over the dorsal first web space as compared to the right hand (a). Magnetic resonance imaging films in coronal (b) and axial (c) section confirming and delineating a well-defined focal area of increased signal intensity surrounded by adjacent tissue oedema over first dorsal inter-osseous muscle suggestive of abscess formation and pyomyositis
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| Discussion | | |
Tropical or bacterial pyomyositis is an uncommon form of infection involving striated muscles that warrant clinical acumen for early diagnosis. Occult localized trauma or vigorous exercise may also be associated with its causation in a few cases.[4] Bacterial pyomyositis may present as focal muscle necrosis in contrast to diffuse involvement in viral or parasitic infections.[5] Muscle abscess in thigh, psoas, forearm and those around the hip with the predominant organism as S. aureus. The tropical pyomyositis is also common in the hip and lower extremity muscles such as iliopsoas, glutei, serratus anterior, gastrocnemius, abdominal and spinal muscles.[4],[6] The diagnosis is based on clinico-radiological evaluation coupled with the isolation of causative organisms by microbiological testing. MRI is the best modality to diagnose these cases even at an early stage for early identification. Conservative management suffices in most cases, whereas evacuation of pus by minimal or radical surgery is reserved for complicated cases. Early initiation of treatment yields a good outcome, and there is always a risk of osteomyelitis or septic arthritis if the disease is managed late, neglected or multifocal.[4],[6],[7] Initial course of inappropriate antibiotic treatment, lower 1st-day serum albumin and advanced stage at initial consultation were found to be poor prognostic factors in a study from North India involving 62 cases.[7] In rare instances, some uncommon disorders such as focal eosinophilic infiltration of the inter-osseous muscles have been reported to present resembling refractory pyogenic hand infection.[8] The cases reported from temperate areas are similar to those reported in tropical zones, but most temperate zone cases occur in immunocompromised hosts such as human immunodeficiency virus (HIV)-infected persons.[9] The concurrence of comorbidities such as diabetes, neoplastic conditions or rheumatologic disorders increases the risk of bacterial pyomyositis in non-HIV cases. A recent meta-analysis also highlighted a significant association between pyomyositis and HIV infection and further advocated more work for a comprehensive understanding of this disorder.[9] This case, an example of tropical pyomyositis at a rare anatomical site from a non-tropical region, was managed successfully with a prompt aspiration of pus and antibiotic therapy, leading to decreased viral load and quicker healing. Our case was evaluated first in a resource-limited primary centre and referred promptly which always is a crucial factor in a final good outcome. This rare presentation has educative potential for both general or specialist clinicians.
Declaration of patient consent
The authors certify that an appropriate parental consent form has been obtained with permission to use images and clinical information to be reported for the journal. The parent understands that the name of the child and theirs will not be published and due efforts will be made to conceal the identity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 4. | Orlicek SL, Abramson JS, Woods CR, Givner LB. Obturator internus muscle abscess in children. J Pediatr Orthop 2001;21:744-8. |
| 5. | Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 2008;21:473-94. |
| 6. | Angelis S, Trellopoulos A, Kondylis AK, Mirtsios H, Katsimantas A, Solakis EP, et al. Multifocal Οsteomyelitis localization after pyomyositis in children: Importance of timely response. Cureus 2019;11:e4463. |
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| 8. | Roh YH, Koh YD, Noh JH, Gong HS, Baek GH. Focal eosinophilic myositis of the hand presenting as a refractory pyogenic infection. J Hand Surg Am 2017;42:842.e1-3. |
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