PEDIATRIC EMERGENCY MEDICINE BLOG
October 20, 2015
Previously healthy 14-yo M presents with fever, dyspnea, inability to bear weight, and draining abscess on left abdomen. Developed small abscess 1 week prior after seemingly negligible trauma, which older brother drained at home. Over next 5 days, developed inability to walk, spiking fevers, and severe dyspnea. No PMH. Lives at home with older brother. Both parents deceased.
Patient is sitting upright, severely distressed with tachypnea and heavily labored breathing. T 40, BP 110/70, HR 130s, RR 50s, SpO2 82% RA. Lungs: tachypneic with intercostal retractions and nasal flaring. Generally clear, but bibasilar diminished breath sounds. CV: tachycardic, hyperdynamic. Abdomen: distended and firm. Severe LLQ tenderness. Incised abscess on left abdomen with minimal active drainage, no erythema. Ext: severe pain with palpation of left thigh. Indurated. Pain with internal/external rotation. Unable to flex. Neuro: GCS 13-14.
HD 0: Formal incision and drainage of abdominal wound and empiric dicloxacillin. CXR as below. BiPAP. NS at 1.5 maintenance. Fever spikes > 39.5 despite drainage and antibiotics.
HD 1: US of left hip/leg showed large abscess formation tracking upwards towards abdominal wound. I&D performed in OR. Continued fevers, now > 40. Antibiotics changed to vancomycin and clindamycin.
HD 2: Hypotensive (90s/40s) requiring numerous NS boluses. 48 hours post second I&D, respiratory status improving, but new left elbow pain.
HD 4: US demonstrates intramuscular abscess along proximal forearm. Taken to OR for I&D.
HD 6: Blood pressure normalizing, fever curve improving.
HD 8: Clinically improved. However, recurrent fever and mild left-sided chest pain and tachypnea. US shows left-sided pulmonary abscess. Surgical drainage planned.
Discussion: This patient presents with classic findings of myositis tropicans (MT). MT is a disease most commonly encountered in the tropics, but there has been a steady rise in temperate regions.1, 2 It is characterized by skeletal muscle inflammation that leads to intramuscular abscess formation. The most common culprit is Staphylococcus aureus, accounting for 90% of tropical cases and 75% of temperate cases .1 Pathogenesis occurs in three stages: 1) Invasive – pain +/- fever without systemic symptoms; 2) Suppurative – abscess formation and systemic symptoms; and 3) Late stage – bacteremia and septic shock.3 Risk factors for development include trauma or strenuous exercise, and most importantly, immunocompromise. Diagnosis includes abscess aspirate or muscle biopsy for culture. However, approximately 15-30% of aspirates are sterile.4 Blood cultures, although recommended, are only positive in 5-10% of cases.5, 6 Imaging modalities such as US or CT/MRI are useful. Laboratory evaluation typically shows leukocytosis with left-shift, anemia, and thrombocytosis. ESR is elevated. Treatment is aimed at staphylococcus, and empiric therapy is dicloxacillin. Immunocompromised patients have higher risk for poly-microbial infection and should be covered accordingly. Recurrent fever is common due to new foci of infection. Repeat examination for new abscesses and subsequent drainage is essential. Treatment continues until abscess is clean, leukocytosis normalizes, and patient is afebrile x 7 days, usually 4-6 weeks.
Clinical Pearls for ED:
* Consider myositis tropicans in any patient presenting with muscle pain, fever, and leukocytosis
o Higher suspicion in patients who are from the tropics – specifically sub-Saharan Africa, Caribbean, and Asia
o High suspicion in immunocompromised – HIV, poorly controlled DM, chemotherapy
* Late presentation is common. Must consider in septic/bacteremic patients with multiple abscesses
* Persistent fever typically means missed foci of infection – look for new abscesses, especially in children that have been treated elsewhere and are newly presenting to the ED
* Incision and drainage is essential once abscesses have developed
1. Christin L, Sarosi GA. “Pyomyositis in North America: case reports and review.” Clin Infect Dis, 1992; 15:668-77.
2. Bonafede P, Butler J, et al. “Temperate zone pyomyositis.” West J Med, 1992; 156:419-23.
3. Chauhan S, Jain S, Varma S, Chauhan SS. “Tropical Pyomyositis (myositis tropicans): current perspective.” Postgrad Med J, 2004; 80:267-70.
4. Shepherd JJ. “Tropical myositis, is it an entity and what is its cause?” Lancet, 1983;ii:1240-2.
5. Gambhir IS, Singh DS, Gupta SS, et al. “Tropical pyomyositis in India, a clinic-histopathological study.” J Trop Med Hyg, 192; 95:42-6.
6. Brown JD, Wheeler B. “Pyomyositis: report of 18 cases in Hawaii. Arch Intern Med, 1984; 288:300-5.
Author - JR Young
This is a full-term 2 week female infant here with 4 episodes of bright red blood mixed with her stool over 24 hours. Last episode occurred in the examination room. She has continued to breast feed well with no fevers, vomiting, weight loss, abdominal pair, or irritability.
Mom was 26yrs, G1P1. Birth weight 3.1 kg. SVD and GBS negative. Received vitamin K at birth. Born in hospital and had pre-natal care. All serologies negative.
Afebrile and all vital signs are within normal limits. Wt 3.2kg. Well appearing. Abdomen is soft, non-distended, non-tender with normal bowel sounds. No hepatosplenomegaly. Normal external female genitalia. No anal fissures/tears/skin tags visualized. Normal rectal tone. Stool in diaper is yellow and seedy with blood mixed throughout (guaiac positive).
Mom has a normal breast exam without signs of fissures or active bleeding.
- Thorough history and physical exam
o Age of patient
o NSAID use
o Color of blood (Bright red blood, maroon stools, dark tarry stools, etc) – i.e. is it upper GI or lower GI
o Volume of blood and how often it occurs
o Associated symptoms
o Palpation of a polyp on rectal exam, anal fissures, anal tears?
- Hemoccult (false-negative and false-positives are possible) – i.e. is it blood?
- Apt-Downey test may help distinguish between fetal and maternal blood (swallowed blood during delivery or fissured maternal breast with feeding)
- CBC with diff (and serial hemoglobin levels with admission) level
- Consider coagulation studies, liver function tests, and stool evaluation (C. diff)
- Cross and match if profuse bleeding
- Consider supine, upright, and lateral decubitus abdominal radiographs to evaluate for air-fluid levels, dilated loops of bowel, pneumoperitoneum, or pneumatosis
- Additionally radiographic imaging should be directed by your history and physical – i.e. an upper GI with small bowel follow-through if concerned about malrotation, ultrasound for possible intussusception, etc.
- Cardiopulmonary and fluid resuscitation as needed (with crystalloid or colloid as needed)
- Consider a surgery consult if concern for surgical entity such as NEC
- Consider broad-spectrum antibiotics if concern for an acute abdomen or sepsis
- Consider NG tube placement for gastric decompression
- Admission unless clear benign source and they have good follow-up
- May require GI consult or hematology consult on admission as indicated
- Lower GI bleeds account for 30% of cases of GI bleeding presenting to the ED
- Hematochezia is usually a manifestation of bleeding from the distal small bowel or proximal colon but can represent severe upper GI bleed
- Often benign and self-limited but can represent serious illness and is very anxiety provoking in parents/physicians
- Red Kool-Aid, red gelatin, fruit punch, tomato/cranberry juice, beets, peach skin, rifampin, medications with red syrup may lead to red appearing stool
- Eosinophilia may indicate milk protein allergy
- 10% of cases of necrotizing enterocolitis present in full-term infants and may present with non-specific symptoms and blood in the stool
- Melena may occur with malrotation and volvulus when vascular compromise occurs – 10-20% of the time
- 25% of patients with Hirschsprung related enterocolitis will present with blood in the stool
- Changing to an elemental formula like alimentum or nutramigen if concerned about milk-protein allergy
This 2 week old was noted to have mild abdominal distention on re-examination and had an additional 3 episodes of hematochezia in the ED. A KUB with lateral decubitus view was ordered and radiology reported questionable signs of pneumatosis. Surgery was consulted who felt she was fussy and requested an abdominal ultrasound which was negative for intussusception. At that time, the patient was hospitalized with CHIPS and a surgical consult. Coagulation studies were obtained and she was found to have a greatly prolonged PT and aPTT. Hematology was consulted who recommended a coagulation work-up in addition to repeating the PT and aPTT. These were normal and it was felt the initial laboratory values were in error. GI was consulted as well and patient was ultimately discharged home with a diagnosis of milk-protein allergy and is doing well on an elemental formula.
By Jeremiah Smith, MD
Pediatric EM Blog
Pediatric EM Fellows at CMC/Levine Children's Hospital.
Disclaimer: All images are the sole property of CMC Emergency Medicine Residency and cannot be reproduced without written consent. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the authors and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.