Correspondence

Pyomyositis Caused by Methicillin-Resistant Staphylococcus aureus

N Engl J Med 2005; 352:1488-1489April 7, 2005

Article

To the Editor:

Pyomyositis is common in tropical regions but is rarely reported in temperate climates. In the United States, most cases are associated with human immunodeficiency virus infection or other immunosuppressive conditions, including diabetes mellitus, cancer, connective-tissue diseases, and cirrhosis.1 Christin and Sarosi observed that Staphylococcus aureus was the causative organism in 70 percent of cases, and that 31 percent of the patients had bacteremia.2 We describe four patients with community-acquired pyomyositis caused by methicillin-resistant S. aureus who presented to our hospital within a span of six months.

Patient 1 was a 22-year-old Nicaraguan woman without previous medical problems who presented with a boil on the right upper thigh that was treated with incision and drainage. Two weeks later, she presented with increasing thigh pain, swelling, and a temperature of 99.5°F (37.5°C). Magnetic resonance imaging (MRI) showed an abscess of the vastus intermedius muscle (Figure 1Figure 1Coronal, Fat-Suppressed, T₁-Weighted MRI Scan of the Thigh of Patient 1, Obtained after the Intravenous Administration of Gadolinium.). Incision and drainage were performed, and wound cultures grew methicillin-resistant S. aureus.

Patient 2 was a 33-year-old woman with no history of medical problems who presented after three days of pain and swelling in the right thigh and difficulty walking. She had been treated for axillary and gluteal boils with incision and drainage and cephalexin. MRI revealed phlegmon of the piriformis muscle. Blood cultures grew methicillin-resistant S. aureus.

Patient 3 was a 31-year-old woman with AIDS (CD4 cell count, 15 per cubic millimeter) who was not receiving antiretroviral therapy. She had had pain in the right thigh for one week and fever and leg swelling for two days. A computed tomographic (CT) scan showed fluid collection in the right anterior thigh. Blood cultures grew methicillin-resistant S. aureus.

Patient 4 was a 51-year-old man with type 2 diabetes mellitus. He presented with pain and swelling in the left lower extremity and was treated with cephalexin. One week later, he presented with difficulty walking and increased leg swelling. A CT scan showed a 2-cm fluid collection in the anterior thigh. The collection was surgically drained. Wound and blood cultures grew methicillin-resistant S. aureus.

Isolates were tested with an automated system (Vitek, BioMérieux) and were sensitive to tetracycline, vancomycin, gentamicin, and rifampin; all were resistant to azithromycin but sensitive to clindamycin. The isolates showed no inducible resistance to clindamycin with the use of the D-test. Two isolates were further tested against ciprofloxacin and were found to be resistant.

Patients with locally invasive soft-tissue infection should be suspected of having methicillin-resistant S. aureus. These four patients were treated with vancomycin for two to three weeks; two received oral clindamycin to complete their antibiotic course. All four patients had complete resolution of infection. This cluster of cases suggests that community-acquired methicillin-resistant S. aureus is emerging as an important cause of pyomyositis.

Maria E. Ruiz, M.D.
Seife Yohannes, M.D.
Christopher G. Wladyka, M.D.
Washington Hospital Center, Washington, DC 20010
maria.e.ruiz@medstar.net

2 References

1. 1

   Crum NF. Bacterial pyomyositis in the United States. Am J Med 2004;117:420-428
   CrossRef | Web of Science | Medline

2. 2

   Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15:668-677
   CrossRef | Web of Science | Medline

Citing Articles (20)

Citing Articles

1. 1

   Steven D. Burdette, Richard R. Watkins, Ken K. Wong, Stephanie D. Mathew, Donald J. Martin, Ronald J. Markert. (2012) Staphylococcus aureus pyomyositis compared with non-Staphylococcus aureus pyomyositis. Journal of Infection
   CrossRef

2. 2

   M. Morgan. (2011) Treatment of MRSA soft tissue infections: An overview. Injury 42, S11-S17
   CrossRef

3. 3

   Carolyn D. Alonso, Sam Barclay, Xuguang Tao, Paul G. Auwaerter. (2011) Increasing incidence of iliopsoas abscesses with MRSA as a predominant pathogen. Journal of Infection 63:1, 1-7
   CrossRef

4. 4

   Lena M. Napolitano. (2010) Perspectives in Surgical Infections: What Does the Future Hold?. Surgical Infections 11:2, 111-123
   CrossRef

5. 5

   Joseph F. Woodward, Dhruba J. Sengupta, Brad T. Cookson, James O. Park, E. Patchen Dellinger. (2010) Disseminated Community-Acquired USA300 Methicillin-Resistant Staphylococcus aureus Pyomyositis and Septic Pulmonary Emboli in an Immunocompetent Adult. Surgical Infections 11:1, 59-63
   CrossRef

6. 6

   R. Prasad, N. Verma, O. P. Mishra. (2009) Pyomositis: a report of three cases. Annals of Tropical Paediatrics: International Child Health 29:4, 313-316
   CrossRef

7. 7

   Evangelos Cholongitas, Chrysa Georgousaki, Simos Spyrou, Konstadinos Rellos, Maria Dasenaki. (2009) Staphylococcal pneumonia with multiple muscle abscesses in an immunocompetent patient. International Journal of Infectious Diseases 13:6, e521
   CrossRef

8. 8

   Loren G. Miller, Sheldon L. Kaplan. (2009) Staphylococcus aureus: A Community Pathogen. Infectious Disease Clinics of North America 23:1, 35-52
   CrossRef

9. 9

   Bruce M. Lo, Benjamin A. Fickenscher. (2008) Primary pyomyositis caused by ca-MRSA. International Journal of Emergency Medicine 1:4, 331-332
   CrossRef

10. 10

    Kishore Yalamanchili, Jihad El Hayek, Pradeep Gujja. (2008) Methicillin-Resistant Staphylococcus aureus Nontropical Pyomyositis Leading to Empyema Thoracis. Infectious Diseases in Clinical Practice 16:6, 403-404
    CrossRef

11. 11

    Rachel J. Gordon, Franklin D. Lowy. (2008) Pathogenesis of Methicillin‐Resistant Staphylococcus aureus Infection. Clinical Infectious Diseases 46:S5, S350-S359
    CrossRef

12. 12

    Georgios Kalambokis, Areti Theodorou, Paraskevi Kosta, Epameinondas V. Tsianos. (2008) Multiple myeloma presenting with pyomyositis caused by community-acquired methicillin-resistant Staphylococcus aureus: report of a case and literature review. International Journal of Hematology 87:5, 516-519
    CrossRef

13. 13

    C. G. Zalavras, N. Rigopoulos, L. Poultsides, M. J. Patzakis. (2008) Increased Oxacillin Resistance in Thigh Pyomyositis in Diabetic Patients. Clinical Orthopaedics and Related Research 466:6, 1405-1409
    CrossRef

14. 14

    Thomas R. Wallin, H. Gene Hern, Bradley W. Frazee. (2008) Community-Associated Methicillin-Resistant Staphylococcus aureus. Emergency Medicine Clinics of North America 26:2, 431-455
    CrossRef

15. 15

    Bradley W. Frazee. (2007) Commentary. Annals of Emergency Medicine 50:5, 614-616
    CrossRef

16. 16

    Nancy F. Crum-Cianflone. (2006) Infectious myositis. Best Practice & Research Clinical Rheumatology 20:6, 1083-1097
    CrossRef

17. 17

    Pia S. Pannaraj, Kristina G. Hulten, Blanca E. Gonzalez, Edward O. Mason, Jr., Sheldon L. Kaplan. (2006) Infective Pyomyositis and Myositis in Children in the Era of Community‐Acquired, Methicillin‐Resistant Staphylococcus aureus Infection. Clinical Infectious Diseases 43:8, 953-960
    CrossRef

18. 18

    Lorne N. Small, John J. Ross. (2005) Tropical and Temperate Pyomyositis. Infectious Disease Clinics of North America 19:4, 981-989
    CrossRef

19. 19

    John S. Francis, Karen Carroll. (2005) Community-acquired MRSA: A Notable Adversary. Southern Medical Journal 98:11, 1061-1062
    CrossRef

20. 20

    J. Etienne. (2005) Panton-Valentine Leukocidin: A Marker of Severity for Staphylococcus aureus Infection?. Clinical Infectious Diseases 41:5, 591-593
    CrossRef