Streptococcus agalactiae pyomyositis in diabetes mellitus Deepa Panikkath, MD, Pakpoom Tantrachoti, MD, Ragesh Panikkath, MD, and Kenneth Nugent, MD
Pyomyositis is an acute infectious disorder affecting the skeletal muscle. Although seen more commonly in the tropics, cases are being reported in temperate countries, including the United States. We report a case of nontropical pyomyositis in a 58-year-old diabetic man who presented with a vague chest wall swelling. His initial clinical presentation and imaging findings suggested an intramuscular hematoma. He later developed fever with increased swelling, and pyomyositis was diagnosed after an aspiration of the swelling yielded Streptococcus agalactiae. Aspiration of the abscess and the use of appropriate antibiotics led to complete resolution of the disease. We discuss possible factors in diabetics that might predispose them to pyomyositis.
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yomyositis is a primary suppurative infection of the skeletal muscle occurring in the absence of adjacent bone, soft tissue, and skin involvement. This entity was first described as an endemic disease of the tropics by Scriba in 1885 (1). Since then, many reports have emerged in temperate climates, with the first case in the US described in 1971 (2). We present the case of a 58-year-old man with a history of Hodgkin’s lymphoma and diabetes who developed an acute swelling of the chest wall that was ultimately diagnosed as pyomyositis. CASE REPORT A 58-year-old man presented with a painful swelling of the right chest wall of 1 week duration. He denied fever, chills, night sweats, or recent trauma to that area and had no cough or dyspnea. His pain radiated from his chest to the right axilla and shoulder and increased with active movement of his arm. At the age of 51, the patient was diagnosed with Hodgkin’s lymphoma, with extensive lymphadenopathy in the right inguinal area extending to the right iliac vein. He completed chemotherapy and radiation therapy to the right inguinal and pelvic areas and had been in remission for the past 5 years. A computed tomography (CT) scan of the chest, abdomen, and pelvis done 1 week prior to admission as part of surveillance was normal. His vital signs were within normal limits. He had a poorly defined 8 × 8 cm tender erythematous mass involving his right chest wall with a soft consistency. The mass centered around an old surgical scar from a port-a-cath that was removed 290
Figure. Axial CT scan of the chest with contrast showing poorly defined fluid with a nonenhancing wall between the right pectoralis major and minor muscles.
a year earlier. There were no enlarged lymph nodes. Lungs were clear to auscultation, and the rest of the physical examination was within normal limits. The white blood cell count was 16.8 × 109/L with a left shift and 82% neutrophils. A random blood sugar was 310 mg/dL, and the hemoglobin A1c level was 10.4%. Blood cultures were negative. An ultrasound revealed a diffuse soft tissue swelling with no evidence of an abscess. A CT of the chest with contrast demonstrated a nonspecific fluid loculation measuring 5.0 × 2.8 cm between the right pectoralis major and minor muscle (Figure). On day 3, the patient spiked a temperature of 100.5°F with an increase in the size of the swelling. An ultrasound-guided incision and drainage was done, and 35 mL of thick pus was aspirated. The culture from the aspirate grew Streptococcus agalactiae. He was treated with 4 weeks of intravenous antibiotics resulting in good clinical improvement. There was no recurrence of symptoms on follow-up a month later. DISCUSSION Pyomyositis is an acute bacterial infection reported in young healthy children and adults residing in the tropics. The From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas. Corresponding author: Deepa Panikkath, MD, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(3):290–291
nontropical entity seen in temperate climates is more common in older patients and in those with immunocompromising diseases, such as HIV, diabetes mellitus, malignancies, autoimmune disorders, and chronic liver disease (3, 4). The pathogenesis of pyomyositis is poorly understood. Prior muscle injury and transient bacteremia probably contribute to its development (5). The fibronectin-binding receptors on muscle cells are possible pathways for bacterial entry (6). Muscles frequently involved are the large muscle groups, like the quadriceps, glutei, and trunk muscles (7). Staphylococcus aureus is the most common organism isolated (5, 7). The other rare causative organisms include Streptococcus groups B and C, gram-negative organisms including Escherichia coli and Klebsiella species, anaerobic bacteria, Mycobacterium species (M. avium complex and M. tuberculosis), and fungi (5, 6, 8). Pyomyositis is often misdiagnosed in its initial stages, as the clinical presentation is similar to muscle hematoma, cellulitis, osteomyelitis, and thrombophlebitis. The diagnosis is facilitated by radiologic techniques that can demonstrate the presence of fluid collections, and contrast magnetic resonance imaging is the preferred technique (9). Definitive treatment includes drainage of the abscess and long-term intravenous antibiotic therapy. This patient developed pyomyositis at the site where he had a prior port placed for chemotherapy, which might represent an area of local muscle injury. His diabetes was uncontrolled with a hemoglobin A1c of 10.9%. In a review of 246 cases of pyomyositis in non–HIV infected patients, diabetes mellitus was the most common association seen (6). Diabetes mellitus may predispose a patient to muscle damage and various bacterial infections. Microangiopathic changes and large vessel atherosclerosis are associated with microinfarcts in the muscle (10). The subsequent decrease in blood supply and local hypoxia may increase the risk of infection and abscess formation. Markedly thickened basement membranes in capillaries have been noted in diabetics and may inhibit migration of neutrophils (11). Diabetic patients have defective neutrophilic function and defective T cell–mediated immune responses, which make them prone to infections (12–14). This patient had pyomyositis secondary to Streptococcus agalactiae, which was isolated from his aspirate. S. agalactiae is known to cause infection in neonates and pregnant women,
July 2016
but rarely causes infection in adults. A PubMed search revealed only 2 cases of pyomyositis in diabetics caused by S. agalactiae (15, 16). The patient improved dramatically on 4 weeks of intravenous antibiotic therapy. Prolonged intravenous antibiotic therapy is recommended to avoid mortality and complications such as sepsis and toxic shock syndrome. 1. 2. 3. 4.
5. 6. 7. 8.
9.
10.
11.
12.
13. 14. 15.
16.
Scriba J. Beitrag zur Aetiologie der Myositis Acuta. Deutsche Zeitschrift flir Chirurgie 1885;22:497–502. Levin MJ, Gardner P, Waldvogel FA. An unusual infection due to Staphylococcus aureus. N Engl J Med 1971;284(4):196–198. Yoneda M, Oda K. Type 2 diabetes complicated by multiple pyomyositis. Intern Med 2003;42(2):174–177. Chiu SK, Lin JC, Wang NC, Peng MY, Chang FY. Impact of underlying diseases on the clinical characteristics and outcome of primary pyomyositis. J Microbiol Immunol Infect 2008;41(4):286–293. Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15(4):668–677. Crum NF. Bacterial pyomyositis in the United States. Am J Med 2004;117(6):420–428. Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J 2004;80(943):267–270. Sigler M, Midturi J, Byrd T. Escherichia coli pyomyositis presenting as right hip pain—a case report and review of literature. Southwest Respiratory and Critical Care Chronicles 2014;2(5):45–47. Theodorou SJ, Theodorou DJ, Resnick D. MR imaging findings of pyogenic bacterial myositis (pyomyositis) in patients with local muscle trauma: illustrative cases. Emerg Radiol 2007;14(2):89–96. Reich S, Wiener SN, Chester S, Ruff R. Clinical and radiologic features of spontaneous muscle infarction in the diabetic. Clin Nucl Med 1985;10(12):876–879. Feingold KR, Browner WS, Siperstein MD. Prospective studies of muscle capillary basement membrane width in prediabetics. J Clin Endocrinol Metab 1989;69(4):784–789. Marhoffer W, Stein M, Maeser E, Federlin K. Impairment of polymorphonuclear leukocyte function and metabolic control of diabetes. Diabetes Care 1992;15(2):256–260. Mowat A, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. N Engl J Med 1971;284(12):621–627. Calvet HM, Yoshikawa TT. Infections in diabetes. Infect Dis Clin North Am 2001;15(2):407–421, viii. Caldwell DS, Jr Kernodle GW, Seigler HF. Pectoralis pyomyositis: an unusual cause of chest wall pain in a patient with diabetes mellitus and rheumatoid arthritis. J Rheumatol 1986;13(2):434–436. Back SA, O’Neill T, Fishbein G, Gwinup G. A case of group B streptococcal pyomyositis. Rev Infect Dis 1990;12(5):784–787.
Streptococcus agalactiae pyomyositis in diabetes mellitus
291
Pyomyositis is an acute infectious disorder affecting the skeletal muscle. Although seen more commonly in the tropics, cases are being reported in temperate countries, including the United States. We report a case of nontropical pyomyositis in a 58-year-old diabetic man who presented with a vague chest wall swelling. His initial clinical presentation and imaging findings suggested an intramuscular hematoma. He later developed fever with increased swelling, and pyomyositis was diagnosed after an aspiration of the swelling yielded Streptococcus agalactiae. Aspiration of the abscess and the use of appropriate antibiotics led to complete resolution of the disease. We discuss possible factors in diabetics that might predispose them to pyomyositis.
P
yomyositis is a primary suppurative infection of the skeletal muscle occurring in the absence of adjacent bone, soft tissue, and skin involvement. This entity was first described as an endemic disease of the tropics by Scriba in 1885 (1). Since then, many reports have emerged in temperate climates, with the first case in the US described in 1971 (2). We present the case of a 58-year-old man with a history of Hodgkin’s lymphoma and diabetes who developed an acute swelling of the chest wall that was ultimately diagnosed as pyomyositis. CASE REPORT A 58-year-old man presented with a painful swelling of the right chest wall of 1 week duration. He denied fever, chills, night sweats, or recent trauma to that area and had no cough or dyspnea. His pain radiated from his chest to the right axilla and shoulder and increased with active movement of his arm. At the age of 51, the patient was diagnosed with Hodgkin’s lymphoma, with extensive lymphadenopathy in the right inguinal area extending to the right iliac vein. He completed chemotherapy and radiation therapy to the right inguinal and pelvic areas and had been in remission for the past 5 years. A computed tomography (CT) scan of the chest, abdomen, and pelvis done 1 week prior to admission as part of surveillance was normal. His vital signs were within normal limits. He had a poorly defined 8 × 8 cm tender erythematous mass involving his right chest wall with a soft consistency. The mass centered around an old surgical scar from a port-a-cath that was removed 290
Figure. Axial CT scan of the chest with contrast showing poorly defined fluid with a nonenhancing wall between the right pectoralis major and minor muscles.
a year earlier. There were no enlarged lymph nodes. Lungs were clear to auscultation, and the rest of the physical examination was within normal limits. The white blood cell count was 16.8 × 109/L with a left shift and 82% neutrophils. A random blood sugar was 310 mg/dL, and the hemoglobin A1c level was 10.4%. Blood cultures were negative. An ultrasound revealed a diffuse soft tissue swelling with no evidence of an abscess. A CT of the chest with contrast demonstrated a nonspecific fluid loculation measuring 5.0 × 2.8 cm between the right pectoralis major and minor muscle (Figure). On day 3, the patient spiked a temperature of 100.5°F with an increase in the size of the swelling. An ultrasound-guided incision and drainage was done, and 35 mL of thick pus was aspirated. The culture from the aspirate grew Streptococcus agalactiae. He was treated with 4 weeks of intravenous antibiotics resulting in good clinical improvement. There was no recurrence of symptoms on follow-up a month later. DISCUSSION Pyomyositis is an acute bacterial infection reported in young healthy children and adults residing in the tropics. The From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas. Corresponding author: Deepa Panikkath, MD, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(3):290–291
nontropical entity seen in temperate climates is more common in older patients and in those with immunocompromising diseases, such as HIV, diabetes mellitus, malignancies, autoimmune disorders, and chronic liver disease (3, 4). The pathogenesis of pyomyositis is poorly understood. Prior muscle injury and transient bacteremia probably contribute to its development (5). The fibronectin-binding receptors on muscle cells are possible pathways for bacterial entry (6). Muscles frequently involved are the large muscle groups, like the quadriceps, glutei, and trunk muscles (7). Staphylococcus aureus is the most common organism isolated (5, 7). The other rare causative organisms include Streptococcus groups B and C, gram-negative organisms including Escherichia coli and Klebsiella species, anaerobic bacteria, Mycobacterium species (M. avium complex and M. tuberculosis), and fungi (5, 6, 8). Pyomyositis is often misdiagnosed in its initial stages, as the clinical presentation is similar to muscle hematoma, cellulitis, osteomyelitis, and thrombophlebitis. The diagnosis is facilitated by radiologic techniques that can demonstrate the presence of fluid collections, and contrast magnetic resonance imaging is the preferred technique (9). Definitive treatment includes drainage of the abscess and long-term intravenous antibiotic therapy. This patient developed pyomyositis at the site where he had a prior port placed for chemotherapy, which might represent an area of local muscle injury. His diabetes was uncontrolled with a hemoglobin A1c of 10.9%. In a review of 246 cases of pyomyositis in non–HIV infected patients, diabetes mellitus was the most common association seen (6). Diabetes mellitus may predispose a patient to muscle damage and various bacterial infections. Microangiopathic changes and large vessel atherosclerosis are associated with microinfarcts in the muscle (10). The subsequent decrease in blood supply and local hypoxia may increase the risk of infection and abscess formation. Markedly thickened basement membranes in capillaries have been noted in diabetics and may inhibit migration of neutrophils (11). Diabetic patients have defective neutrophilic function and defective T cell–mediated immune responses, which make them prone to infections (12–14). This patient had pyomyositis secondary to Streptococcus agalactiae, which was isolated from his aspirate. S. agalactiae is known to cause infection in neonates and pregnant women,
July 2016
but rarely causes infection in adults. A PubMed search revealed only 2 cases of pyomyositis in diabetics caused by S. agalactiae (15, 16). The patient improved dramatically on 4 weeks of intravenous antibiotic therapy. Prolonged intravenous antibiotic therapy is recommended to avoid mortality and complications such as sepsis and toxic shock syndrome. 1. 2. 3. 4.
5. 6. 7. 8.
9.
10.
11.
12.
13. 14. 15.
16.
Scriba J. Beitrag zur Aetiologie der Myositis Acuta. Deutsche Zeitschrift flir Chirurgie 1885;22:497–502. Levin MJ, Gardner P, Waldvogel FA. An unusual infection due to Staphylococcus aureus. N Engl J Med 1971;284(4):196–198. Yoneda M, Oda K. Type 2 diabetes complicated by multiple pyomyositis. Intern Med 2003;42(2):174–177. Chiu SK, Lin JC, Wang NC, Peng MY, Chang FY. Impact of underlying diseases on the clinical characteristics and outcome of primary pyomyositis. J Microbiol Immunol Infect 2008;41(4):286–293. Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15(4):668–677. Crum NF. Bacterial pyomyositis in the United States. Am J Med 2004;117(6):420–428. Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J 2004;80(943):267–270. Sigler M, Midturi J, Byrd T. Escherichia coli pyomyositis presenting as right hip pain—a case report and review of literature. Southwest Respiratory and Critical Care Chronicles 2014;2(5):45–47. Theodorou SJ, Theodorou DJ, Resnick D. MR imaging findings of pyogenic bacterial myositis (pyomyositis) in patients with local muscle trauma: illustrative cases. Emerg Radiol 2007;14(2):89–96. Reich S, Wiener SN, Chester S, Ruff R. Clinical and radiologic features of spontaneous muscle infarction in the diabetic. Clin Nucl Med 1985;10(12):876–879. Feingold KR, Browner WS, Siperstein MD. Prospective studies of muscle capillary basement membrane width in prediabetics. J Clin Endocrinol Metab 1989;69(4):784–789. Marhoffer W, Stein M, Maeser E, Federlin K. Impairment of polymorphonuclear leukocyte function and metabolic control of diabetes. Diabetes Care 1992;15(2):256–260. Mowat A, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. N Engl J Med 1971;284(12):621–627. Calvet HM, Yoshikawa TT. Infections in diabetes. Infect Dis Clin North Am 2001;15(2):407–421, viii. Caldwell DS, Jr Kernodle GW, Seigler HF. Pectoralis pyomyositis: an unusual cause of chest wall pain in a patient with diabetes mellitus and rheumatoid arthritis. J Rheumatol 1986;13(2):434–436. Back SA, O’Neill T, Fishbein G, Gwinup G. A case of group B streptococcal pyomyositis. Rev Infect Dis 1990;12(5):784–787.
Streptococcus agalactiae pyomyositis in diabetes mellitus
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