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Tropical pyomyositis as a presenting feature of subclinical leukemia: a case report.

Navinan MR, Yudhisdran J, Kandeepan T, Kulatunga A - J Med Case Rep (2015)

Bottom Line: Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient's complicated state.Awareness of tropical pyomyositis is lacking.Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed.

View Article: PubMed Central - PubMed

Affiliation: National Hospital of Sri Lanka, Regent Street, Colombo, 10, Sri Lanka. rayno.navinan@gmail.com.

ABSTRACT

Introduction: Pyomyositis, though classically considered a tropical disease, has a variable geographic prevalence. Among the predisposing risk factors, immunodeficiency plays an important role. Pyomyositis has a tendency to mimic more commonly considered diseases, and a lack of familiarity with it is a cause of delayed diagnosis.

Case presentation: A 53-year-old South Asian man with newly diagnosed type 2 diabetes mellitus was referred to our medical unit in an advanced stage of the disease, which was complicated by sepsis and acute kidney injury. Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient's complicated state. Antibiotic therapy was initiated, and clinical stabilization was achieved with supportive measures. Following the patient's recovery from sepsis, his persistent leukopenia and anemia was suggestive of an underlying immunodeficiency, and a subsequent bone marrow biopsy revealed acute myeloid leukemia, M2 variant. Multi-disciplinary care was initiated by the medical, surgical and oncological teams.

Conclusion: Awareness of tropical pyomyositis is lacking. Common predisposing behaviors and conditions should always be sought and investigated. Immunosuppressive state is an important predisposing factor in the pathogenesis of pyomyositis. Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed. Identifying one cause should not halt the search for others, as pyomyositis may herald underlying sinister diseases.

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Related in: MedlinePlus

T2-weighted magnetic resonance image of the left thigh shows pyomyositis. T2-weighted magnetic resonance image of the left thigh taken in the sagittal plane reveals a multi-loculated mass in the medial aspect that demonstrates high signal intensity.
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Fig1: T2-weighted magnetic resonance image of the left thigh shows pyomyositis. T2-weighted magnetic resonance image of the left thigh taken in the sagittal plane reveals a multi-loculated mass in the medial aspect that demonstrates high signal intensity.

Mentions: His blood picture revealed normocytic normochromic red cells, polychromatic cells, red cell fragments with toxic neutrophils and mild thrombocytopenia. These features were compatible with hemolysis secondary to sepsis. The result of retroviral screening was negative. Ultrasound imaging of the abdomen revealed a slightly hypoechoic, mildly enlarged liver with normal ducts and splenomegaly of 13.36cm. Magnetic resonance imaging (MRI) of the patient’s left thigh and pelvis revealed a multi-loculated mass, most likely an abscess, which measured 20cm in length and 8mm in its widest diameter. The mass demonstrated high signal intensity in the medial aspect of the thigh on T2-weighted images (Figure 1), confirming our clinical suspicion of pyomyositis. Cultures of the drained pus were found to be sterile. However, a muscle biopsy and culture was positive for a non-lactose fermenting coliform organism (sensitive to cefoperazone and sulbactam, netilmicin and ciprofloxacin; intermediate sensitivity to ticarcillin-clavulanate; and resistance to imipenem, meropenem, amikacin, ceftazidime and gentamicin). A coagulase-negative, methicillin-resistant Staphylococcus aureus isolate was also detected, but contamination was considered likely.Figure 1


Tropical pyomyositis as a presenting feature of subclinical leukemia: a case report.

Navinan MR, Yudhisdran J, Kandeepan T, Kulatunga A - J Med Case Rep (2015)

T2-weighted magnetic resonance image of the left thigh shows pyomyositis. T2-weighted magnetic resonance image of the left thigh taken in the sagittal plane reveals a multi-loculated mass in the medial aspect that demonstrates high signal intensity.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4340827&req=5

Fig1: T2-weighted magnetic resonance image of the left thigh shows pyomyositis. T2-weighted magnetic resonance image of the left thigh taken in the sagittal plane reveals a multi-loculated mass in the medial aspect that demonstrates high signal intensity.
Mentions: His blood picture revealed normocytic normochromic red cells, polychromatic cells, red cell fragments with toxic neutrophils and mild thrombocytopenia. These features were compatible with hemolysis secondary to sepsis. The result of retroviral screening was negative. Ultrasound imaging of the abdomen revealed a slightly hypoechoic, mildly enlarged liver with normal ducts and splenomegaly of 13.36cm. Magnetic resonance imaging (MRI) of the patient’s left thigh and pelvis revealed a multi-loculated mass, most likely an abscess, which measured 20cm in length and 8mm in its widest diameter. The mass demonstrated high signal intensity in the medial aspect of the thigh on T2-weighted images (Figure 1), confirming our clinical suspicion of pyomyositis. Cultures of the drained pus were found to be sterile. However, a muscle biopsy and culture was positive for a non-lactose fermenting coliform organism (sensitive to cefoperazone and sulbactam, netilmicin and ciprofloxacin; intermediate sensitivity to ticarcillin-clavulanate; and resistance to imipenem, meropenem, amikacin, ceftazidime and gentamicin). A coagulase-negative, methicillin-resistant Staphylococcus aureus isolate was also detected, but contamination was considered likely.Figure 1

Bottom Line: Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient's complicated state.Awareness of tropical pyomyositis is lacking.Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed.

View Article: PubMed Central - PubMed

Affiliation: National Hospital of Sri Lanka, Regent Street, Colombo, 10, Sri Lanka. rayno.navinan@gmail.com.

ABSTRACT

Introduction: Pyomyositis, though classically considered a tropical disease, has a variable geographic prevalence. Among the predisposing risk factors, immunodeficiency plays an important role. Pyomyositis has a tendency to mimic more commonly considered diseases, and a lack of familiarity with it is a cause of delayed diagnosis.

Case presentation: A 53-year-old South Asian man with newly diagnosed type 2 diabetes mellitus was referred to our medical unit in an advanced stage of the disease, which was complicated by sepsis and acute kidney injury. Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient's complicated state. Antibiotic therapy was initiated, and clinical stabilization was achieved with supportive measures. Following the patient's recovery from sepsis, his persistent leukopenia and anemia was suggestive of an underlying immunodeficiency, and a subsequent bone marrow biopsy revealed acute myeloid leukemia, M2 variant. Multi-disciplinary care was initiated by the medical, surgical and oncological teams.

Conclusion: Awareness of tropical pyomyositis is lacking. Common predisposing behaviors and conditions should always be sought and investigated. Immunosuppressive state is an important predisposing factor in the pathogenesis of pyomyositis. Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed. Identifying one cause should not halt the search for others, as pyomyositis may herald underlying sinister diseases.

Show MeSH
Related in: MedlinePlus