|Year : 2021 | Volume
| Issue : 2 | Page : 80-82
Primary tuberculous pyomyositis in an immunocompetent individual
Jayabal Pandiaraja1, Arumugam Shalini2
1 Department of General Surgery, Dr Mehta Hospital Global Campus, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Velappanchavadi, Chennai, Tamil Nadu, India
|Date of Submission||15-Oct-2020|
|Date of Decision||15-Dec-2020|
|Date of Acceptance||08-Apr-2021|
|Date of Web Publication||4-Aug-2021|
Dr. Jayabal Pandiaraja
Department of General Surgery, Dr Mehta Hospital Global Campus, Kaveri street, Rajaji Nagar, Villivakkam, Chennai, Tamil Nadu, 600049
Source of Support: None, Conflict of Interest: None
Tuberculous pyomyositis is a rare complication of Mycobacterium tuberculosis infection. The reported incidence is around 1% of musculoskeletal tuberculosis. In most cases, tuberculous pyomyositis is misdiagnosed as malignancy or autoimmune disorder due to its nonspecific presentation. The incidence of extrapulmonary tuberculosis is more common in patients with diabetes mellitus and immunocompromised individuals. The reported incidence of mortality in tuberculous pyomyositis is more than 30%. We report a patient of primary tuberculous pyomyositis of the back extending up to right hypochondrium. He was diagnosed with histopathological examination and microbiological examination of aspirate from the muscle. Prompt diagnosis and treatment can save the patient’s life in tuberculous pyomyositis.
Keywords: Chest wall swelling, immunocompetent, tuberculous pyomyositis
|How to cite this article:|
Pandiaraja J, Shalini A. Primary tuberculous pyomyositis in an immunocompetent individual. J Assoc Chest Physicians 2021;9:80-2
| Introduction|| |
Tuberculosis is caused by M. tuberculosis and it is more common in an immunocompromised individual. Tuberculous pyomyositis can be primary or secondary. Primary tuberculous pyomyositis occurs without a primary source of infection. Secondary tuberculous pyomyositis occurs due to tuberculous infection from an adjacent structure such as joint, bone, synovial sheath, cold abscess, and hematogenous spread. Primary tuberculous pyomyositis is very rare compared to secondary tuberculous pyomyositis. Tuberculous pyomyositis is a rare complication of M. tuberculosis infection. The reported incidence is around 1% of musculoskeletal tuberculosis. In most cases, tuberculous pyomyositis is misdiagnosed as malignancy or autoimmune disorder due to its nonspecific presentation.
| Case presentation|| |
A 60-year-old male presented with a complaint of swelling on the right side of the chest and back for 2 weeks. It was associated with pain on the right side of the chest and back for 2 weeks. He also complained multiple discharging sinus on the back side for 2 weeks. Patient also complained on and off fever for 3 days. There was no history of loss of appetite and loss of weight. He denied a history of chronic cough with expectoration and contact with tuberculosis. There was no family history of tuberculosis. He was not a known case of diabetes, hypertension, bronchial asthma, ischemic heart disease, and retroviral infection. He was not on any prolonged medication. There was no history of previous surgery.
On examination, he was well built and nourished. There was evidence of pallor. There were no icterus, cyanosis, clubbing, pedal edema, and generalized lymphadenopathy. On local examination, diffuse large swelling of back starting from the shoulder on the right side and extending up to the right hypochondrium and the loin was found [Figure 1]. There were multiple erythematous lesions with the discharging wound on the back and hypochondrium [Figure 2]. Examination of the spine, ribs, and hip joint was normal. Examination of the chest, the cardiovascular system, and the central nervous system was normal.
|Figure 1 Diffuse large swelling of back starting from the shoulder in the right side and extending up to the right hypochondrium and the loin.|
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|Figure 2 Multiple erythematous lesions with the discharging wound on the back and hypochondrium.|
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The blood investigations showed hemoglobin 8.6 g/dL, total count 32,470 cells/cumm, platelet count 4.85 lakhs/cumm, erythrocyte sedimentation rate (ESR) 89 mm/hour. Peripheral smear showed hypochromic anemia with neurophilic leukocytosis. Fasting plasma glucose, renal function test, and liver function tests were normal. Computed tomography of the chest and abdomen showed ill-defined hypodense fluid collection involving a subcutaneous plane, intramuscular plane, and intermuscular plane [Figure 3]. It involved the right posterolateral chest wall, posterolateral abdominal wall, and right hypochondrium. There was no intrathoracic, intraspinal, or intra-abdominal extension [Figure 4]. There was no significant lymphadenopathy. The underlying spinal cord, ribs, and hip joint appeared normal. Image-guided fine-needle aspiration cytology of intramuscular lesion showed sheets of neutrophils, lymphocytes, degenerated histocytes, epithelioid cells, giant cells, and caseation on histology. The collected fluid was positive for acid-fast bacilli.
|Figure 3 Computed tomography of the chest shows ill-defined hypodense fluid collection involving a subcutaneous plane, intramuscular plane, and intermuscular plane.|
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|Figure 4 Computed tomography of the chest shows no intrathoracic extension.|
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Autoinflammatory diseases with myositis, bacterial pyomyositis, and fungal pyomyositis were considered a few of the differential diagnoses here in patients with large collections in the intermuscular plane and intramuscular plane. Histopathological examination and microbiological examination of aspirate from the suspected lesions confirmed the diagnosis here. Histopathology of fine needle aspiration shows epithelioid giant cell along with caseation necrosis and microbilogy of aspirate shows presence of acid fast bacilli confirm the diagnosis of tuberculous pyomyositis in the present study.
The patient was started on category I antituberculous treatment (ATT) for 6 months [isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E) for 2 months, followed by 4 months of isoniazid and rifampicin) with surgical drainage of fluid collection. He was started on intravenous vancomycin 1 g every 12 hourly along with ATT for superadded bacterial infection. The patient showed significant improvement with the above treatment. He was discharged with ATT. The patient recovered well following ATT and he was on follow-up for more than 3 years without any recurrence.
| Discussion|| |
Tuberculous pyomyositis can present with swelling, muscle mass, weakness of the limb or part, discharge from the wound, and ulceration. Apart from the above symptoms, the patient also presents with classical symptoms of tuberculosis such as an evening rise of temperature, loss of appetite, loss of weight, and easy fatigability. Skeletal muscle is rarely affected with tuberculosis due to its high blood flow, high differentiation, high lactic acid content, and absence of lymphoid tissue.
Most of the reported cases of primary pyomyositis are associated with diabetes, prolonged immunosuppression with steroids, anticancer treatment, chronic renal failure, and intravenous drug abusers. Our case is not associated with diabetes or immunosuppression. Sometimes tuberculous pyomyositis is associated with rhabdomyolysis leading to acute renal failure.
Magnetic resonance imaging of tuberculous pyomyositis shows low or intermediate signal on T1 weighted images and high signal intensity on T2 weighted images. The definitive diagnosis of tuberculous pyomyositis is confirmed with the histopathological examination and microbiological confirmation of acid-fast bacilli. Histopathology may show epithelioid granuloma, caseous necrosis, and giant cells.Prompt surgical drainage with debridement along with antituberculous drugs is the treatment of choice for tuberculous pyomyositis. The addition of antibiotics for bacterial infection depends on bacterial culture and sensitivity. Most of the time it is associated with staphylococcus infection.
| Conclusion|| |
In conclusion, primary tuberculous pyomyositis is a rare form of skeletal tuberculosis. Primary tuberculous pyomyositis can occur in an immunocompetent individual. Imaging with computed tomography and magnetic resonance imaging are useful primary investigations. Histology and microbiology of fine-needle aspiration of muscle will confirm the diagnosis. Prompt surgical drainage with ATT will improve the outcome of the disease.
Learning points/take-home messages
- Primary tuberculous pyomyositis is a rare form of skeletal tuberculosis.
- Primary tuberculous pyomyositis can occur in an immunocompetent individual.
- Imaging with computed tomography and magnetic resonance imaging are useful primary investigations.
- Histology and microbiology of fine-needle aspiration of muscle will confirm the diagnosis.
- Prompt surgical drainage with ATT will improve the outcome of the disease
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]