IMAGES IN NEUROLOGY
|Year : 2017 | Volume
| Issue : 1 | Page : 58
Boby Varkey Maramattom1, Rony K Varghese1, Anila Sudhakaran2, Kurian Ninan3
1 Department of Neurology, Aster Medcity, Kochi, Kerala, India
2 Department of Emergency Medicine, Aster Medcity, Kochi, Kerala, India
3 Department of Radiology, Aster Medcity, Kochi, Kerala, India
|Date of Submission||20-Oct-2016|
|Date of Decision||23-Nov-2016|
|Date of Acceptance||15-Dec-2016|
|Date of Web Publication||9-Feb-2017|
Boby Varkey Maramattom
Department of Neurology, Aster Medcity, Kothad, Kochi - 682 027, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Maramattom BV, Varghese RK, Sudhakaran A, Ninan K. Nocardial pyomyositis. Ann Indian Acad Neurol 2017;20:58
A 70-year-old male with Type II diabetes underwent plasmapheresis through the internal jugular vein 2 months ago for chronic inflammatory demyelinating polyneuropathy. Subsequently, he was on high-dose prednisolone and azathioprine. He presented to the emergency department with severe right thigh pain for 2 weeks. Examination revealed a fluctuant tender swelling of 4 cm × 7 cm size in the upper anterior thigh and antalgic weakness of adduction of right thigh. Ultrasound showed a well-defined intramuscular cystic lesion in the medial aspect of the right thigh measuring 8 cm × 4 cm. Magnetic resonance imaging showed a well-circumscribed ovoid-shaped T2-weighted homogenously hyperintense and T1-weighted hypointense lesion in the right adductor longus muscle, measuring 5.4 cm × 4.2 cm × 8.7 cm [Figure 1]. The lesion showed avid peripheral enhancement and thin enhancing septae and did not encase the underlying femoral artery. Ultrasound-guided aspiration revealed frank pus. Gram smear [Figure 2] and culture showed Gram-positive filamentous bacteria which were weakly acid fast (Nocardia sp.). He was initiated on treatment with trimethoprim-sulfamethoxazole for 3 months with good improvement.
|Figure 1: (a) Ultrasound showing 8 cm × 4 cm cystic lesion. (b) Coronal T1-weighted magnetic resonance imaging. (c) Axial T2 magnetic resonance imaging. (d) Axial T1 with contrast. A well-circumscribed ovoid-shaped altered signal intensity lesion in the right adductor longus muscle|
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|Figure 2: (a) Gram stain and (b) 1% acid-fast stain showing filamentous bacteria|
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Pyomyositis (tropical pyomyositis) is an uncommon primary infection of skeletal muscles. Seventy-five percent of cases occur in immunocompromised individuals, the thigh being a common site. Staphylococcus aureus (90%) accounts for the majority of cases. Nocardial pyomyositis is extremely rare but responds well to treatment if initiated early. Skeletal muscles are very resistant to infection; however, our patient could have developed nocardial pyomyositis from transient bacteremia during plasmapheresis as there was no evidence of systemic nocardiosis.
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| References|| |
Agarwal V, Chauhan S, Gupta RK. Pyomyositis. Neuroimaging Clin N
Sagar V, Pinto B, Lal A, Kumar M, Rathi M, Sharma K, et al.
Nocardia pyomyositis in a patient with granulomatosis with polyangiitis. Int J Rheum Dis 2015. doi: 10.1111/1756-185X.12623. [Epub ahead of print].
[Figure 1], [Figure 2]