Spontaneous pyomyositis and AIDS: An infrequent association

Summary Pyomyositis is an acute bacterial infection of striated muscle. It is common in the tropics, but rarely reported in temperate climates. We present two cases in patients with the acquired immune deficiency syndrome (AIDS), one an active homosexual, and one an intravenous drug user. A brief review of the clinical findings and diagnostic procedures is included. We conclude that pyomyositis should be included in the list of locations of pyogenic infections that can occur in AIDS patients.

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Spontane Pyomyositis und AIDS: ein seltenes Zusammentreffen

Zusammenfassung Die Pyomyositis ist eine akute bakterielle Infektion der quergestreiften Muskulatur. Im Gegensatz zu den Tropen, wo sie häufig auftritt, wird die Pyomyositis in gemäßigten Klimazonen nur selten beobachtet. Wir stellen zwei Patienten mit Pyomyositis und AIDS vor: der eine Patient ist Homosexueller, der andere intravenös drogenabhängig. Klinische Befunde und diagnostisches Vorgehen werden kurz dargestellt. Nach unserer Meinung sollte die Pyomyositis in die Liste pyogener Infektionslokalisationen bei AIDS-Patienten eingereiht werden.

     

An uncommon infection in an uncommon host

We present the case of an international traveller who was eventually diagnosed with amoebiasis and autosomal dominant polycystic kidney disease (ADPKD) after she presented with recurring fevers. The patient was also diagnosed with non-amoebic bacterial hepatitis. Positron emission tomography (PET) can play an important role in locating the source of infection in patients with ADPKD when hepatic or renal infection is suspected. It can also be used to document clinical resolution of infection in difficult cases. Hepatic parenchymal infections in ADPKD patients may warrant a prolonged course of rotating antibiotics.     

Duodenal manifestations of nontropical sprue

Barium studies of the upper gastrointestinal tract and small bowel were performed in 16 adult patients with biopsy-proven nontropical sprue. Commercially available contrast media containing micropulverized barium sulfate, suspending agents, and various other additives were used. Radiographs were analyzed for the incidence and pattern of duodenal vs. small-bowel changes associated with celiac disease. Thirteen of 16 patients (81%) demonstrated abnormalities of the duodenum which ranged from focal erosions to diffusely thickened and nodular folds. A nonspecific, mild dilatation pattern was present on the small-bowel series of 11 patients (69%). The classic radiographic signs of malabsorption, such as flocculation and segmentation, however, occurred in less than 20% of cases, apparently because of the stability of new barium suspensions. The pathogenesis of duodenal changes in sprue and its diagnostic implications are emphasized.     

Tropical pyomyositis

Two cases of "tropical" pyomyositis or bacterial abscess of striated muscle are presented. In the first patient, a Pakistani, computed tomography gave the clue to the diagnosis. The other patient never lived outside Belgium. His history suggested staphylococcal bacteraemia preceding trauma. Familiarity with the disease considerably reduced the delay in diagnosis and treatment.     

An uncommon cause of syncope

The authors present a case of a man with recurrent syncopal episodes. The patient had been hospitalized twice before reaching a correct diagnosis. The syncope was originally ascribed to a sick sinus syndrome, which led to pacemaker implantation. Nonetheless, the patient relapsed with no evidence of pacemaker dysfunction, and was readmitted to the hospital where the likely cause for his symptoms was identified: an adenocarcinoma of the lung infiltrating the vagus and recurrent laryngeal nerves. No further syncopal episodes occurred after thoracic surgery. This syncope led to an early diagnosis of lung cancer leading to appropriate and life extending treatment.     

An uncommon cause of scleroderma

The human immunodeficiency virus (HIV) pandemic is nearly 20 years old. HIV infection is characterized by profound immunodeficiency resulting in an increased incidence of opportunistic infections and neoplasms. However, the greatest paradox is the occurrence of certain autoimmune disorders in the setting of HIV. These include diffuse interstitial lymphocytosis syndrome (DILS), reactive arthritis, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA). It has also been seen that even in the absence of these well-defined diseases, various rheumatological manifestations such as arthralgias, arthritis, myopathy, vasculitis, and sicca syndrome are commonly associated with HIV. To the best of our knowledge, the association of HIV with scleroderma has not previously been reported.     

Bacterial pyomyositis

Bacterial pyomyositis has been defined as a subacute, deep bacterial infection of the soft tissues. The entity was originally described only in tropical climates, but it is increasing in incidence in temperate climates, such as in the United States. This is mainly attributed to the presence of immunocompromising states such as HIV/AIDS or liver disease. The etiology of pyomyositis remains a mystery, but its characteristics are well-described. If untreated, the disease process progresses through three distinct stages. The first stage is defined by vague complaints, muscle pain, and a low-grade fever. The second stage presents as worsening pain, swelling, fever, and actual abscess formation in the muscle. If the patient remains untreated, pyomyositis progresses to the third stage, which includes septicemia and possible septic shock. Large muscles around the pelvis are most commonly affected, and Staphylococcus aureus is the bacteria seen in most documented cases. To make a timely diagnosis and prevent serious sequelae, physical examination, laboratory results, imaging studies, and a high clinical suspicion must all be combined. Magnetic resonance imaging is the diagnostic study of choice, but it may be inconclusive early in the disease process. Definitive diagnosis must be made with aspiration or surgical drainage. Once diagnosed, treatment consists of appropriate intravenous antibiotics and possible surgical intervention. A full recovery is expected if appropriate treatment is initiated early in the process.     

An unusual case of Lemierre's syndrome presenting as pyomyositis

Fusobacteria are most often associated with the classic presentation of Lemierre's syndrome consisting of a sore throat, internal jugular vein thrombophlebitis, and septic emboli to the lungs. Unusual presentations due to the causative organism, F. necrophorum, may occur. We present such a case involving a 17-year-old male patient with pyomyositis and fasciitis due to necrobacillosis. Fusobacterium spp. should be considered in the differential diagnosis of cases involving sepsis syndrome and pyomyositis.     

Tropical and temperate pyomyositis

Pyomyositis is a primary infection of skeletal muscle not arising from contiguous infection, presumably hematogenous in origin, and often, but not invariably, associated with abscess formation. Classically, pyomyositis is an infection of the tropics, occurring in previously active and healthy young men. Pyomyositis in temperate countries is often regarded as an infection that occurs in hosts who are immunocompromised or otherwise debilitated. However,this distinction may be somewhat artificial, as tropical pyomyositis may be partly related to underlying infection with HIV or parasites, and temperate pyomyositis has been reported in healthy and athletic persons. This article discusses the pathogenesis, clinical presentation, diagnosis, and management of pyomyositis in the tropical and temperate settings.     

Postvagotomy unmasking of nontropical sprue.

Adult celiac disease which became clinically evident after exophagectomy and vagotomy is described. The diagnosis was suggested by small bowel roentgenography and confirmed by intestinal biopsy and response to a gluten-free diet. The possibility that vagotomy unmasks asymptomatic adult celiac disease is discussed.