American Journal of Emergency Medicine 33 (2015) 740.e5–740.e6
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute respiratory distress syndrome in a young soccer player: search obturator internus primary pyomyositis. A reverse Lemierre syndrome☆,☆☆ Abstract Pyomyositis of the obturator internus muscle is a rare condition, usually affecting children after trauma or muscular effort. Diagnosis is often delayed and may lead to severe infectious complications. We discuss hereafter the case of a 24-year-old patient who presented a primary pyomyositis of the right obturator internus muscle complicated by a thrombosis of the adjacent internal iliac vein and septic pulmonary emboli and acute respiratory distress syndrome. A 24-year-old man with no medical history was referred to the intensive care unit for acute respiratory failure. Ten days before intensive care unit referral, he complained of an acute right groin pain that occurred during a soccer match. He took nonsteroidal antiinflammatory drug. At admission, he had acute respiratory failure with fever and no sign of shock. A CT scan revealed bilateral extensive alveolar consolidations with cavitations (Fig. 1). As the right groin pain increased despite morphine, a pelvic CT scan was performed and revealed an abscess of the right obturator internus muscle associated with a right internal iliac venous thrombosis (Fig. 2A and B). Finally, blood cultures grew methicillin-sensitive Staphylococcus aureus. The definite diagnosis was a primary pyomyositis of the right obturator internus muscle, complicated by a suppurative iliac thrombophlebitis responsible for septic pulmonary emboli resulting in acute respiratory distress syndrome. The patient was successfully treated with noninvasive ventilation, methicillin, heparinotherapy, and CT-guided aspiration of pyomyositis. On day 14, the patient had no more groin pain and breathed room air. A control CT showed a marked improvement of pelvic lesions and lungs despite right upper lobe sequelae of necrotizing pneumonia (Fig. 3). The evolution was favorable thereafter. Pyomyositis is usually described in tropical countries. It refers to a primary skeletal muscle abscess that is distinct from subcutaneous tissue abscess [1]. The main muscles involved are quadriceps, glutei, and ilio-psoas muscles. Pyomyositis of the obturator internus muscle is an exceptional condition, which usually affects children or young adults nonimmunocompromised, with a history of a recent hip trauma such as fall or strenuous exercise [2]. The diagnosis is based on a localized muscle pain with movement restriction, fever, and compatible imaging in CT scan or MRI [3,4]. Blood cultures are always positive and yield mainly S aureus. Intravenous antibiotics usually ☆ Conflict of interest statement: None of the authors had conflicts of interest. ☆☆ Financial support: None.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
control the sepsis, the need for drainage being necessary in less than 25% of the cases. The scarcity of this pathology may contribute, as our patient, to the delay in diagnosis and treatment and lead to the high number of complications, such as septic arthritis, lung and brain abscesses, and septicemia [5]. Our case is exceptional by its unusual initial presentation with acute respiratory failure and its severity that was probably favored by the use of NSAID [6]. Pulmonary septic emboli resulted in acute respiratory distress syndrome as described in Lemierre syndrome [7,8] but with a reversed location: obturator interne muscle instead of primary oropharyngeal infection with evidence of septic iliac thrombophlebitis instead of internal jugular vein. Diagnosis of primary obturator pyomyositis is challenging and often delayed, which may lead to severe infectious complications as reported in this case. Physicians should be aware of this diagnosis in any patient presenting a febrile pain of the hip, especially if there is a notion of trauma or strenuous exercise. As soon as physicians consider this diagnosis, it is essential to perform a pelvic CT or magnetic resonance imaging to confirm the diagnosis and initiate early intravenous antimicrobial treatment and therapeutic anticoagulation in case of associated local thrombophlebitis. Drainage of the abscess is necessary in 25% of cases. Aude Gibelin, MD⁎ Damien Contou, MD Vincent Labbé, MD Antoine Parrot, MD Michel Djibré, MD Muriel Fartoukh, MD, PhD Service de Pneumologie et Réanimation. Hôpital Tenon Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie 4 Rue de la Chine, 75020 Paris, France ⁎Corresponding author. Service de Réanimation médico-chirurgicale Hôpital Tenon, Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie, 4 Rue de la Chine, 75020 Paris, France E-mail addresses: [email protected]; [email protected] [email protected]; [email protected] [email protected]; [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.11.033
740.e6
A. Gibelin et al. / American Journal of Emergency Medicine 33 (2015) 740.e5–740.e6
Fig. 1. Coronal chest CT scan slice showing bilateral alveolar infiltrates with extensive lesions, pulmonary nodules, and cavitation.
Fig. 3. Coronal chest CT scan slice on day 14 showing an improvement of lesions but persistence of necrotizing pneumonia with right upper lobe cavitation.
References
Fig. 2. Coronal pelvic CT scan slice showing abscess of the right obturator internus muscle (A) associated with an iliac venous thrombosis (B).
[1] Chiedozi LC. Pyomyositis: review of 205 cases in 112 patients. Am J Surg 1979;137: 255–9. [2] Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin Infect Dis 1999;28:117–22. [3] King RJ, Laugharne D, Kerslake RW, Holdsworth BJ. Primary obturator pyomyositis: a diagnostic challenge. J Bone Joint Surg (Br) 2003;85-B:895–8. [4] Soler R, Rodriguez E, Aguilera C, Fernandez R. Magnetic résonance imaging of pyomyositis in 43 cases. Eur J Radiol 2000;35:59–64. [5] Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15:668–77. [6] Voiriot G, Dury S, Parrot A, Mayaud C, Fartoukh M. Nonsteroidal antiinflammatory drugs may affect the presentation and course of community-acquired pneumonia. Chest 2011;139(2):387–94. [7] Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C. A Lemierre syndrome variant caused by Staphylococcus aureus. Am J Emerg Med 2008; 26(3):380.e5–7. [8] Cook RJ, Ashton RW, Aughenbaugh GL, Ryu JH. Septic pulmonary embolism: presenting features and clinical course of 14 patients. Chest 2005;128(1): 162–6.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute respiratory distress syndrome in a young soccer player: search obturator internus primary pyomyositis. A reverse Lemierre syndrome☆,☆☆ Abstract Pyomyositis of the obturator internus muscle is a rare condition, usually affecting children after trauma or muscular effort. Diagnosis is often delayed and may lead to severe infectious complications. We discuss hereafter the case of a 24-year-old patient who presented a primary pyomyositis of the right obturator internus muscle complicated by a thrombosis of the adjacent internal iliac vein and septic pulmonary emboli and acute respiratory distress syndrome. A 24-year-old man with no medical history was referred to the intensive care unit for acute respiratory failure. Ten days before intensive care unit referral, he complained of an acute right groin pain that occurred during a soccer match. He took nonsteroidal antiinflammatory drug. At admission, he had acute respiratory failure with fever and no sign of shock. A CT scan revealed bilateral extensive alveolar consolidations with cavitations (Fig. 1). As the right groin pain increased despite morphine, a pelvic CT scan was performed and revealed an abscess of the right obturator internus muscle associated with a right internal iliac venous thrombosis (Fig. 2A and B). Finally, blood cultures grew methicillin-sensitive Staphylococcus aureus. The definite diagnosis was a primary pyomyositis of the right obturator internus muscle, complicated by a suppurative iliac thrombophlebitis responsible for septic pulmonary emboli resulting in acute respiratory distress syndrome. The patient was successfully treated with noninvasive ventilation, methicillin, heparinotherapy, and CT-guided aspiration of pyomyositis. On day 14, the patient had no more groin pain and breathed room air. A control CT showed a marked improvement of pelvic lesions and lungs despite right upper lobe sequelae of necrotizing pneumonia (Fig. 3). The evolution was favorable thereafter. Pyomyositis is usually described in tropical countries. It refers to a primary skeletal muscle abscess that is distinct from subcutaneous tissue abscess [1]. The main muscles involved are quadriceps, glutei, and ilio-psoas muscles. Pyomyositis of the obturator internus muscle is an exceptional condition, which usually affects children or young adults nonimmunocompromised, with a history of a recent hip trauma such as fall or strenuous exercise [2]. The diagnosis is based on a localized muscle pain with movement restriction, fever, and compatible imaging in CT scan or MRI [3,4]. Blood cultures are always positive and yield mainly S aureus. Intravenous antibiotics usually ☆ Conflict of interest statement: None of the authors had conflicts of interest. ☆☆ Financial support: None.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
control the sepsis, the need for drainage being necessary in less than 25% of the cases. The scarcity of this pathology may contribute, as our patient, to the delay in diagnosis and treatment and lead to the high number of complications, such as septic arthritis, lung and brain abscesses, and septicemia [5]. Our case is exceptional by its unusual initial presentation with acute respiratory failure and its severity that was probably favored by the use of NSAID [6]. Pulmonary septic emboli resulted in acute respiratory distress syndrome as described in Lemierre syndrome [7,8] but with a reversed location: obturator interne muscle instead of primary oropharyngeal infection with evidence of septic iliac thrombophlebitis instead of internal jugular vein. Diagnosis of primary obturator pyomyositis is challenging and often delayed, which may lead to severe infectious complications as reported in this case. Physicians should be aware of this diagnosis in any patient presenting a febrile pain of the hip, especially if there is a notion of trauma or strenuous exercise. As soon as physicians consider this diagnosis, it is essential to perform a pelvic CT or magnetic resonance imaging to confirm the diagnosis and initiate early intravenous antimicrobial treatment and therapeutic anticoagulation in case of associated local thrombophlebitis. Drainage of the abscess is necessary in 25% of cases. Aude Gibelin, MD⁎ Damien Contou, MD Vincent Labbé, MD Antoine Parrot, MD Michel Djibré, MD Muriel Fartoukh, MD, PhD Service de Pneumologie et Réanimation. Hôpital Tenon Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie 4 Rue de la Chine, 75020 Paris, France ⁎Corresponding author. Service de Réanimation médico-chirurgicale Hôpital Tenon, Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie, 4 Rue de la Chine, 75020 Paris, France E-mail addresses: [email protected]; [email protected] [email protected]; [email protected] [email protected]; [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.11.033
740.e6
A. Gibelin et al. / American Journal of Emergency Medicine 33 (2015) 740.e5–740.e6
Fig. 1. Coronal chest CT scan slice showing bilateral alveolar infiltrates with extensive lesions, pulmonary nodules, and cavitation.
Fig. 3. Coronal chest CT scan slice on day 14 showing an improvement of lesions but persistence of necrotizing pneumonia with right upper lobe cavitation.
References
Fig. 2. Coronal pelvic CT scan slice showing abscess of the right obturator internus muscle (A) associated with an iliac venous thrombosis (B).
[1] Chiedozi LC. Pyomyositis: review of 205 cases in 112 patients. Am J Surg 1979;137: 255–9. [2] Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin Infect Dis 1999;28:117–22. [3] King RJ, Laugharne D, Kerslake RW, Holdsworth BJ. Primary obturator pyomyositis: a diagnostic challenge. J Bone Joint Surg (Br) 2003;85-B:895–8. [4] Soler R, Rodriguez E, Aguilera C, Fernandez R. Magnetic résonance imaging of pyomyositis in 43 cases. Eur J Radiol 2000;35:59–64. [5] Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15:668–77. [6] Voiriot G, Dury S, Parrot A, Mayaud C, Fartoukh M. Nonsteroidal antiinflammatory drugs may affect the presentation and course of community-acquired pneumonia. Chest 2011;139(2):387–94. [7] Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C. A Lemierre syndrome variant caused by Staphylococcus aureus. Am J Emerg Med 2008; 26(3):380.e5–7. [8] Cook RJ, Ashton RW, Aughenbaugh GL, Ryu JH. Septic pulmonary embolism: presenting features and clinical course of 14 patients. Chest 2005;128(1): 162–6.
