|Year : 2012 | Volume
| Issue : 1 | Page : 40-42
Gram-negative bacterial pyomyositis in a patient with diabetes mellitus and chronic renal failure
OP Kalra1, Alpana Raizada2
1 Division of Nephrology; Department of Medicine, University College of Medical Sciences (University of Delhi), UCMS-GTBH, Delhi, India
2 Department of Medicine, University College of Medical Sciences (University of Delhi), UCMS-GTBH, Delhi, India
|Date of Web Publication||3-Dec-2012|
C-57/Y3, C-Block, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Pyomyositis is a suppurative infection of the skeletal muscles. The predisposing conditions include immunosuppression accompanying malignancy, diabetes mellitus, renal failure, and acquired immunodeficiency syndrome, etc. We report a 49-year-old female with diabetes mellitus and chronic renal failure undergoing maintenance hemodialysis who presented with the suppurative stage of gram-negative bacterial pyomyositis due to Escherichia coli. She fully recovered following incision and drainage and appropriate antibiotic therapy. We highlight the importance of timely diagnosis of this uncommon and potentially life-threatening entity and the role of chronic renal failure and hemodialysis in causing this condition.
Keywords: Diabetes mellitus, hemodialysis, pyomyositis
|How to cite this article:|
Kalra O P, Raizada A. Gram-negative bacterial pyomyositis in a patient with diabetes mellitus and chronic renal failure. J Acad Med Sci 2012;2:40-2
|How to cite this URL:|
Kalra O P, Raizada A. Gram-negative bacterial pyomyositis in a patient with diabetes mellitus and chronic renal failure. J Acad Med Sci [serial online] 2012 [cited 2019 Oct 19];2:40-2. Available from: http://www.e-jams.org/text.asp?2012/2/1/40/104015
| Introduction|| |
Pyomyositis is a suppurative infection of the skeletal muscles. Normal skeletal muscle is relatively resistant to bacterial infection. Local muscle injury with resultant bacteremia has been implicated as a likely mechanism for infection. Pyomyositis usually involves large muscle groups of the pelvic girdle and lower extremities with Staphylococcus aureus being the most common pathogen. It commonly occurs in the tropics with diabetes mellitus and acquired immunodeficiency syndrome being the main predisposing factors. We came across a case of diabetes mellitus with chronic renal failure on maintenance hemodialysis who developed gram-negative bacterial pyomyositis due to Escherichia coli and fully recovered following incision and drainage and appropriate antibiotic therapy.
| Case Report|| |
A 49-year-old woman with insulin-dependent diabetes mellitus with chronic renal failure who had been on maintenance hemodialysis for 3 months presented with history of pain and swelling of right hip and thigh for 1 week. Hemodialysis was being done through right internal jugular catheter. The patient denied history of recent trauma or insect bite and there was no history of concomitant febrile illness. Comorbidities included ischemic heart disease and hypertension. Physical examination revealed a malnourished afebrile woman, hemodynamically stable with a tender, tense, and swollen right thigh. Her right hip was held in semi-flexed position and there was restriction of all movements at right hip joint. There was no erythema or palpable lymphadenopathy.
Laboratory results revealed leucocytosis (25.5×10 9 /L), neutrophilia (80%), low hematocrit (24%), C-reactive protein >6 mg/L, and serum albumin 2.0 g/dL. Ultrasonography of the right hip showed evidence of right periarticular soft tissue swelling with no evidence of effusion. Blood and urine culture showed no growth.
The patient was empirically treated with intravenous teicoplanin and ceftriaxone. Despite antibiotic therapy for 1 week, no clinical improvement was evident. Magnetic resonance imaging of pelvis and hip joints done during the second week of therapy revealed diffuse myofascial and subcutaneous edema involving the gluteal and proximal thigh muscles, more on right side with loculated fluid collection in right gluteal region and posterolateral aspect of right upper thigh [Figure 1] and [Figure 2]. Both hip joints were found to be normal. The patient was subjected to incision and drainage and 300 mL of thick yellow pus was drained. Gram's stain of the drained fluid was negative; however, pus culture revealed growth of E. coli.
|Figure 1: T2-weighted coronal image with vertical arrow pointing to a multiloculated fluid collection in the right gluteal region and the horizontal arrow pointing to myofascial edema involving pelvic and proximal thigh muscle|
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|Figure 2: T2-weighted axial image with arrow showing fluid collection in the right gluteal region|
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Following surgical drainage, there was progressive disappearance of tenderness, swelling, and local pain. The patient was put on oral amoxicillin-clavulanic acid and teicoplanin was continued. The patient recovered and was subsequently discharged.
| Discussion|| |
Pyomyositis is an uncommon and potentially life-threatening condition characterized by purulent infection of the striated muscles. The muscle groups most frequently affected are large muscles of lower extremities mostly thigh and trunk muscles. S. aureus is responsible for 95% of cases in tropical areas and 70% of cases in nontropical areas.  The clinical course consists of three stages: invasive stage, suppurative stage, and stage of systemic toxicity.
The suggested etiological factors include muscle trauma with concomitant bacteremia, parasitemia, and tropical climate. The predisposing factors include immunosuppression accompanying acquired immunodeficiency syndrome, malignancy, diabetes mellitus, renal failure, neutropenia, and immunosuppressive therapy.  In dialysis patients, there is impairment of several aspects of lymphocyte and granulocyte function presumably due to unidentified uremic toxins, malnutrition, and periodic exposure of blood to certain dialysis membranes. Bacterial infections occur more often in dialysis patients than in their nonuremic counterparts probably because of more frequent violation of normal skin and mucosal barriers. In addition, bacterial infections in dialysis patients appear to progress more quickly and resolve less promptly than in nonuremic patients. In dialysis patients, the incidence of urinary tract infections is also high. In our case, the patient had diabetes mellitus coupled with malnutrition and chronic renal failure requiring hemodialysis. Bacteremia in this patient could have been catheter related as the patient was on maintenance hemodialysis or could have originated from urinary tract.
Tropical pyomyositis has been reported frequently from Latin America and Africa and only a few cases have been reported from India. Malhotra et al. had reported 22 cases of tropical pyomyositis admitted to Post graduate Institute of Medical Education and Research, Chandigarh. They observed that the disease was more common in young adults with males outnumbering females. They also found that S. aureus was the commonest causative organism.  Sarubbi et al. had mentioned that skeletal muscle infection due to gram-negative bacteria is an acknowledged rarity, even in tropical areas. They had observed that gram-negative pyomyositis is more likely in lower leg muscles and that clinical cure is often achieved following appropriate drainage and antibiotic therapy. 
Most of the laboratory findings in pyomyositis are nonspecific. In a patient with diabetes mellitus, myonecrosis may present with similar clinical manifestations. Positive blood cultures have been documented in less than 5% cases in tropical climates.  Till culture reports become available, empirical therapy directed primarily toward S. aureus infections and also for gram-negative coverage should be instituted. There are no guidelines for treatment of this entity and surgical drainage is the mainstay of treatment. The mortality rate of pyomyositis in tropical climates is reported to be as high as 14%.  Thus, diagnosis of this disease largely depends on a high index of clinical suspicion which can lead to timely intervention and a substantial reduction in morbidity and mortality.
| Conclusion|| |
This case report has highlighted how a diabetic female on maintenance hemodialysis could have tipped off from the suppurative stage of pyomyositis to the stage of systemic toxicity had there been a delay in diagnosis. Thus, a high index of suspicion coupled with timely radiological investigation and surgical intervention and appropriate antibiotic therapy can prevent fatal complications.
| References|| |
|1.||Christin L, Sarosi GA. Pyomyositis in North America: Case reports and review. Clin Infect Dis 1992;15:668-77. |
|2.||Hossain A, Reis ED, Soundararajan K, Kerstein MD, Hollier LH. Nontropical pyomyositis: analysis of eight patients in an urban center. Am Surg 2000;66:1064-6. |
|3.||Malhotra P, Singh S, Sud A, Kumari S. Tropical pyomyositis: Experience of a tertiary care hospital in north-west India. J Assoc Physicians India 2000;48:1057-9. |
|4.||Sarubbi FA, Gafford GD, Bishop DR. Gram-negative bacterial pyomyositis: Unique case and review. Rev Infect Dis 1989;11:789-92. |
|5.||Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg 1979;137:255-9. |
|6.||Bonafede P, Butler J, Kimbrough R, Loveless M. Temperate zone pyomyositis. West J Med 1992;156:419-23. |
[Figure 1], [Figure 2]