MRSA Pyomyositis in a South Texas Teen

1
MRSA Pyomyositisin a South Texas Teen

• Andrea Setlik, MD, PL-3
• Melissa DeLario, MD, PL-2
• Glen Medellin, MD

2
Introduction

• Staph aureus pyomyositis is a common affliction
  in the tropics. However, it was largely unknown
  in the US until recent years. An increasing
  number of cases among immunocompetent patients in
  the US are being identified, and MRSA is an
  increasingly common pathogen. Infection
  typically does not spread to organs outside
  skeletal muscle, though bacteremia is common.

3
Case

• We present a case of pyomyositis in a previously
  healthy, active 15 yo African-American male (JR).
  He developed back pain after playing basketball,
  and symptoms progressed over 4 days to include
  severe myalgias in all extremities, difficulty
  walking, and fever to 104F. JR also complained
  of chest soreness with deep inspiration.

4
Case (continued)

• PMH Term SVD, no complications. No
  hospitalizations, no surgeries
• SH Born in Michigan, in custody of
  grandparents. Moved to San Antonio 1 year ago. No
  recent history of travel
• Development 10th grade, doing well. Plays
  basketball and runs track
• FH Mother with Guillain-Barre Syndrome as a
  child
• HEADSS No EtOH, no drugs, not sexually active.
  Takes a protein supplement only

5
Exam

• Febrile but alert and cooperative
• HEENT normal exam
• CV 2/6 SEM at LUSB. No gallops or rubs. 2
  pulses and cap refill
• Resp Clear lungs bilaterally but complains of
  pain on deep inspiration
• Abd Nontender, no masses, no HSM
• Neuro Cranial nerves intact. Strength 4-/5 in
  large muscles and 5/5 in small muscles.
  Difficulty sitting up. Reflexes difficult to
  elicit but present throughout. Normal sensation
  throughout
• Skin No rashes
• Musculoskeletal - Tender to palpation over right
  paraspinal region. Chest pain not reproducible on
  palpation
• Back No spinous process tenderness or stepoffs

6
Labs

• WBC 6.3 (63 segs, 23 bands, 9 lymphs, 5
  monos). Hematocrit and platelet count were
  normal
• Na 132 K 4.0 Cl 101 CO2 22 BUN 10
• Cr 0.8 Glu 153 Ca 8.8
• ESR 53 mm/h (elevated)
• CRP 26.37 mg/L (elevated)
• CPK 247 U/L
• LDH 287 U/L
• Aldolase 9.5 U/L
• Blood culture drawn

7
Differential Diagnosis

• Differential diagnosis included Guillain-Barre
  Syndrome, infectious myositis, dermatomyositis,
  pyomyositis, CNS inflammation, post-traumatic
  back pain, and a viral syndrome such as
  influenza. However, JR had no rash or headache,
  and the number of systemic symptoms was
  inconsistent with simple muscle strain or injury.

8
Differential Diagnosis

• JRs family history of Guillain-Barre raised some
  concern, as there are reports of pediatric
  patients with this syndrome presenting with
  myalgias, difficulty walking, and fever. In one
  study, 79 of children with Guillain-Barre had
  pain and 93 complained of leg weakness. Another
  report suggested 53 of children with
  Guillain-Barre over age 5 had pain as the first
  sign of disease.

9
Diagnosis

• An enhanced thoracolumbar MRI was obtained and
  showed an abscess of the right erector spinae
  from L4-S1.

10
Thoracolumbar MRI
Thoracolumbar MRI demonstrating an abscess in the
right erector spinae from L4 to S1.
11
Treatment

• JR was started empirically on IV vancomycin and
  clindamycin. His muscle abscess was drained via
  percutaneous drainage, and the wound culture and
  blood cultures were positive for MRSA sensitive
  to above antibiotics and D-test negative.

12
Hospital Course

• Blood cultures remained positive for 6 days on IV
  antibiotics and patient continued to be febrile
  and have myalgias
• Bone scan was negative for osteomyelitis
• JR reported increased chest pain, and a chest CT
  showed multiple microabscesses in the left lower
  and right upper lobes of the lungs

13
Chest CT
Chest CT demonstrating multiple lung abscesses
throughout both lungs.
14
Hospital Course (continued)

• Cardiology was consulted to evaluate for
  endocarditis in light of S. aureus bacteremia and
  abscesses
• Prior to evaluation, JR developed a fixed split
  S2 with prominent pulmonary component
• An echocardiogram was negative for endocarditis
  but showed moderate pulmonary hypertension
• Repeat echocardiogram 4 days later showed
  resolution of pulmonary hypertension

15
Hospital Course (continued)

• JR received a total of 11 days IV clindamycin, 8
  days IV vancomycin, and 10 days oral clindamycin
• Prior to discharge, CRP had decreased to 11.98
  mg/L
• Myalgias, back pain, weakness, and fever improved
  but had not resolved at time of discharge
• At followup 6 weeks later, JR had no residual
  symptoms or sequelae

16
Pyomyositis

• Tropical pyomyositis was described in 1885 and
  peak incidence has classically been in those 2-5
  yo and 35-40 yo. In recent years pyomyositis has
  emerged in the US population, with some studies
  citing a peak incidence in teen males. Vigorous
  exercise is also correlated with disease. Fever
  and elevation of the WBC, ESR, and CRP are
  characteristic.

17
Pyomyositis (continued)

• S. aureus is the most common agent in all
  pyomyositis, though cases in immunocompromised
  patients have been shown to grow such organisms
  as M. tuberculosis, N. gonorrheae, and
  Pseudomonas species.
• Disseminated infection is also more common in
  immunocompromised patients. However, there is a
  single reported case of a 6 yo immunocompetent
  patient with widespread disease to include CNS,
  lung, and cardiac involvement.

18
Pyomyositis (continued)

• MRSA has become a common and sometimes aggressive
  agent in South Texas. However, disseminated
  infection from community-acquired MRSA is
  uncommon in a healthy host. It is extremely rare
  to identify lung abscesses in a young, healthy
  patient. Review of the literature showed no
  prior reports of pulmonary hypertension
  associated with pyomyositis.

19
Conclusion

• This is a rare case of disseminated
  community-acquired MRSA pyomyositis in a healthy
  teen. It is the second reported case of lung
  abscesses occurring in a young, healthy host, and
  the only reported case of pyomyositis leading to
  pulmonary hypertension.

20
References

• 1. Chau CLF, Griffth JF. Musculoskeletal
  infections ultrasound appearances. Clinical
  Radiology. 200560(2)149-59.
• 2. Chauhan S, Jain S, Varma S, Chauhan SS.
  Tropical pyomyositis (myositis tropicans)
  current perspective. Postgrad Med J.
  200480267-70.
• 3. Crum NF. Bacterial pyomyositis in the United
  States. Am J Med. 2004117420-28.
• 4. Cummings D. Case 11 Could this be
  Guillain-Barre Syndrome? Medscape Neurology
  Neurosurgery 20024(1).
• 5. Flier S, Dolgin SE, Saphir RL, Shlasko E,
  Midulla P. A case confiring the progressive
  stages of pyomyositis. J Pediatr Surg.
  2003381551-53.
• 6. Fox LP, Geyer AF, Grossman ME. Pyomyositis. J
  Am Acad Dermatol 200451308-14.
• 7. Grose C. Staphylococcal pyomyositis in South
  Texas. J Pediatrics. 197893(3)457-58.

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References (continued)

• 8. Mukhtyar C, Bradlow A. Primary obturator
  pyomyositis. Rheumatology. 200544(3)408-410.
• 9. Ruiz ME, Yohannes S, Wladyka CG. Pyomyositis
  caused by methicillin-resistant Staphylococcus
  aureus. N Engl J Med. 200535214.
• 10. Spiegel DA, Meyer JS, Dormans JP, Flynn JM,
  Drummond DS. Pyomyositis in children and
  adolescents report of 12 cases and review of the
  literature. J Pediatr Orthop. 199919(2)143-50.
• 11. Trusen A, Beissert M, Schultz G, Chittka B,
  Darge K. Ultrasound and MRI features of
  pyomyositis in children. Eur Radiol.
  2003131050-55.
• 12. Walji S, Rubenstein J, Shannon P, Carette S.
  Disseminated pyomyositis mimicking idiopathic
  inflammatory myopathy. J Rheumatol.
  200532184-87.
• 13. Wang C, Chuang C, Chiu C. Community-acquired
  disseminated methicillin-resistant Staphylococcus
  aureus infection case report and clinical
  implications. Annals of Tropical Paediatrics.
  20052553-57.
• 14. Yu C, Hsiao J, Hsu C, Shih TT. Bacterial
  pyomyositis MRI and clinical correlation. Magn
  Reson Imaging. 2004221233-41.