QJM Advance Access originally published online on August 24, 2008
QJM 2008 101(12):983-984; doi:10.1093/qjmed/hcn092
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Pyomyositis of the iliacus muscle complicated with septic sacroiliitis
From the Infectious Disease Division, Hospital General of Castellon, University of Valencia, Spain
Address correspondence to B. Roca, Catalunya, 33-A, 4. 12004 Castellon, Spain. email: brocav{at}meditex.es
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Summary |
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We report a rare case of pyomyositis of the iliacus muscle in a 29-year-old woman. After 2 weeks of adequate treatment, secondary septic sacroiliitis occurred, a complication that had not been described previously. Pyomyositis of the iliacus muscle must be considered in the differential diagnosis of acute pain in the hip region.
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Introduction |
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Pyomyositis is a primary bacterial infection of skeletal muscle, presumably hematogenous in origin, and often associated with abscess formation.1 We report a case of pyomyositis of the iliacus muscle, which was complicated by septic sacroiliitis.
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Case report |
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A 29-year-old woman presented with a 48-h history of severe pain in the right hip area and fever. The previous days she had noticed mild symptoms of upper respiratory infection. Otherwise, her past medical record was nil, and she had never used parenteral drugs. Physical examination only revealed high fever and intense pain in the right hip region, especially on external rotation of the joint.
Blood analysis showed a C-reactive protein of 46 mg/l and white blood cell count of 12 080/mm3 (87% neutrophils), while all other results were normal. Radiographs of the chest and right hip were unrevealing. Treatment with cloxacillin and ceftriaxone was initiated for suspected septic arthritis of the hip. A magnetic resonance imaging (MRI) disclosed diffuse thickening and signal change in the right iliacus muscle, with edema surrounding the muscle (Figure 1), while the right hip and sacroiliac joints were normal. Three blood cultures grew Staphylococcus aureus, sensitive to cloxacillin. A transthoracic echocardiography was normal. Treatment was continued with the same antibiotics, with disappearance of fever and slow improvement of pain over the next days. Twelve days after starting treatment, a repeated MRI showed an abscess formation in the affected muscle, which was percutaneously drained. Three days later pain in the right hip area suddenly worsened, and a new MRI disclosed diffuse signal change and edema in the right sacroiliac joint. Over the next weeks, pain slowly subsided and finally completely disappeared. Antibiotic treatment was administered for a total of 6 weeks.
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Discussion |
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Pyomyositis is an uncommon infection that has been reported predominantly in patients living in tropical areas, although in recent years it has been increasingly recognized in temperate zones. The disease is more prevalent in the pediatric population, particularly in boys 2–5 years of age. Staphylococcus aureus is the most common causative agent. Conditions that favor its development are diabetes mellitus, alcohol abuse, parenteral drug abuse, HIV infection, cancer, traumatic injuries and systemic sclerosis. The muscles most commonly affected include those in the lower extremities, especially quadriceps femoris and gluteus, and those in the abdomen, especially psoas. MRI is the preferred imaging modality for diagnosis of the disease.1–4
Pyomyositis rarely affects the iliacus muscle. In a review of the literature of the last 10 years, by means of a Medline search using ‘pyomyositis AND iliacus’ as search strategy key words, we found only four reports of the condition. Most cases occurred in children and were produced by S. aureus.5–8 As in our patient, the diagnosis of septic arthritis of the hip was initially suspected in the majority of cases. Moreover, in two patients, both conditions, i.e. pyomyositis of the iliacus muscle and septic arthritis of the hip, presented simultaneously.7–8
For the best of our knowledge, sacroiliitis has not been reported as a complication of pyomyositis of the iliacus muscle so far. In a review of the literature, by means of a Medline search using ‘sacroil* AND iliacus’ as search strategy key words, we found no reports of such complication; although a case exists, belonging to the pre-MRI era, of an iliacus muscle abscess originating from the sacroiliac joint9.
In brief, pyomyositis of the iliacus muscle is a rare condition, but the disease must be taken into account as a possible cause acute pain in the hip region.
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References |
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1. Small LN, Ross JJ. Tropical and temperate pyomyositis. Infect Dis Clin North Am (2005) 19:981–9.[CrossRef][Web of Science][Medline]
2. Theodorou SJ, Theodorou DJ, Resnick D. MR imaging findings of pyogenic bacterial myositis (pyomyositis) in patients with local muscle trauma: illustrative cases. Emerg Radiol (2007) 14:89–96.[CrossRef][Medline]
3. Karmazyn B, Kleiman MB, Buckwalter K, Loder RT, Siddiqui A, Applegate KE. Acute pyomyositis of the pelvis: the spectrum of clinical presentations and MR findings. Pediatr Radiol (2006) 36:338–43.[CrossRef][Web of Science][Medline]
4. Martin-Millan M, Garcia-Ibarbia C, Gutierrez-Cuadra M, Gutierrez-Santiago M, Fernandez-Sampedro M, Gonzalez-Macias J, et al. Pyomyositis: retrospective review in a third-level hospital in the north of Spain. [Article in Spanish]. Enferm Infecc Microbiol Clin (2006) 24:173–7.[CrossRef][Web of Science][Medline]
5. Zlotkin D. Pyomyositis of the iliacus muscle in an adolescent. South Med J (2005) 98:1224–5.[CrossRef][Web of Science][Medline]
6. Peckett WR, Butler-Manuel A, Apthorp LA. Pyomyositis of the iliacus muscle in a child. J Bone Joint Surg Br (2001) 83:103–5.[CrossRef][Medline]
7. Jou IM, Chiu NT, Lai KA, Chuang YC. Synchronous pyomyositis and septic hip arthritis. Clin Rheumatol (2000) 19:385–8.[CrossRef][Web of Science][Medline]
8. Romeo S, Sunshine S. Pyomyositis in a 5-year-old child. Arch Fam Med (2000) 9:653–6.
9. Simons GW, Sty JR, Starshak RR. Iliacus abscess. Clin Orthop Relat Res (1984) 183:61–3.[Medline]
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