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CASE REPORT

Pneumococcal Pyomyositis Of A Hip Adductor In An Infant : A Case Report

Chikahisa Higuchi, Akio Nakura, and Hideki Yoshikawa

Department of Orthopaedic Surgery,
Osaka University Graduate School of Medicine,
2-2 Yamadaoka, Suita, Osaka 565-0871, Japan

Address for Correspondence:
Chikahisa Higuchi
Osaka University Graduate School of Medicine,
2-2 Yamadaoka, Suita, Osaka City, 565-0871, Japan


Phone :
81-6-6879-3552
Fax     :
81-6-6879-3559
E-mail : c-higuchi@umin.ac.jp

Abstract:

Background: Pyomyositis is a rare disorder in children without underlying diseases. It primarily caused by Staphylococcus aureus. Especially, pyomyositis due to Streptococcus pneumoniae is much rarer. We report a case of pneumococcal pyomyositis in hip adductors of a child.
Case presentation: A 14-month-old girl without previous history of disease developed infection of the adductor longus due to Streptococcus pneumoniae. Pneumococcal pyomyositis in this case was misdiagnosed as suppurative arthritis of the hip on the affected side. Diagnosis of pyomyositis was determined by clinical features including inflammatory signs around the medial thigh and magnetic resonance imaging. Drainage of pyogenic discharge and administration of antibiotics completely resolved symptoms without complications.
Conclusions: Pnuemococcal pyomyositis in hip adductors is a very rare condition in respect of pathogenic bacteria and lesion site. A proper diagnosis and treatment is necessary when encountered with this disease.

J.Orthopaedics 2010;7(2)e7

Keywords:

Pyomyositis; Streptococcus pneumoniae; hip adductor

Introduction:

Pyomyositis can occur in patients with underlying diseases such as immunodeficiency. The disease is primarily caused by Staphylococcus aureus. Pneumococcal pyomyositis (pyomyositis due to Streptococcus pneumoniae) is a very rare condition, and only a few cases in children < 15 years old have been reported [1-5]. We report herein the case of an infant with pneumococcal pyomyositis who was successfully diagnosed and treated.

Case Presentation:

A 14-month-old girl was transferred to our hospital for treatment of general fever and pain in the left lower limb. She had suffered from severe cough and fever for 2 days before pain around the left hip was identified. The first orthopedic surgeon at a nearby hospital diagnosed septic arthritis of the hip. On our first medical examination, she could move the affected lower limb despite her bad humor. The left crotch was swollen and reddish (Figure. 1).

Figure-1: Swelling and reddening thigh in the affected limb

Radiography of bilateral hip joints revealed lateral shift of the left femoral head without osteolytic changes (Figure. 2).

Figure-2: Radiography revealed lateralization of the left femoral head without osteolysis

Magnetic resonance imaging (MRI) disclosed the existence of a lesion in the left thigh. Compared with muscle, that lesion was isointense on T1-weighted imaging and hyperintense on T2-weighted imaging (Figure 3).

Figure-3: T2 MR image showed high-signal mass in left hip adductor

This physiological and radiographic information led us to diagnose pyomyositis in the adductor muscles. The abscess was emergently removed by surgical intervention and drainage under general anesthesia. Postoperatively, the patient was treated with intravenous antibiotics until C-reactive protein levels reduced to within normal range. No deformities of the hip joint or femur were evident on the last examination (Figure 4).

Figure-4: No deformity of left hip after treatment

Discussion :

Pyomyositis is a suppurative infection of skeletal muscles caused by bacteria, and predominantly affects muscles around the hip joint such as the quadriceps, gluteal muscles and obturator internus [1-3, 6-10]. Misdiagnosis is common because the uncommon nature of this entity. In particular, orthopedic surgeons tend to misdiagnose this condition as septic arthritis of the hip [4,11,12]. In the present case, septic arthritis of the hip was initially diagnosed by a pediatrician and an orthopedic surgeon. Laterality of the femoral head in hip radiography seemed to be septic arthritis. However, we identified two clinical features suggesting that septic arthritis was the wrong diagnosis on our first examination. One of these features was her active motion of the affected hip, which is typically limited in cases of septic arthritis. The other was the inflammatory skin lesion on the thigh. This symptom was regarded as a sign of strong inflammation immediately beneath the skin. These features led us to consider other diagnoses. As most previous reports have suggested [8,13,14], MRI was helpful in reaching the definitive diagnosis in this case.  As a result, the laterality of the femoral head in the affected limb was judged to be caused by mass effect.

Pneumococcal pyomyositis is a pyogenic myositis caused by S. pneumoniae, which has rarely been demonstrated to invade muscles. Common pyomyositis is caused by S. aureus. Streptococcus pyogenes is the second-most common etiological agent. Pneumococcal pyomyositis is very uncommon, particularly among children < 15 years old, and only 5 cases have been reported [1-5]. Some cases showed a preceding upper respiratory tract infection. None of the children with pneumococcal pyomyositis had an underlying illness such as diabetes mellitus, human immunodeficiency virus infection, or connective tissue diseases. Conversely, younger infants are known to have little ability to mount an immune response to streptococcal infection [15]. Our patient also displayed no underlying diseases and the first symptom was cold-like. Skeletal symptoms appeared after several days. A speculative route of infection in this case was hematogenous spread and infection from the respiratory system to the hip adductors.

Administration of antibiotics represents the first-choice therapy. Some groups have reported that surgical drainage is not always needed. However, this procedure should be performed if antibiotics show a lack of effect. In the case of pyomyositis with large abscess as in our patient (MRI revealed large abscess in the thigh), an orthopedic surgeon should select the surgical intervention. MRI is thus regarded as an indispensable examination to determine the need for surgical drainage.

In summary, we have reported a case with pyomyositis caused by S. pneumoniae in a 14-month-old girl. Successful diagnosis and treatment depend on familiarity with the disease.

Reference :

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This is a peer reviewed paper 

Please cite as: Chikahisa Higuchi: Pneumococcal Pyomyositis Of A Hip Adductor In An Infant : A Case Report

J.Orthopaedics 2010;7(2)e7

URL: http://www.jortho.org/2010/7/2/e7

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