Soft tissue disease

Arthritis or an Adjacent Fascial Response? A Case Report of Combined Pyomyositis and Aseptic Arthritis

Pyomyositis, accompanied by aseptic arthritis, has been previously documented in several publications. However, none of the authors in the mentioned case reports offered a pathophysiological explanation for this unusual phenomenon or proposed a treatment protocol. We present a case of a healthy, 70-year-old male who was presented to the emergency department 4 days after tripping over a pile of wooden planks and getting stabbed by a nail to his thigh. The right thigh was swollen. Unproportional pain was produced by a light touch to the thigh. A laboratory test and a CT scan were obtained. The working diagnosis was pyomyositis of the thigh and septic arthritis of the ipsilateral knee. The patient underwent urgent debridement and irrigation of his right thigh. An arthroscopic knee lavage was performed as well. Intraoperative cultures from the thigh revealed the growth of Streptococcus pyogenes and Staphylococcus aureus. Cultures from synovial fluid were sterile; thus, septic arthritis was very unlikely. The source of the knee effusion might have been an aseptic inflammatory response due to the proximity of the thigh infection. Anatomically, the quadriceps muscle inserts on the patella, and its tendon fuses with the knee capsule, creating a direct fascial track from the thigh to the knee. The inflammatory response surrounding the infection may have followed this track, creating a domino effect, affecting adjacent capillaries within the joint capsule, and causing plasma leakage into the synovial space, leading to joint effusion. Our suggested treatment is addressing the primary infection with antibiotics and considering adding anti-inflammatory therapy, given our suspicion that this process has an inflammatory component.

Best Clinical Practice: Blood Culture Utility in the Emergency Department

BACKGROUND

Bacteremia affects 200,000 patients per year, with the potential for significant morbidity and mortality. Blood cultures are considered the most sensitive method for detecting bacteremia and are commonly obtained in patients with fever, chills, leukocytosis, focal infections, and sepsis.

OBJECTIVE

We sought to provide emergency physicians with a review of the literature concerning blood cultures in the emergency department.

DISCUSSION

The utility of blood cultures has been a focus of controversy, prompting research evaluating effects on patient management. Bacteremia is associated with increased mortality, and blood cultures are often obtained for suspected infection. False-positive blood cultures are associated with harm, including increased duration of stay and cost. This review suggests that blood cultures are not recommended for patients with cellulitis, simple pyelonephritis, and community-acquired pneumonia, because the chance of a false-positive culture is greater than the prevalence of true positive cultures. Blood cultures are recommended for patients with sepsis, meningitis, complicated pyelonephritis, endocarditis, and health care-associated pneumonia. Clinical prediction rules that predict true positive cultures may prove useful. The clinical picture should take precedence. If cultures are obtained, two bottles of ≥7 mL should be obtained from separate peripheral sites.

CONCLUSIONS

Blood cultures are commonly obtained but demonstrate low yield in cellulitis, simple pyelonephritis, and community-acquired pneumonia. The Shapiro decision rule for predicting true bacteremia does show promise, but clinical gestalt should take precedence. To maximize utility, blood cultures should be obtained before antibiotic therapy begins. At least two blood cultures should be obtained from separate peripheral sites.

Hip pain and fever: when it's not a septic joint, what's next?

Hip pain and fever in children include a broad differential. Most concerning is the possible diagnosis of a septic joint, which carries significant morbidity. We describe the case of a 13-year-old boy with fever and hip pain who was referred to the emergency department with concern for septic hip. The etiology was later discovered to be pyomyositis from methicillin-resistant Staphylococcus aureus. In areas with high prevalence of community-acquired methicillin-resistant Staphylococcus aureus, it is important for physicians to be aware of this rare, but potentially complicated condition.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Community-associated methicillin-resistant Staphylococcus aureus pyomyositis complicated by compartment syndrome in an immunocompetent young woman

Pyomyositis is a bacterial infection of skeletal muscle common in the tropics. Pyomyositis has historically been rare in temperate regions. However, the epidemiology is changing, and over the past decade, the number of cases in the United States and Europe has increased significantly. One major factor appears to be the increase in community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections. This pathogen now accounts for most of the skin and soft tissue infections throughout much of the United States. Most community-associated MRSA infections carry specific virulence factors, most notably the Panton-Valentine leukocidin gene, known to increase invasive capability and predispose to abscess and deep tissue infections. We report a case of a young healthy woman who was initially treated as an outpatient for tendonitis. She presented 3 days later to the emergency department where she was diagnosed with upper extremity pyomyositis complicated by compartment syndrome. A fasciotomy was performed in the operating room, and intraoperative cultures grew MRSA. She did not have any traditional risk factors for the acquisition of health care-associated MRSA. Her subsequent course was complicated by osteomyelitis of the proximal radius. This is the first report of pyomyositis complicated by compartment syndrome in the emergency medicine literature. This case emphasizes the need to remain vigilant for deep muscle infections given the evolving epidemiology. It also highlights possible complications of pyomyositis including the rare but serious complication of compartment syndrome.

Gangrenous, Hemorrhagic, Bullous Cellulitis Associated with Pseudomonas aeruginosa in a Patient with Waldenström's Macroglobulinemia

BACKGROUND

Patients with Waldenström's macroglobulinemia may manifest several types of skin lesions. We present our experience with a patient with the disease that adds to the literature on the topic.

CASE DESCRIPTION

A 57-year-old man with history of multiple sclerosis and Waldenström's macroglobulinemia was admitted to the intensive care unit in shock. His family members reported that the patient had complained of fever and the gradual development of gangrenous, hemorrhagic, bullous cellulitis lesions on the abdomen and lower extremities for 7 days prior to his admission to the hospital. Pseudomonas aeruginosa was isolated from fluid specimens collected from the cutaneous lesions. Appropriate antimicrobial treatment including continuous intravenous administration of meropenem (6 g every 24 h) led to the cure of the infection.

CONCLUSIONS

We postulate that the underlying Waldenström's macroglobulinemia contributed to the pathophysiology of the development of the rare skin manifestations of the infection observed in our patient.

Skin and Soft Tissue Infections

Primary skin infections (ie, pyodermas) typically are initiated by some breach in the epidermis, resulting in infection by organisms, such as Streptococcus pyogenes and Staphylococcus aureus, that normally colonize the skin. Host-associated factors, such as immunosuppression, vasculopathy, neuropathy, or decreased lymphatic drainage, may predispose to skin infection. The clinical syndromes associated with skin infections are often characteristic and are defined most simplistically by anatomic distribution. Although often mild and self-limited, skin infections can be more aggressive and involve deeper structures, including fascia and muscle. This article discusses skin and soft tissue infections, including impetigo, hair follicle-associated infections (ie, folliculitis, furuncles, and carbuncles) erysipelas, cellulitis, necrotizing fasciitis, pyomyositis, septic bursitis, and tenosynovitis.

Suppurative tenosynovitis and septic bursitis

Suppurative tenosynovitis and septic bursitis are closed space infections of the musculoskeletal system. Appropriate antibiotics in combination with incision and drainage are generally recommended. Aggressive surgical management is particularly important in tenosynovitis to prevent tendon necrosis. Empiric antibiotic coverage should be directed toward staphylococci and streptococci. Patient characteristics and epidemiologic exposures may provide clues to unusual causative organisms that are occasionally encountered, such as Neisseria gonorrhoeae, Pasteurella multocida, atypical mycobacteria, fungi, and protothecosis.

Community-acquired methicillin-resistant Staphylococcus aureus pyomyositis in an intravenous drug user

Pyomyositis is a disease of abscess formation deep within large striated muscles. Outside of the tropics it is a rare disease which occurs mainly in certain patient populations such as the immunosuppressed or intravenous drug users (IDUs). A case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pyomyositis in an IDU is described. The incidence of both CA-MRSA and pyomyositis is currently increasing. To the authors' knowledge this is the first reported case of CA-MRSA pyomyositis in the UK. Cases of CA-MRSA pyomyositis are likely to increase and it may be necessary to empirically treat certain patients with glycopeptides.