John, an eight-year-old boy, loved to play soccer with his friends. Barely a week ago, he had fallen while he was playing a game with his friend. He never thought anything went wrong at that time being since he only felt some little pain in his left leg on that day. As the days passed, the pain he felt on the first day began to worsen. 

Soon enough, fever crept in and he could barely walk again. He was taken to a pharmacy by his parents where he was given some medicine; however, the meds didn't help at all.

As a result of this lack of improvement, he was taken to the hospital. On reaching the hospital, the doctors noticed his left leg had swollen and was painful, especially near his hip. An attempt at moving it made him scream in pain.

John’s parents were worried. They would just understand what was going on with their boy. “Why isn’t he getting better?” they wondered.

Little did they know it was a serious infection going on deep in his muscle which his body was fighting against.

Join me as we look at Pyomyositis, its complications and how it can be managed to prevent life-threatening complications.

Introduction

Pyomyositis is also known as pyomyositis Tropicana or Tropical pyomyositis because it is commonly found in the tropical region especially Sub-Saharan Africa, Asia, and Oceania.^1,2

It is an acute bacterial infection that affects skeletal muscles in the body and leads to the formation of pus. It is mainly caused by a bacteria called Staphylococcus aureus in 40% to 100% of cases. Other bacteria species that have been found to cause pyomyositis include:^1,2

• Streptococci
• Pseudomonas aeruginosa
• Escheriscia coli
• Klebsiella spp

Recently, the incidence has also increased in temperate regions. It occurs in both males and females and doesn't spare any age group. However it is more common in children (2-5 years), young adults (20-45 years) and people with low immune defence systems as well as higher in males as compared to females with a ratio of 1.5: 1^1,2

Pyomyositis can be found in people whose immune systems are weak such as in:^1,2

• Diabetes mellitus
• Human Immunodeficiency Virus (HIV)
• Cancer
• Kidney failure, and
• Leukemias

It can also be seen when the skeletal muscles have some injury from:¹

• Injection of drugs through the muscle
• Rigorous physical exercises
• Underlying viral or parasitic myositis

Pyomyositis can be classified into 3 clinical stages:⁴

The early stage

• Usually associated with pain and some swelling.
• Lasts for days to weeks after the symptoms begin to show.

The next stage is called the Suppurative Stage

• Usually occurs between days 10 and 21 after symptoms begin to show
• Fever, malaise, high levels of white cells and low red cells may be noticed at this stage
• Associated with severe pain and swelling
• 90% of patients come at this stage

The third stage is the septicemic stage

• It occurs due to delay in identifying and treating the infection
• The abscess formed may begin to scatter around the body such as the brain, lungs, and heart
• The blood may also get filled with the bacterium, this is called bacteraemia

Anatomic distribution of pyomyositis.³

What are the complications of Pyomyositis?

The most common complication of pyomyositis is sepsis. Other complications include: compartment syndrome, osteomyelitis and chronic infections. With early detection and treatment, the complications can be avoided.^1,4

Sepsis

Sepsis is a life-threatening condition whereby the defence system of the body reacts in an extreme response to an infection found in the blood. This may result in organs functioning improperly.^5,6

Sepsis if not identified and treated promptly is capable of causing damage to the individual infected tissues and organs and it can result in shock, multiple organ failure and sometimes even death.⁵

How does pyomyositis lead to sepsis?

As bacteria from the infected muscles spread into the blood it results in Sepsis.⁵

What are the signs and symptoms you see in sepsis?

The signs and symptoms of sepsis include:^5,6

• Fever
• Fast heart rate
• Confusion
• Low blood pressure.
• Clammy and sweaty skin
• Reduced passage of urine
• Breathing difficulty

Children may:⁵

• Convulse
• Feel cold to touch
• Breathe abnormally fast
• Vomiting
• Feeding problems

What are the possible consequences of sepsis?

Sepsis is very dangerous and may result in:⁵

• Multi-organ failure
• Shock
• Death if not treated

How can sepsis be treated?^5,6

• Treatment with antibiotics at the earlier stage is very effective
• Intravenous fluids are also very important
• Surgery may be required for the draining of the abscess
• In severe cases, care in the Intensive Care Unit (ICU) may be required

How can you prevent sepsis?

Prevention of sepsis is possible by:⁵

• Ensuring good hygiene at home and in the hospitals through :

• Proper hand washing
• Proper and safe food preparation
• Avoiding dirty toilets
• Avoiding unclean water for drinking
• Eating healthy meals and breastfeeding babies 
• Getting recommended vaccines
• Treating infections early with appropriate antibiotics

Compartment syndrome

Compartment syndrome is a painful emergency condition occurring due to increasing pressure in the muscle which results in the decrease of blood flow which in turn results in reduced oxygen in the muscle. It can be either acute or chronic.^7,8

How does pyomyositis trigger compartment syndrome?

As a result of the infection and swelling pressure builds up on the muscle resulting in a reduction in the flow of blood and therefore reduction in oxygen flow also through the vessels to the muscle which over time then results in the death of the muscle cell called Necrosis.⁸

What are the signs and symptoms of compartment syndrome?

The signs and symptoms include

• Severe pain
• Tingling or burning 
• Numbness
• Swollen or tight muscles
• Weakness

What are the serious consequences of compartment syndrome? 

This may result in:⁸

• Loss of function
• Permanent nerve and muscle damage
• Contracture
• Infection
• Death

How do you manage and prevent compartment syndrome? ^8,9

• Surgical release of the pressure called fasciotomy should be done within the first 6 hours of infection. Fasciotomy is not necessary any longer if compartment syndrome has exceeded 36 hours
• In the presence of necrosis (cell death), the dead tissue should be removed, the site cleaned and a graft done

Other treatment modalities include:⁸

• Taking pain medications
• Giving oxygen to the patient through the nose or mouth where necessary
• Keeping the body part affected below the level of the heart so blood can flow into the compartment 
• Giving fluids intravenously

Chronic infection

Chronic infection may happen:

• When the infection persists despite treatment
• When treatment is incomplete
• When there is resistance to antibiotic
• When there are hidden pockets of infection

This may cause damage to the muscles, reduce mobility of the affected muscle and result in prolonged use of antibiotics.

Conclusion

Pyomyositis is a bacterial infection that may begin as a mere pain in the muscle, however, it may progress and lead to sepsis, compartment syndrome, or a chronic infection that is quite difficult to treat.

These complications can be prevented if pyomyositis is detected and treated in time. If you notice a child who is having a fever with increasing pain in the muscles, and or problems with moving limbs, don't wait: get help immediately. 

With the right care, children like John in the story will get better treatment and recover well.

Summary

Pyomyositis though starting following a supposed small fall during a soccer game for 8-year-old John led to something a lot more serious. His worsening leg pain, fever, and swelling eventually turned out to be. 

Pyomyositis is a bacterial infection that affects the deep skeletal muscles, mostly caused by Staphylococcus aureus. It is commonly called a disease of tropical regions, but it has gradually spread to temperate regions. It affects especially children, young adults, and people with weaker defence systems.

Pyomyositis usually begins with muscle pain and swelling, then progresses to fever, and the formation of pus. Delays in identifying and treating polymyositis would usually result in life-threatening complications such as sepsis, chronic infections, and compartment syndrome.

Early detection, proper administration of antibiotics, and sometimes pus drainings can help with healing and prompt recovery.

Therefore, parents/caregivers and healthcare professionals are encouraged to be proactive if they notice persistent muscle pain, fever, and problems with movement in any individual.