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122 Pyomyositis
Excluding Underlying Disease In patients presenting early, treatment with antibiotics alone may
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A serological test for HIV infection should be done, after appropriate control infection. However, the duration of antibiotic therapy is often
counselling. Diabetes mellitus should also be excluded by ascertaining long (2–8 weeks). 11,19
the blood sugar level. Analgesia
Differential Diagnosis When pain is a prominent symptom, appropriate analgesics should be
The differential diagnoses are varied and include osteomylitis, septic given to control it.
arthritis, intermuscular abscess, muscle contusion, polymyositis, cel- Rest of Affected Limb
lulitis, rhabdomyosarcoma, pyrexia of unknown origin, and appendix When a limb muscle is affected, some form of splinting and rest-
abscess. Pyomyositis of a limb may be difficult to differentiate from ing of that limb helps to relieve pain. Elevation of the limb would
acute osteomyelitis at the early stage, and radiography may not be be helpful in the presence of oedema and should help to prevent a
helpful in excluding osteomyelitis. As the latter is more serious and compartment syndrome.
damaging, it is safer to make that diagnosis and institute appropriate Prognosis and Outcome
treatment until proven otherwise.
Another area of clinical diagnostic difficulty is differentiating Although mortality is low, morbidity could be high and hospital stay
pyomyositis of the anterior abnormal wall from appendix abscess. prolonged for several weeks. Extramuscular involvement, especially
of the lung and heart, is life threatening and could lead to death,
Localisation of the abscess can be done easily by ultrasonography.
despite treatment.
Differentiating between pyomyositis and a rapidly growing
2
In one report, extraskeletal complications (pneumonia, pericarditis)
rhabdomyosarcoma with erythema and tenderness of the overlying skin
occurred in 6.5% of patients. Complications with pericarditis resulted
is extremely difficult in children and requires a high index of suspicion,
in the only mortality of 3% in that report. In one large series, mortality
3
especially when the history and site of the lesion are not entirely typical
in all patients (adults and children) was <1%.
of pyomyositis.
Management Evidence-Based Research
Early diagnosis and treatment are critical to survival and outcome. Table 19.2 presents one of the few reports on pyomyositis in children
Diagnosis may be missed due to unfamiliarity with the disease, atypical in sub-Saharan Africa.
presentation, a wide range of differential diagnoses, and lack of early Table 19.2: Evidence-based research.
specific signs. The treatment includes resuscitation, abscess drainage,
antibiotics, analgesia, and rest of the affected limb. Title Pyomyositis in children: analysis of 31 cases
Resuscitation
Patients may be anaemic, particularly those presenting late. Any Authors Ameh EA
severe anaemia may require correction by blood transfusion. Patients Institution Paediatric Surgery Unit, Department of Surgery, Ahmadu
who are malnourished will require some form of nutritional support Bello University Teaching Hospital, Zaria, Nigeria
and rehabilitation. Reference Ann Trop Paediatr 1999; 19:263–265
Abscess Drainage Problem Pyomyositis in children.
The definitive treatment of full-blown pyomyositis remains adequate Intervention Open drainage, local dressing of abscess cavity, antibiotics.
drainage. Following this, the abscess cavity must be prevented from Thirty-one children were treated for 35 instances of
premature closure by any one of several methods, such as packing and pyomyositis in Nigeria. Most (71%) were younger than 10
years of age, and the lower limb (51%) and trunk (26%)
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daily dressing. EUSOL or honey are effective, but sterile saline may muscles were mostly afflicted. Patients presented after
serve the same purpose. Closure of the skin and drainage with a Penrose Results a symptom duration of 2–12 days (mean, 6 days) and
drain or other appropriate drain are also effective and obviate the need a preceding history of trauma was obtained only in one
for daily dressing. patient. A pure culture of Staphylococcus aureaus was
obtained in 75% of cultured specimens, but mixed growth of
If properly drained, the abscess is unlikely to recur. In the very staphylococci and streptococci and sterile growth were also
early stage of the disease, before an abscess has formed, antibiotic obtained in a few patients.
administration and resting the affected part may suffice. Recurrence of abscess occurred in one abscess (3%) after
Percutaneous drainage, preferably under imaging guidance 3 days of open drainage. The hospital stay for survivors
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(ultrasonography), is also effective and avoids an incision and resulting Outcome/ was long, at an average of 20 days (range, 12–30 days).
scar, which would otherwise prolong the hospital stay. effect Two patients (6.5%) developed extramuscular complications
(pneumonia, pneumonia and pericarditis), resulting in
Antibiotics mortality in one patient (3.2%) from pericarditis.
Appropriate antibiotics should always be given (initially intravenous-
ly). Before culture and antibiogram results are received, the choice of Historical This is only one of the few reports of pyomyositis in children
from sub-Saharan Africa. It characterises the clinical profile
antibiotics should be based on the microbiological knowledge of com- significance/ of the disease in African children and shows that life-
monly involved bacteria. Any antibiotic regime should include a potent comments threatening complications, although uncommon, can occur
antibiotic effective against Staphylococcus aureus, which is the most and even result in mortality.
common bacteria involved.