Pyomyositis in the setting of complicated diverticulitis: case report

International Journal of General Medicine Dovepress open access to scientific and medical research C A S E R E P O RT International Journal of General Medicine downloaded from https://www.dovepress.com/ by 213.32.59.119 on 13-Jul-2018 For personal use only. Open Access Full Text Article Pyomyositis in the setting of complicated diverticulitis: case report This article was published in the following Dove Press journal: International Journal of General Medicine James Sun 1 David Leor Kashan 1 Jolita Marie Auguste 1 Akella Chendrasekhar 2 1 Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; 2 Department of Surgery, Richmond University Medical Center, Staten Island, NY, USA Abstract: Pyomyositis is typically thought of as a disease of the tropics. However, it is becoming more prevalent in temperate regions, and may be underdiagnosed. Here, pyomyositis is encountered as a complication of perforated diverticulitis, which has not been previously reported. A 61-year-old Caucasian man initially presented in respiratory distress and was diagnosed with respiratory failure due to COPD exacerbation. The patient was taking highdose prednisone, 60 mg daily for the past 2 years. Initially, he was afebrile, normotensive, tachycardic to 178 beats/minute and tachypneic to 28 breaths/minute, requiring noninvasive ventilation to maintain oxygenation. Blood tests revealed leukocytosis of 16.7×103/μL, and blood cultures grew Escherichia coli. Broad-spectrum antibiotics were started but leukocytosis and bacteremia persisted on repeated tests. On the seventh hospital day, a CT scan of the abdomen was performed for complaints of abdominal pain, and the patient was diagnosed with Hinchey stage 3 diverticulitis. A Hartmann’s procedure was performed with intraoperative findings of purulent peritonitis. Intraoperative cultures grew E. coli and vancomycinresistant Enterococcus faecium. The patient continued to have leukocytosis of 15.1×103/μL despite surgical therapy. He began to complain of left lower extremity pain, and a CT scan on hospital day 24 revealed gluteal intramuscular abscesses, which were percutaneously drained. Persistent symptoms prompted another CT scan on hospital day 28, which revealed additional intramuscular abscesses in the vastus lateralis muscle, which was also drained, with subsequent resolution of pain and normalization of inflammatory markers. This is the first case demonstrating pyomyositis as a complication of diverticulitis. While the mechanism of pyomyositis may not be unique, it is important to recognize the potential complications of frequently encountered diseases. In this critically ill and immunosuppressed patient, there was delayed diagnosis of both diverticulitis and pyomyositis, but the patient quickly improved once the diseases were recognized and treated. Keywords: abscess, immunosuppression, steroid use, COPD, intramuscular infection Introduction Correspondence: James Sun SUNY Downstate Department of Surgery, 450 Clarkson Ave, Box 40, Brooklyn, NY 11203, USA Tel +1 718 270 5800 Fax +1 718 270 2826 Email 11 submit your manuscript | www.dovepress.com International Journal of General Medicine 2018:11 11–14 Dovepress © 2018 Sun et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/IJGM.S141581 Powered by TCPDF (www.tcpdf.org) Pyomyositis is defined as an acute, primary, intramusuclar infection that is hematogenously disseminated from transient bacteremia.1,2 This condition was first described by Scriba as a disease of the tropics.1–4 It was nearly 100 years before the first reported case in North America by Levin et al and its prevalence has been increasing.5 To the author’s knowledge, it has only been associated with a surgical disease of the abdomen in a report described by Ea et al as a complication of laparoscopy.6 We submit a case of pyomyositis as an adverse outcome of complicated diverticulitis to underscore the importance of this disease as a consideration in a surgical patient. Dovepress Sun et al International Journal of General Medicine downloaded from https://www.dovepress.com/ by 213.32.59.119 on 13-Jul-2018 For personal use only. Case report A 61-year-old Caucasian male initially presented with COPD exacerbation with delirium, visual hallucinations and altered mental status. The patient had been taking high-dose prednisone 60 mg daily for 2 years for COPD. On presentation, the patient was afebrile with a temperature of 98.3°F, normotensive with a blood pressure of 140/85, tachycardic to 178 beats/minute and tachypneic to 28 breaths/minute, with oxygen saturation of 98% on bilevel positive airway pressure ventilation. Blood tests were significant for leukocytosis of 16.7×103/μL, with a left shift of 89.1% and a lactic acid of 5.8 mmol/L. He was admitted to the medical service for respiratory failure secondary to COPD exacerbation. The patient was treated with piperacillin/tazobactam and vancomycin empirically. Leukocytosis improved and blood cultures from admission grew Escherichia coli resistant to ampicillin and levofloxacin, confirmed on repeated blood culture. On the fifth hospital day, the source of bacteremia was not identified and routine evaluations of the urinary tract and lungs failed to show evidence of infection. The patient had complaints of left flank pain; however, with improved leukocytosis and no other sources of infection, work-up was deferred. On the seventh hospital day, persistent abdominal pain prompted CT imaging of the abdomen, which revealed a 14×3.7×7.2 cm abscess along the medial wall of the left psoas muscle (Figure 1) and 2 additional abscesses at the L5–S1 level; 5.4×3.6 cm in the midline and 3.4×2.3 cm left of midline, and intramuscular air in the left gluteal muscles. The patient was diagnosed with Hinchey stage 3 complicated diverticulitis and the surgery service was consulted. A Hartmann’s procedure and abdominal washout was performed, with intraoperative findings of purulent peritonitis. Figure 1 Initial CT-scan showing abscess with air–fluid level abutting left psoas muscle, indicated by red arrow. 12 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress The patient was taken back to the operating room for two additional abdominal washouts during the following week. Cultures of the peritoneal fluid from the init (...truncated)