Team Approach: Pyomyositis

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A 10-year-old boy presented to the emergency department with pain in the posterior part of the right thigh after knee-boarding (an activity in which the individual is pulled behind a ski boat while riding on the knees on a specially designed fiberglass board) for multiple hours the previous day. He recalled no specific injury. He had no history of injury involving the right lower extremity. The medical history was unremarkable. The patient was afebrile and walked with an antalgic gait. Palpation revealed tenderness along the posteromedial aspect of the thigh. The patient grimaced when the knee was flexed and the hip was internally rotated. The skin was intact, and neurovascular examination revealed normal findings. Two radiographs of the entire right femur were made to rule out a fracture, and both revealed normal findings. The patient was diagnosed with a hamstring injury and was discharged to home with his family. Nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed for the relief of pain, and the patient was given instructions for follow-up.
The patient presented to the orthopaedic clinic the next day. He reported increasing right thigh pain but no fever. Examination revealed the patient to be afebrile, alert, and in no distress. Gait remained antalgic. Palpation revealed pain along the course of the proximal aspect of the medial hamstrings. Flexion of the right hip did not provoke pain, but internal rotation of the hip did provoke pain. Pelvic radiographs were made to rule out an injury that may have been referring pain to the hip or thigh but were unremarkable. The patient was again diagnosed with a hamstring injury and was instructed to continue taking NSAIDs for the relief of pain, to modify his activities, and to return for follow-up in 2 weeks.
The following day, the patient was seen and evaluated by a physical therapist. The pain in the posteromedial part of the right thigh decreased after the application of ice and an elastic bandage. A home exercise program was developed for the patient.
The patient presented to the emergency department 5 days after the first visit. His mother reported that a fever had developed 2 days previously. The pain in the right thigh was increasing. Examination revealed a maximum temperature of 103.6°F (39.8°C). Gait remained antalgic. The right hip rested in a flexed and externally rotated position. The patient had acute tenderness over the posteromedial part of the thigh, which was warm to the touch. No erythema was present, and neurovascular function was intact. Laboratory tests revealed an elevated white blood-cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein level (CRP), and blood specimens were obtained for culture. A computed tomography (CT) scan revealed a collection of fluid in the internal obturator, with displacement of the bladder, as well as a second collection posterior to the sacrotuberous ligament. The patient was diagnosed with pyomyositis, was admitted to the hospitalist service, and was started on intravenous (IV) clindamycin.
An orthopaedic surgeon was consulted, and the patient was managed with irrigation and debridement. An infectious-disease specialist was consulted. The patient initially was managed with IV vancomycin and then was switched to intravenous oxacillin. When culture specimens demonstrated growth of methicillin-sensitive Staphylococcus aureus (MSSA), the patient was switched to IV cefazolin. The patient gradually improved and was discharged. The infection completely resolved, and the patient had no sequelae.

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