Letter to the Editor
Multiple pyomyositis secondary to septic thrombophlebitis
Piomiositis múltiple secundaria a tromboflebitis séptica
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Losno, Sergi Vidal-Sicart, Josep Maria Grau" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ricardo A." "apellidos" => "Losno" "email" => array:2 [ 0 => "ralosno@clinic.cat" 1 => "losnoric@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Sergi" "apellidos" => "Vidal-Sicart" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Josep Maria" "apellidos" => "Grau" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Hospital Clínic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Piomiositis múltiple secundaria a tromboflebitis séptica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 2500 "Tamanyo" => 155048 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Volumetric reconstruction from a SPECT/CT study with <span class="elsevierStyleSup">111</span>In-labeled leukocytes. (A) Fused axial slices of the right thigh that show an area of pyomyositis (thin arrow) and the site of an abscess (thick arrow). (B) Volume rendering that shows an irregular uptake in muscle tissue in yellow-orange color and multiple abscesses (thin arrows). (C) CT axial section of the right thigh showing the site of an abscess (thick arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pyomyositis is a subacute, suppurative infection of skeletal muscle resulting from hematogenous spread. It is a rare disease in our environment, since it is typical from tropical areas.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Oxacillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MSSA) is the most prevalent etiologic agent, with a recent increase in the incidence of oxacillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MRSA).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 53-year-old woman with a history of removal of left acoustic neuroma the month prior to admission, complicated by postoperative facial paralysis. Therefore, she was undergoing therapy with corticosteroids, and went to the emergency department for edema and pain in her left upper limb associated with pain and loss of strength in lower limbs. Upon arrival she was afebrile and hemodynamically stable. On physical examination she showed edema, pain and collateral circulation in left upper limb, and pain with functional impairment in both lower limbs. The blood test showed leukocytosis by 13,600 with 90% of neutrophils, CK 347<span class="elsevierStyleHsp" style=""></span>IU/l, LDH 682<span class="elsevierStyleHsp" style=""></span>IU/l, PCR 28<span class="elsevierStyleHsp" style=""></span>mg/dl and a ESR 120<span class="elsevierStyleHsp" style=""></span>mm/h.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a Doppler ultrasound of the affected limb, a deep thrombosis of the cephalic, axillary and subclavian veins was verified, so anticoagulation was initiated. In the report of the previous surgery it was stated that a central catheter had been placed through that vein. Although the patient remained afebrile after surgery and throughout the admission, the possibility of septic thrombophlebitis was considered. Serial blood cultures were requested and intravenous antibiotic therapy was initiated. In the cultures, MSSA grew rapidly. The echocardiography did not show any signs of endocarditis. The patient remained with functional impairment in both lower limbs and high CK levels, so she underwent an electromyography with no evidence of myopathy or neuropathy. Given the persistence of positive blood cultures, it was decided that the patient should undergo a gammagraphy with <span class="elsevierStyleSup">111</span>In-labeled leukocytes, which showed an irregular uptake pattern in muscle tissues of lower limbs suggestive of pyomyositis with multiple microabscesses (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The study was completed with an MRI of soft tissues that identified multiple abscesses spread in the muscles of pelvis and lower limbs.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">It was treated as a septic thrombophlebitis caused by MSSA of endovascular origin and secondary multiple pyomyositis and antibiotic therapy was completed for 6 weeks. The patient presented a favorable evolution with gradual recovery of muscle strength and disappearance of pain. Ultrasound monitoring showed size reduction of the muscle abscesses and negative control blood cultures.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pyomyositis usually involves only one muscle group, mostly of the lower limb (thigh, calf or buttocks) but any muscle group can be affected. In Spain, most reported cases are male children or adolescents with predominantly pelvic involvement. In this case, staphylococcal pyomyositis occurred as a complication of septic thrombophlebitis due to the insertion of a catheter. The characteristics of common pyomyositis are fever and pain in the affected muscle group. Muscle enzymes tend to be normal since the disease is usually localized; in the most evolved cases these enzymes may be increased.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Although blood cultures are not too useful,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> in staphylococcal pyomyositis blood cultures are frequently positive.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In pyomyositis the most sensitive test for diagnosis is MRI.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The optimal duration of antibiotic therapy, as well as the indication of abscess drainage varies depending on the patient's condition and the clinical response.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The singularity of this case is the strange presentation form of pyomyositis with multiple muscle involvement, high CK levels and absence of fever, the latter probably due to corticosteroid therapy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Losno RA, Vidal-Sicart S, Grau JM. Piomiositis múltiple secundaria a tromboflebitis séptica. Med Clin (Barc). 2019;152:515–516.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 2500 "Tamanyo" => 155048 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Volumetric reconstruction from a SPECT/CT study with <span class="elsevierStyleSup">111</span>In-labeled leukocytes. (A) Fused axial slices of the right thigh that show an area of pyomyositis (thin arrow) and the site of an abscess (thick arrow). (B) Volume rendering that shows an irregular uptake in muscle tissue in yellow-orange color and multiple abscesses (thin arrows). (C) CT axial section of the right thigh showing the site of an abscess (thick arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Piomiositis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Moralejo-Alonso" 1 => "G. 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González Tomé" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr" "fecha" => "2007" "volumen" => "67" "paginaInicial" => "578" "paginaFinal" => "581" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000012/v1_201906160657/S2387020619301962/v1_201906160657/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000012/v1_201906160657/S2387020619301962/v1_201906160657/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619301962?idApp=UINPBA00004N" ]
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