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Cervical Pyomyositis – A Rare Cause of Cervicalgia Presenting to the Emergency Room

Published online by Cambridge University Press:  04 March 2020

Hidy Girgis
Affiliation:
The Ottawa Hospital Civic Campus, University of Ottawa, 1053 Carling Avenue, Ottawa, Ontario, Canada
Matthias Georg Ziller*
Affiliation:
St. Mary’s Hospital Centre, McGill University, 3830, Lacombe Avenue, Montreal, Quebec, Canada
*
Correspondence to: Dr Matthias Georg Ziller, St. Mary’s Hospital Centre, McGill University, 3830, Lacombe Avenue, Montreal, Quebec, H3T 1M5, Canada. Email: [email protected]
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Abstract

Type
Letter to the Editor
Copyright
© 2020 The Canadian Journal of Neurological Sciences Inc.

We are reporting on a 22-year-old female, native of Burundi, who presented to the emergency department with a 2-week history of severe bilateral cervico-occipital pain and nuchal rigidity. She denied any fever, rashes, neurological deficits, trauma, or recent infections. She was afebrile and hemodynamically stable. Physical examination revealed nuchal swelling, tenderness, and rigidity. There were no lymphadenopathies or focal neurological deficits. Laboratory investigations revealed leukocytosis at 14.4 × 109/L. Serologies for HIV, hepatitis, and syphilis were negative.

The patient had been discharged from the emergency department 2 weeks prior with a diagnosis of occipital neuralgia. However, clinical presentation and nuchal rigidity were concerning for an infectious process, and a CT scan was ordered prior to lumbar puncture.

Imaging demonstrated evidence of abscess formation in the semispinalis capitis muscles (Figure 1). The abscess was surgically drained and cultures grew Staphylococcus aureus. She rapidly improved on intravenous Ceftriaxione, Vancomycin, and Metronidazole and was discharged on a 2-week course of Cloxacillin.

Figure 1: Computed tomography of the head and neck with intravenous contrast showed a 37 × 17 × 8 mm homogenous hypodense collection with ring enhancement extending from the occiput to the cervical spine C3-4 level. (A, sagittal view, arrow). The collection was located predominantly within the right semispinalis capitis muscle (B, axial view, arrowheads) with a smaller extension in the upper left semispinalis capitis muscle.

The patient presented with unprovoked cervico-occipital pain. An infectious process was not initially suspected as she was afebrile. Classically, patients with pyomyositis present with fever, myalgia, and localized tenderness.Reference Chauhan, Jain and Varma1 Pyomyositis is most frequently seen in tropical regions, occurs in males aged 20–40 years, and most commonly affects lower limb muscles.Reference Chauhan, Jain and Varma1 Pyomyositis can occur in healthy individuals, but often predisposing factors such as immunodeficiency, trauma, injection drug use, concurrent infection, and malnutrition can be identified.Reference Crum2

Pyomyositis is thought to arise via hematogenous spread and leads to multiple abscess formation.Reference Stevens, Bisno and Chambers3 It can be complicated by local destruction of the vertebrae, septic shock, endocarditis, septic emboli, brain abscess, or rhabdomyolysis.Reference Lin, Rezai and Schwartz4S. aureus has been implicated in 75–90% of cases.Reference Crum2 Early diagnosis and source control via high-dose antibiotics plus either percutaneous drainage or surgical intervention are necessary to reduce the risk of morbidity.Reference Chiedozi5

The initial misdiagnosis as occipital neuralgia underlines the importance of considering this rare condition in the differential diagnosis of cervicalgia in the emergency setting, even in healthy immunocompetent patients.

Acknowledgments

The authors wish to acknowledge the contribution of Dr Sebastian Demyttenaere, Department of General Surgery, and Dr Joe Dylewski, Division of Infectious Diseases, St Mary’s Hospital Centre, Montreal, to the clinical care of this patient.

Disclosures

The authors have no conflicts of interest to declare.

Statement of Authorship

HG is involved in initial clinical evaluation, literature review, and drafting of the manuscript and revision. MGZ supervised clinical evaluation and management of the patient and contributed to drafting and final review of the manuscript.

References

Chauhan, S, Jain, S, Varma, S, et al.Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J. 2004;80:267–70.10.1136/pgmj.2003.009274CrossRefGoogle ScholarPubMed
Crum, NF. Bacterial pyomyositis in the United States. Am J Med. 2004;117:420.CrossRefGoogle ScholarPubMed
Stevens, DL, Bisno, AL, Chambers, HF, et al.Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:147.10.1093/cid/ciu444CrossRefGoogle ScholarPubMed
Lin, MY, Rezai, K, Schwartz, DN. Septic pulmonary emboli and bacteremia associated with deep tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. J Clin Microbiol. 2008;46:1553.10.1128/JCM.02379-07CrossRefGoogle ScholarPubMed
Chiedozi, LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg. 1979;137:255.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1: Computed tomography of the head and neck with intravenous contrast showed a 37 × 17 × 8 mm homogenous hypodense collection with ring enhancement extending from the occiput to the cervical spine C3-4 level. (A, sagittal view, arrow). The collection was located predominantly within the right semispinalis capitis muscle (B, axial view, arrowheads) with a smaller extension in the upper left semispinalis capitis muscle.