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Case Challenge
A 10-Week-Old Female with Fever and
an Inability to Move Her Left Leg
Bilge Aldemir-Kocabas, MD; Adem Karbuz, MD; Suat Fitöz, MD; Ergin Çiftçi, MD; and Erdal Ince, MD
Bilge Aldemir-Kocabaş, MD, is a Fellow, Division of Pediatric Infectious Diseases, Department
of Pediatrics, School of Medicine, Ankara University. Adem Karbuz, MD, is a Fellow, Division of
Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Ankara University.
Suat Fitöz, MD, is a Professor, Department of Radiology, School of Medicine, Ankara University.
Ergin Çiftçi, MD, is a Professor, Division of Pediatric Infectious Diseases, Department of Pediatrics,
School of Medicine, Ankara University. Erdal İnce,
MD, is a Professor, Division of Pediatric Infectious
Diseases, Department of Pediatrics, School of
Medicine, Ankara University.
Address correspondence to Bilge AldemirKocabaş, MD, Division of Pediatric Infectious
Diseases, Department of Pediatrics, School of
Medicine, Ankara University, TR-06590 Cebeci,
Ankara, Turkey; email: [email protected].
Disclosure: The authors have no relevant financial relationships to disclose.
doi: 10.3928/00904481-20141022-06
Figure 1. Magnetic resonance images showing signal hyperintensity and contrast enhancement (arrows) in the left quadriceps muscle group on the (A) coronal and (B) axial axes.
A
previously healthy 10-weekold female was admitted to
our hospital with a fever and
an inability to move her left leg. The
mother also noted a decrease in the
child’s breast-feeding in the 3 days
prior to presentation. Although there
was no history of major trauma, it was
revealed that her brother had picked
her up roughly by her leg 5 days before her admission. On initial physical
examination, she had increased capillary refill and tachycardia with toxic
appearance. Flexion-adduction and
internal rotation posture, and warmth,
tenderness, and limitation of movement of the left hip joint were detected. Her laboratory findings were
as follows: white blood cell count of
11700/mm3, erythrocyte sedimentation rate of 87 mm/h, and C-reactive
protein level of 86 mg/L.
For diagnosis, see page 443
Editor’s note: Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome
via email at [email protected].
442
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Case Challenge
Diagnosis:
Pyomyositis Caused by
Streptococcus pneumoniae
The diagnoses of soft tissue infection and
septic shock were established. Fluid replacement therapy was given to the patient immediately. After a blood culture
was taken, intravenous ceftriaxone at a
dose of 75 mg/kg/d was initiated. A heterogeneous appearance on the left quadriceps muscle group was detected sonographically. Pathological signal change,
contrast enhancement, and myositis of
the left quadriceps muscle group were
identified by magnetic resonance imaging (Figure 1). The blood culture was
positive for Streptococcus pneumoniae.
Her fever resolved and limitation of abduction of the hip joint gradually improved at follow-up. Ceftriaxone treatment was continued for a total of 10 days,
after which she was discharged from the
hospital. Sonographic findings and physical examination were completely normal
at the end of the first month of follow-up.
The pneumococcal serotype was typed as
S. pneumoniae serotype 5 according to
polymerase chain reaction (PCR) assays.
DISCUSSION
Pyomyositis (PM) is a rare infection of
the muscle tissue that occurs most often
in childhood. Striated muscle is actually
resistant to microorganism invasion. The
most common cause of PM is Staphylococcus aureus. It is suggested that trauma
is a facilitating factor for microorganism
invasion in patients with PM,1-5 but trauma
has been reported in only about 10% of
PM patients (in our case there was a possibility of accidental trauma caused by the
patient’s brother). Thus, invasion of pneumococci to the hip muscle might be facilitated by this event during the bacteremia
caused by S. pneumoniae.
PEDIATRIC ANNALS • Vol. 43, No. 11, 2014
A number of risk factors have been
identified for the development of pneumococcal infections and related complications
such as PM. These include age (older than
65 years or younger than 2 years), chronic
heart, lung, kidney, and liver diseases; diabetes mellitus; cerebrospinal fluid leaks;
cochlear implants; some hematological
diseases and malignancies; functional or
anatomic asplenia; HIV infection; use
of immunosuppressive drugs (including
steroids); and solid organ transplantation
or hypocomplementemia.5-7 In an at-risk
group, gram-negative enteric organisms,
anaerobes, and fungi also can be causative
pathogens for PM. Diagnosis of PM requires both radiologic evidence and positive culture of blood, muscle aspirate, or
other fluid. PM can be classified into three
stages. In the early stage, treatment with
antibiotics alone can be effective for controlling local infection and does not require
surgery.5 Osteomyelitis, septic arthritis,
fever of unknown origin, cellulitis, thrombophlebitis, and appendicitis should be
kept in mind in the differential diagnosis of
PM.1 Also, PM should be considered in the
differential diagnosis of septic-appearing
children as well as children complaining of
joint pain or muscle pain.2
Our 10-week-old infant had received a
13-valent pneumococcal conjugate vaccine
(PCV-13) 15 days before admission (PCV13 includes type 5). The incidence of invasive pneumococcal diseases in children
younger than age 5 years has decreased
dramatically with routine use of PCV.8
Bacteremia without a known site of infection is the most common invasive clinical
presentation of pneumococcal infection
among children age 2 years and younger,
and it accounts for approximately 70% of
invasive diseases in this age group. Before
routine use of PCV, the burden of pneumococcal diseases among children younger
than age 5 years was significant.8,9 Complete immune response requires at least
three dosages of vaccine. Due to insuf-
ficient maturity of the immune system in
infancy and lack of a full dose of pneumococcal vaccination, infants are more prone
to invasive pneumococcal infections.
In conclusion, PM should be considered in the differential diagnosis of pain
and restriction in movement of the hip joint
in a child, especially in a child with a toxic
appearance. Moreover, PM should also be
kept in mind if a child with pneumococcal
bacteremia has pain and limitation of hip
joint on physical examination, and a child
with these symptoms should be evaluated
immediately with imaging techniques.
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