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NONTROPICAL PYOMYOSITIS IN PATIENTS WITH AIDS Suresh J. Antony, MD, and Douglas S. Kernodle, MD Nashville, Tennessee

Nontropical pyomyositis in persons with acquired immunodeficiency syndrome (AIDS) is an unusual entity with only a few cases having been described in the United States. Staphylococcus aureus is the most common organism implicated. The infection usually presents in a subacute indolent fashion with minimal inflammation. Fever and leukocytosis may be absent, and blood cultures are frequently negative. The diagnosis usually can be established by a combination of clinical features, computed tomography or ultrasound, and prompt examination of material obtained by aspiration or debridement. This article describes two cases of S aureus pyomyositis in patients with AIDS and reviews the literature relevant to this infection. (J Nat! Med Assoc. 1 996;88:565-569.) Key words * pyomositis * acquired immunodeficiency syndrome (AIDS) * Staphylococcus aureus Pyomyositis involving the skeletal muscles in acquired immunodeficiency syndrome (AIDS) is a rare condition with only a few cases having been reported in the United States. 1-4 Staphylococcus aureus has been the predominant organism isolated.5'6 This article presents two cases of severe pyomyositis in AIDS patients at different anatomical sites and discusses the pathogenesis, complications, and treatment of this condition.

From the Division of Infectious Diseases, Vanderbilt University School of Medicine and the Department of the Veterans Affairs Medical Center, Nashville, Tennessee. Requests for reprints should be addressed to Dr Suresh J. Antony, El Paso Cancer Treatment Ctr, 7848 Gateway E, El Paso, TX 79915. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 9

CASE REPORTS Case 1 A 31-year-old male with AIDS (CD4 count of 89 cell/cu mm3) and a history of active intravenous drug abuse, disseminated histoplasmosis, and perianal herpes was admitted to the hospital with pain and minimal swelling of the lateral aspect of the left lower extremity. The symptoms had progressed slowly over 4 weeks, and the patient denied fever, chills, or night sweats. There was no history of trauma, muscle sprain, or injection with needles at this site. On physical examination, the patient's temperature was 99.10, blood pressure was 118/76 mm Hg, and pulse rate was 87 beats/minute. Minimal swelling of the lateral compartment of the leg was noted with faint erythema of the overlying skin and mild to moderate tenderness. There was no evidence of fluctuance. The dorsalis pedis and posterior tibial pulses were palpable, and Homan's sign was negative. There were one to two single, nonmatted, nontender lymph nodes palpable in the left groin. The rest of the physical examination was normal. Laboratory values were as follows: white blood cell count, 2400 cells/cu mm3 with 72% neutrophils, 15% lymphocytes, 10% monocytes, and 3% basophils; hematocrit, 33%; and platelet count, 59,000 cells/cu mm3. Blood cultures were negative and remained negative throughout the course of the illness. A computed tomography scan of the leg revealed an 11 X9 cm tubular mass in the lateral compartment of the left leg involving the peroneus longus muscle (Figure 1). The patient was started on intravenous nafcillin and gentamicin and underwent resection of the peroneus longus muscle and debridement of the area, which had a significant amount of necrotic tissue and pus. Cultures from the debridement site grew a strain of methicillinsusceptible S aureus that was resistant to penicillin but sensitive to oxacillin, clindamycin, erythromycin, and ofloxacin. 565

NONTROPICAL PYOMYOSITIS

Figure 1. Case 1. Computed tomography scan of the left leg. The 11 x9 cm tubular mass was confined to the lateral compartment and tracked down to the Achilles tendon.

Two days after surgery, the patient became hypotensive and developed acute respiratory distress requiring intubation and ventilation. He became oliguric and his creatinine level rose to >12 mmol/L, and he underwent hemodialysis. The antibiotics were changed to imipenem and rifampin to broaden the antimicrobial coverage, and he was extubated after 5 days of ventilator assistance. He received 2 weeks of parenteral antibiotics and was discharged from the hospital on a further 3-week course of oral ofloxacin. At no time during his hospitalization did he develop a fever. On follow-up 10 days later, the wound had healed well, and creatinine levels had returned to normal.

Case 2 A 40-year-old bisexual male with AIDS and a past history of Pneumocystis carinii pneumonia, syphilis, giardiasis, intravenous drug abuse, and right wrist cellulitis presented to the hospital with a 2-week history of pain and swelling of the posterior aspect of the left chest associated with fever, chills, and weight loss. He denied trauma, injection with needles, or previous injury to the area. There was no history of tuberculosis or known Mycobacterium avium-intracellulare infection. On examination, he had a temperature of 970, blood pressure of 122/67 mm Hg, and a pulse rate of 96 beats/minute. The chest wall was notable for an 8 X 14 cm fluctuant mass over the left posterior aspect of the chest. The mass appeared to be confined to the skin and subcutaneous area without involvement of the muscle. The rest of the examination was unremarkable. Laboratory values were: white blood cell count of 6300 cell/cu mm3, with 85% neutrophils, 10% lymphocytes, and 5% monocytes; and hematocrit, 19%. The chest roentgenogram demonstrated a large mass over 566

the left lateral chest wall and a 2X2cm mass in the left upper lung (Figure 2). The patient underwent incision and drainage of the mass. The abscess had loculated areas of pus extending into the underlying muscle planes with edema and inflammation of the muscle and fascial planes. Cultures taken during surgery grew a strain of methicillin-susceptible S aureus. He was placed on intravenous oxacillin for 10 days and discharged on dicloxacillin after 3 weeks. Bronchoscopy to evaluate the pulmonary mass was negative for an infectious etiology. The patient was readmitted 10 days later with a temperature of 102.40 and a recurrent abscess of the left posterior chest after failing to take the prescribed antibiotics. Repeat drainage of the abscess was performed and the cultures again grew methicillin-susceptible S aureus. In addition, the blood cultures grew the same organism. He was placed on intravenous nafcillin for 14 days and discharged on a 4-week course of dicloxacillin. On follow-up 3 weeks later, the abscess had resolved.

DISCUSSION Pyomyositis is a bacterial infection of the skeletal muscle that is called tropical pyomyositis, myositis tropicans, or tropical myositis in Africa.79 In Uganda, it accounts for up to 4% of all surgical admissions.5'10 It is a rare condition in temperate climates, and approximately 100 cases in non-AIDS patients have been reported in the United States since 197 1.6,11 The first case of pyomyositis in AIDS in North America was reported by Gaut et al12 in 1988. It tends to occur more commonly in adults, males, and homosexuals.2'3"1 There has been no racial predisposition described in North America. It also has been described in other immunocompromised conditions such as diabetes mellitus, neutropenia in cancer patients, agammaglobulinemia,13 leukemia, aplastic anemia, and Felty's syndrome.6'14"5 Travel to and immigration from tropical countries has been proposed as a diagnostic criteria for pyomyositis7; however, in the United States, only 9% of patients with pyomyositis had a history of travel."I Pyomyositis tends to involve the lower extremities and large muscle groups such as the gluteal muscles, quadriceps femoris, and thigh and calf muscles.'6"7 Abscesses may be present in 15% to 50% of the cases and may be single or multiple and are usually due to direct extension into the muscle or through bacteremic spread and seeding.'8 Pyomyositis has been divided into three stages depending on the degree of induration and severity of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 9


illness in the patient. The early or first stage (invasive) occurs when there is no induration or pus and minimal pain'9; the microorganisms enter the tissue through the skin or via the blood vessels.19'20 The second stage (purulent) involves moderate induration with marked leukocytosis and pus on aspiration of the area. Myocytolysis occurs with polymorphonuclear infiltration in this stage. The late stage presents with bacteremia and a fluctuant swelling with complications such as endocarditis, brain abscesses, and occasionally renal failure, pneumonia, and septic shock.5 Adenopathy is rare during any stage of the disease.'9 Staphylococcus aureus is the most common organism isolated in pyomyositis in 85% to 95% of the cases.5'6 Phage typing of S aureus has not demonstrated a definite correlation between pyomyositis and a single type.'8 This issue has not been addressed in AIDS patients: The exact pathogenesis of pyomyositis is unknown, and trauma is implicated in up to 50% of the cases.5"9'20 Other causes have included parasitic infections (usually in tropical countries) such as filaria and nematodes 21,22; nutritional deficiencies such as selenium, vitamin E,23 and thiamine (Engel) deficiencies; coxsackievirus infections24; and leptospirosis.5'6'25 Miyaki and colleagues,6 in their animal model, failed to produce abscess formation in skeletal muscle without muscle injury such as pinched tissue, electric shock, or ischemia. These experiments suggested the high intrinsic resistance of skeletal muscle to bacterial infection and suggested that underlying muscle damage is needed for bacterial infection.26 In the immunocompromised host, defective polymorphonucleaur nuetrophil function, neutropenia, and defective T-lymphocyte function may be responsible for the development of pyomyositis. In patients with AIDS, monocytes and granulocyte show a decrease in the phagocytosis of S aureus in comparison to phagocytes of healthy individuals. It is unclear whether there are intrinsic defects of phagocytosis that are responsible for the diminished antimicrobial killing.27 In addition, the defective B lymphocyte function in AIDS also may be responsible for the decreased resistance to staphylococcal infections.28 Patients with AIDS have an increased incidence of S aureus septicemia. Weinke et a129 noted that 6 out of 136 human immunodeficiency virus (HIV)-infected patients with S aureus nasopharyngeal colonization developed septicemia in their 8-month study period. Persons infected with HIV have a higher prevalence of nasopharyngeal colonization with S aureus (44%) than non-HIV patients (30.8%).29 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 9

Figure 2. Case 2 Chest radiograph demonstrating an 8x14 cm mass over the posterior aspect of the chest.

In the United Kingdom, the rate of asymptomatic carriage of S aureus was increased in homosexual men (45%) with asymptomatic HIV infections when compared with HIV-negative homosexual males (27%).30 The neutrophils from homosexual AIDS patients have a defect in their ability to kill S aureus in vitro compared with neutrophils from normal healthy heterosexual seronegative controls, which may be due to impaired Fc receptor or complement receptor 3-mediated intemalization of the target organism.31 Therefore, it seems possible that the neutrophils of HIV-infected patients manifest with phagocytic, chemotactic, and oxidative defects with resultant impaired bacteriocidal activity against S aureus and increased susceptibility to staphylococcal infections. In AIDS, HIV myopathy,32 parasitic infections with myositis,33 or disseminated mycobacterial infection34'35 need to be considered precipitating causes of bacterial superinfection. Laboratory evaluation may not be helpful in that leukocytosis may be absent or mildly elevated in HIV-infected persons with pyomyositis, and only 5% to 20% of blood cultures are positive, usually in the late stages of the illness.6 Eosinophilia is frequent in tropical countries5 but uncommon in others.'9'20 The sedimentation rate usually is elevated, and muscle enzymes are within normal range. 567


The diagnosis of pyomyositis is not always easy as the affected muscle may be located deep to the subcutaneous plane. The differential diagnosis should include muscle strains, contusions, cellulitis, deep venous thrombosis,36'37 and occasionally lymphomas.3'6'38'39 Other diseases that mimic pyomyositis include osteomyelitis, pyarthrosis,40 and fever of unknown origin.37 Our patients are unusual in that there was no precipitating cause and the area involved was extensive. In addition, these two patients, and indeed the patients in the majority of reported cases, were IV drug abusers, and there is a possibility that hematogenous seeding of the muscle may have occurred with IV drug abuse. It also has been postulated that the impairment of granulocyte phagocytosis is related to IV drug abuse rather than to HIV infection because normal phagocytosis of Candida albicans by granulocytes was found in homosexual men with AIDS.41'42 It is known that in experimental situations, granulocyte-macrophage colony stimulating factor enhances the production of functionally active neutrophils and appears to enhance the antibacterial effect of neutrophils in HIV-infected patients.43 44However, its use cannot be recommended as yet due to the lack of clinical studies. In both cases, the diagnosis was established by a combination of clinical features, computed tomography or ultrasound, and examination of the tissue/pus from the affected area. Magnetic resonance imaging with gadolinium DTPA is highly sensitive but its use in the diagnosis of pyomyositis has yet to be defined.45 Prompt institution of broad-spectrum antimicrobials with good antistaphylococcal ability may be sufficient therapy in the early stages of the condition. Oral cloxacillin and erythromycin have been used in the outpatient management of mild pyomyositis7 but will need to be supplemented by drainage and debridement of the involved tissue in moderate to severe cases of pyomyositis. In the United States, approximately 20% of patients with pyomyositis (AIDS and non-AIDS) were infected with organisms that were usually insensitive to

13-lactamase-resistant synthetic penicillin."I In addition, the duration of antibiotics has to be individualized to each patient, and the average duration of treatment with antibiotics was 22 days in one study."

CONCLUSION Nontropical staphylococcal pyomyositis in AIDS patients is an uncommon infection with a variable clinical presentation. It may present as an indolent, subclinical process with minimal inflammation and without leukocytosis. It usually affects the large muscle groups 568

of the lower extremities. Computed tomography and ultrasonography are helpful in the diagnosis. Staphylococcus aureus is the most common organism isolated. Early suspicion and institution of broad-spectrum antibiotics with surgical drainage if indicated is recommended. Literature Cited 1. Schwartzman WA, Lambertus MW, Kennedy CA, Goetz MB. Staphylococcal pyomyositis in patients infected by the human immunodeficiency virus. Am J Med. 1991;90:595-600. 2. Widrow C, Kellie SM, Saltzman BR, Wagh-Mathur U. Pyomyositis in patients with the human immunodeficiency syndrome: an unusual form of disseminated bacterial infection. Am J Med. 1991;91:129-136. 3. Blumberg HM, Stephens DS. Pyomyositis and human immunodeficiency virus infection. South Med J. 1990;83:10921095. 4. Watt RA, Hoffbrand BI, Paton DF Pyomyositis associated with human immunodeficiency virus infection. Br Med J. 1987;294:1524-1525. 5. Chiedozi LC. Pyomyositis: review of 205 cases in 112 patients. Am J Surg. 1 979;1 37:255-259. 6. Miyake H. Cited by: Gibson RK, Rosenthal SJ, Lukert BP Pyomyositis and its increasing recognition in temperate climates. Am J Med. 1984;77:768-772. 7. Traquair RN. Pyomyositis. J Trop Med Hyg. 1947;50:81 89. 8. Leedham-Green JC, Evans W. Myositis tropica. Trans R Soc Trop Med Hyg. 1943;36:359-362. 9. Burkitt RT. Tropical pyomyositis. J Trop Med Hyg. 1947;50:71 -75. 10. Ajao OG, Ajao AO. Tropical pyomyositis. Int Surg. 1982;67:414. 11. Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis. 1992;15:668-677. 12. Gaut P, Wong PK, Meyer RD. Pyomyositis in a patient with the acquired immunedeficiency syndrome. Arch Intern Med. 1988;148:1608-1610. 13. Anand AC, Narayanan VA, Kalra AS, Ray N, Ganguly SB. Tropical pyomyositis with agammaglobulinaemia. J Assoc Physicians India. 1986;34:745-746. 14. Blatt J, Reaman G, Pizzo PA. Pyomyositis in acute lymphocytic leukemia heralded by cutaneous vasculitis. Brief communication. Med Pediatr Oncol. 1979;7:237-239. 15. Mitsuyasu R, Gale RR Bacterial pyomyositis in a patient with aplastic anemia. Postgrad Med J. 1980;56:61 -62. 16. Taylor JF, Templeton AC, Henderson B. Pyomyositis: a clinico-pathological study based on 19 autopsy cases, Mulago Hospital 1964-1966. East Afr Med J. 1970;47:493-501. 17. Marus RT, Foster WD. Observation on the clinical features, etiology and geographical distribution of pyomysitis in East Africa. East Afr Med J. 1968;45:167-176. 18. Fanney D, Thomas LC, Schwart E. An outbreak of pyomyositis in large refugee camp in Thailand. Am J Trop Med Hyg. 1987;31 :131-135. 19. Eason R, Osbourne J, Ansford T, Stallman N, Forsyth JRL. Tropical pyomyositis in the Solomon Islands; clinical and etiological features. Trans R Soc Trop Med Hyg. 1989;83:275278. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 9


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