Figure 1
Ultrasound
Tropical Pyo-myositis and septic arthritis
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsAhmed S. Issa, MBBCh, Laila A. Mohsen, MD, Adel MS Mohsen, MD
Connected authors
16 years, male
Clinical History
A 16-year-old male patient presented with a diffuse painful swelling of the left thigh and right forearm, fever (39 °C) and limping. His total blood count revealed leukocytosis with absolute neutrophilia. The patient had negative laboratory results for HIV, hepatitis B and C viruses, diabetes mellitus and Still’s disease.
Imaging Findings
With ultrasound of the left thigh an intramuscular abscess was noted in the vastus intermedius. Ultrasound of the right forearm showed another abscess. Aspiration produced pus. Culture of the aspirate revealed methicillin sensitive staphylococcus aureus pathogen.
Left hip MRI revealed oedema in the muscles surrounding the left hip joint. The abscess was only a small component in the proximal vastus intermedius muscle. The left hip joint revealed synovial thickening, marked joint effusion with subluxation of the femoral head and bone marrow oedema in the acetabulum, femoral epiphysis, neck, trochanters and upper shaft. Cortical interruption was seen in the acetabulum and femoral head revealed deformity of its contour.
MRI of the right forearm showed an abscess on the antero-lateral aspect. It was surrounded by extensive oedema in all forearm muscles and bone marrow oedema of the radius and ulna, with no intra-articular extension. Another separate abscess was seen in the antecubital fossa.
Left hip MRI revealed oedema in the muscles surrounding the left hip joint. The abscess was only a small component in the proximal vastus intermedius muscle. The left hip joint revealed synovial thickening, marked joint effusion with subluxation of the femoral head and bone marrow oedema in the acetabulum, femoral epiphysis, neck, trochanters and upper shaft. Cortical interruption was seen in the acetabulum and femoral head revealed deformity of its contour.
MRI of the right forearm showed an abscess on the antero-lateral aspect. It was surrounded by extensive oedema in all forearm muscles and bone marrow oedema of the radius and ulna, with no intra-articular extension. Another separate abscess was seen in the antecubital fossa.
Discussion
Tropical myositis (pyomyositis) is a disease of tropical and developing countries. It is an acute muscular infection that is usually caused by bacterial pathogens, commonly staphylococcus aureus. The infection is the result of hematogenous spread.[1, 2] It is believed to originate from transient sub-clinical bacteremia from an occult focus.
The disease is now recognized in immune compromised subjects, e.g. AIDS, diabetes mellitus and transplant patients.[1-4]
A single muscle group affection is the common form; multiplicity is recorded in 10-20%.[1]
The disease is common in children and adolescents with slight male predominance. It has 3 stages. First stage starts with subacute onset of variable fever, pain, swelling with minimal systemic manifestations. This stage may divert the clinician to more common diseases, e.g. osteomyelitis. The second (Suppurative) stage is characterized by high grade fever and systemic symptoms. Because of the deep seated location and the tense overlying muscles, the classical signs of abscess formation, e.g. fluctuation may be lacking. The third stage occurs if proper treatment is not initiated, e.g. dissemination of infection, septic shock and acute renal failure.[5]
Imaging is essential for patient management. The abscess is the hallmark of pyomyositis.
On ultrasound, the abscess appears as a cystic lesion within the muscle, with internal echoes and trabeculations. Ultrasound is available, safe, and cheap. But it has poor sensitivity for detection of early stage and the deep extension of the abscess is difficult to assess, especially in obese patients.[6]
On CT, an abscess appears as a well defined low attenuation lesion with thin peripheral enhancement after IV contrast injection. Contrast enhanced CT may help detect the extension of infection.
MRI is preferred as the diagnostic tool of choice. An abscess appears as a cystic lesion that is hyperintense on T2W and STIR with thin peripheral enhancement after IV injection of gadolinium. The surrounding muscles and bones show diffuse oedema. MRI is not always available, not to mention, that it requires sedation in young children.
Diagnosis is confirmed by the aspiration of pus from these abscesses.
It is still unknown whether joint involvement is the cause or complication of pyomyositis.[7] Because pyomyositis is common in children and in the thigh, the differentiation between septic arthritis and pyomyositis is important. Clinically, this is impossible.
MRI has the potential to improve the clinical outcome by giving a more precise anatomical diagnosis to differentiate tropical pyomyositis from other more common diseases in the same age group, like osteomyelitis and septic arthritis.
The disease is now recognized in immune compromised subjects, e.g. AIDS, diabetes mellitus and transplant patients.[1-4]
A single muscle group affection is the common form; multiplicity is recorded in 10-20%.[1]
The disease is common in children and adolescents with slight male predominance. It has 3 stages. First stage starts with subacute onset of variable fever, pain, swelling with minimal systemic manifestations. This stage may divert the clinician to more common diseases, e.g. osteomyelitis. The second (Suppurative) stage is characterized by high grade fever and systemic symptoms. Because of the deep seated location and the tense overlying muscles, the classical signs of abscess formation, e.g. fluctuation may be lacking. The third stage occurs if proper treatment is not initiated, e.g. dissemination of infection, septic shock and acute renal failure.[5]
Imaging is essential for patient management. The abscess is the hallmark of pyomyositis.
On ultrasound, the abscess appears as a cystic lesion within the muscle, with internal echoes and trabeculations. Ultrasound is available, safe, and cheap. But it has poor sensitivity for detection of early stage and the deep extension of the abscess is difficult to assess, especially in obese patients.[6]
On CT, an abscess appears as a well defined low attenuation lesion with thin peripheral enhancement after IV contrast injection. Contrast enhanced CT may help detect the extension of infection.
MRI is preferred as the diagnostic tool of choice. An abscess appears as a cystic lesion that is hyperintense on T2W and STIR with thin peripheral enhancement after IV injection of gadolinium. The surrounding muscles and bones show diffuse oedema. MRI is not always available, not to mention, that it requires sedation in young children.
Diagnosis is confirmed by the aspiration of pus from these abscesses.
It is still unknown whether joint involvement is the cause or complication of pyomyositis.[7] Because pyomyositis is common in children and in the thigh, the differentiation between septic arthritis and pyomyositis is important. Clinically, this is impossible.
MRI has the potential to improve the clinical outcome by giving a more precise anatomical diagnosis to differentiate tropical pyomyositis from other more common diseases in the same age group, like osteomyelitis and septic arthritis.
Differential Diagnosis List
Pyomyositis (Tropical myositis) with complicated left hip septic arthritis.
Septic Arthritis
Osteomyelitis
Still\'s disease
Final Diagnosis
Pyomyositis (Tropical myositis) with complicated left hip septic arthritis.
References
[1] Crum-Cianflone NF (2008) Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 21: 473-494 (PMID: 18625683)
[2] Crum-Cianflone NF (2006) Infection and musculoskeletal conditions: Infectious myositis. Best Pract Res Clin Rheumatol 20: 1083-1097 (PMID: 17127198)
[3] Bickels J, Ben-Sira L, Kessler A, Wientroub S (2002) Primary pyomyositis. J Bone Joint Surg Am 84-A: 2277-2286 (PMID: 12473721)
[4] Hall RL, Callaghan JJ, Moloney E, et al (1990) Pyomyositis in a temperate climate, presentation, diagnosis and treatment. J Bone Joint Surg Am 72: 1240-4 (PMID: 2398094)
[5] Chauhan S, Jain S, Varma S, Chauhan SS (2004) Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J 80: 267–270 (PMID: 15138315)
[6] Orlicek SL, Abramson JS, Woods CR, Givner LB (2001) Obturator internus muscle abscess in children. J Pediatr Orthop 21: 744-8 (PMID: 11675547)
[7] Moran GG, Duran CG, Albiñana J (2009) Imaging on pelvic pyomyositis in children related to pathogenesis. J Child Orthop 3:479–484 (PMID: 19806379)
Case information
| URL: | https://www.eurorad.org/case/11748 |
| DOI: | 10.1594/EURORAD/CASE.11748 |
| ISSN: | 1563-4086 |
Figure 2
Left thigh MRI
Axial T2 MR image of the left hip revealing diffuse oedema of all muscles surrounding the left hip joint (red arrows).
Axial T2 image revealing synovial thickening (red arrow), effusion, subluxation of the femoral head laterally and muscle oedema in the adjacent part of rectus femoris.
Axial T2 image. All muscles around the Lt. Femur show diffuse oedema (red arrows), with a small abscess cavity anteriorly (yellow arrow).
Coronal STIR image. Fine erosions are noted in the roof of the acetabulum (red arrow). Femoral head reveals deformity of its contour (yellow arrow).
Figure 3
Right forearm MRI
Coronal STIR MR images of the right forearm. The abscess cavity (red arrow) on the antero-lateral aspect of the forearm, associated with extensive subcutaneous oedema.
Bone marrow oedema is noted along the entire length of the radius and ulna (red arrows) and also in the interosseous muscles (yellow arrow).
The infection extends to the antecubital fossa (red arrow), where there is another smaller abscess that is separate from the first one.
Ultrasound
Ultrasound images of the Rt. forearm abscess (red arrows). Transverse scan (left) and oblique scan (right).
Minia University, Department of Radiology
Minia University, Department of Radiology
Ultrasound images of the Lt. thigh abscess (red arrows). Longitudinal scan (left) and surrounding muscles (transverse scan on right).
Minia University, Department of Radiology
Minia University, Department of Radiology
Left thigh MRI
Axial T2 MR image of the left hip revealing diffuse oedema of all muscles surrounding the left hip joint (red arrows).
Minia University, Radiology department.
Minia University, Radiology department.
Axial T2 image revealing synovial thickening (red arrow), effusion, subluxation of the femoral head laterally and muscle oedema in the adjacent part of rectus femoris.
Minia University, Radiology department.
Minia University, Radiology department.
Axial T2 image. All muscles around the Lt. Femur show diffuse oedema (red arrows), with a small abscess cavity anteriorly (yellow arrow).
Minia University, Radiology department.
Minia University, Radiology department.
Coronal STIR image. Fine erosions are noted in the roof of the acetabulum (red arrow). Femoral head reveals deformity of its contour (yellow arrow).
Minia University, Radiology department.
Minia University, Radiology department.
Right forearm MRI
Coronal STIR MR images of the right forearm. The abscess cavity (red arrow) on the antero-lateral aspect of the forearm, associated with extensive subcutaneous oedema.
Minia University, Radiology department.
Minia University, Radiology department.
Bone marrow oedema is noted along the entire length of the radius and ulna (red arrows) and also in the interosseous muscles (yellow arrow).
Minia University, Radiology department.
Minia University, Radiology department.
The infection extends to the antecubital fossa (red arrow), where there is another smaller abscess that is separate from the first one.
Minia University, Radiology department.
Minia University, Radiology department.