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Tuberculous pyomyositis of the temporalis muscle
European Journal of Radiology Extra 52 (2004) 89–91
Tuberculous pyomyositis of the temporalis muscle C. Sridhar, Ashu Seith∗ Department of Radiodiagnosis, All India Institute of Medical Science, New Delhi, India Received 12 August 2004; received in revised form 29 September 2004; accepted 30 September 2004
Abstract Tuberculosis of the muscles without coexistent skeletal involvement is very rare. A case of tuberculous pyomyositis of the temporalis muscle in an immunocompetent young male is presented. A good response was seen with an antituberculous treatment. Tuberculosis should be considered in the differential diagnosis of any unexplained soft tissue swelling in people born in tubercular endemic areas or those who are immunosuppressed. © 2004 Published by Elsevier Ireland Ltd. Keywords: Mycobacterium tuberculosis; Head and neck; Pyomyositis; Computed tomography
2. Case report
weeks. The swelling was gradually increasing in size. There was no preceding history of trauma. He also had anorexia, weight loss, fever and cough. On physical examination, there was a swelling in the left temporal region with mild tenderness, without local rise in temperature. There were no associated enlarged neck nodes. Chest radiograph showed right paratracheal lymphadenopathy. The hemogram was normal except for an ESR of 40 mm per first hour. Mantoux skin test was positive with 20 mm induration. Contrast-enhanced CT revealed an enhancing, bulky temporalis muscle with central low attenuating areas (Fig. 1). The underlying temporal bone was normal (Fig. 2). Chest CT showed mediastinal adenopathy. Fine needle aspiration cytology from the swelling showed caseating granulomas. The patient’s immune status was normal. The patient was started on antituberculous treatment with four drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol). The swelling completely resolved after 6 months and the patient was symptom-free. Follow-up CT showed a normal left temporalis muscle and complete resolution of mediastinal adenopathy.
A 28-year-old male presented with a swelling in the left temporal region of 1-month duration, with pain for the last 2
3. Discussion
∗ Tel.: +91 9810329748; fax: +91 11 2658 8663. Present address: Flat No. 714, Sector 29, Noida, Gautam Budh Nagar, UP 201301, India. E-mail address: [email protected] (A. Seith).
Tuberculosis is a common infectious disease caused by Mycobacterium tuberculosis, but only rarely does it cause skeletal muscle infection even in countries where tuberculosis
1. Introduction Pyomyositis (PM) is a bacterial infection occurring in a skeletal muscle, with no obvious local or adjacent source of infection [1]. Bacterial pyomyositis is often called tropical pyomyositis because it is more common in tropical areas. It is usually caused by staphylococcus aureus [1]. Trauma, tissue parasites, immunodeficiency and malnutrition have been implicated as causative factors [1,2]. The typical presentation is that of a gradually expanding mass in a large muscle, usually the quadriceps or gluteus, accompanied by slowly increasing pain [3]. Skeletal muscle infection due to Mycobacterium tuberculosis in an immunocompetent person is rare, and only few cases of tuberculous myositis have been reported [4]. We present the computed tomography (CT) findings of tuberculous PM of the temporalis muscle in a young nonimmunocompromised male patient as a case report.
1571-4675/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrex.2004.09.014
90
C. Sridhar, A. Seith / European Journal of Radiology Extra 52 (2004) 89–91
Fig. 1. Contrast-enhanced axial (A–C) and coronal (D) CT shows bulky and enhancing temporalis muscle with central areas of low-attenuation.
Fig. 2. The underlying temporal bone appears normal on bone window setting.
is endemic [5]. Tuberculous PM occurs in about 2% of the patients with tuberculosis. Several hypotheses might explain this rarity, including poor oxygen content, high lactic acid concentration; and paucity of reticuloendothelial and lymphatic tissue within skeletal muscle [6]. Tuberculosis may involve the skeletal muscle by various means: (1) direct extension from adjacent structures (bone, joint, tendon, lymph nodes or pleura); (2) hematogenous spread from a distant focus of infection usually pulmonary; (3) traumatic or iatrogenic inoculation, if there is any history of local trauma or surgery. Hematogenous dissemination plays an important causative role in tuberculous myositis. Our patient had tuberculous PM, which was likely due to hematogenous spread, as mediastinal nodes were also present. Tuberculous PM is usually limited to a single large muscle such as the muscles of the thigh, back, buttock, or arm. However, several muscles may be involved [7]. It is rare to involve small muscle like the temporalis, as in our case. Most commonly, tuberculous PM is chronic and slow growing. Pain is rarely a prominent clinical feature in the early stages, and medical care may be delayed for many months. Localized swelling is usually the first complaint [8]. Our patient also presented with swelling followed by mild pain. Pyomyositis is difficult to diagnose clinically because many other pathological processes such as osteomyelitis, fascitis, cellulitis, abscess, polymyositis, hematoma and even neoplasms may produce similar symptoms [9].
C. Sridhar, A. Seith / European Journal of Radiology Extra 52 (2004) 89–91
Due to its non-specific clinical presentation imaging plays an important role in the evaluation of such patients. CT, magnetic resonance imaging (MRI) and sonography have all been reported as diagnostic tools for PM. CT is of value for localization of the lesion, to assess the underlying bone and to differentiate it from a hematoma, cellulitis or deep venous thrombosis [10]. It shows thickening and edema of the involved muscle layers with reticulation of the adjacent subcutaneous fat. Post contrast, the involved muscles show enhancement with central low attenuation areas. Our patient showed similar CT findings. CT is also useful in guiding percutaneous biopsy and/or drainage procedures. Treatment consists of specific antituberculous chemotherapy and drainage if large collections are noted. Our case showed complete resolution of the temporalis muscle inflammation with antituberculous treatment. In conclusion, tuberculous myositis though rare should be considered in the differential diagnosis of muscle inflammation, especially in areas where tuberculosis is endemic. This case has been reported to increase awareness regarding soft tissue tuberculosis, as its incidence is likely to increase in the future.
91
References [1] Gubbay AJ, Isaacs D. Pyomyositis in children. Pediatr Infect Dis J 2000;19:1009–12. [2] Indudhara R, Singh SK, Minz M, et al. Tuberculous pyomyositis in a renal transplant recipient. Tuber Lung Dis 1992;73:239– 41. [3] Editorial. Pyomyositis. Br Med J 2 (1979) 458–459. [4] Yajko DM, Nassos PS, Sanders CA, Mandej J, Hadley WK. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995;20:1576– 7. [5] Bonomo RA, Graham R, Makley JT, Petersilge CA. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995;20:1576–7. [6] Katz R, Herman MA, Katz S. Tuberculosis of muscle. JAMA 1964;190:472–3. [7] Johnson DW, Herzig KA. Isolated tuberculosis pyomyositis in a renal transplant patient. Nephrol Dial Transplant 2000;15:743. [8] Moore DL, Delage G, Labelle H, Gauthier M. peracute streptococcal pyomyositis: report of two cases and review of the literature. J Pediatr Orthop 1986;6:232–5. [9] McLoughlin MJ. CT and percutaneous fine-needle aspiration biopsy in tropical myositis. Am J Roentgenol 1980;134:167–8. [10] Kim JY, Park YH, Choi KH, Park SH, Lee HY. MRI of tuberculosis pyomyositis. J Comput Assist Tomogr 1999;23:454–7.
Tuberculous pyomyositis of the temporalis muscle C. Sridhar, Ashu Seith∗ Department of Radiodiagnosis, All India Institute of Medical Science, New Delhi, India Received 12 August 2004; received in revised form 29 September 2004; accepted 30 September 2004
Abstract Tuberculosis of the muscles without coexistent skeletal involvement is very rare. A case of tuberculous pyomyositis of the temporalis muscle in an immunocompetent young male is presented. A good response was seen with an antituberculous treatment. Tuberculosis should be considered in the differential diagnosis of any unexplained soft tissue swelling in people born in tubercular endemic areas or those who are immunosuppressed. © 2004 Published by Elsevier Ireland Ltd. Keywords: Mycobacterium tuberculosis; Head and neck; Pyomyositis; Computed tomography
2. Case report
weeks. The swelling was gradually increasing in size. There was no preceding history of trauma. He also had anorexia, weight loss, fever and cough. On physical examination, there was a swelling in the left temporal region with mild tenderness, without local rise in temperature. There were no associated enlarged neck nodes. Chest radiograph showed right paratracheal lymphadenopathy. The hemogram was normal except for an ESR of 40 mm per first hour. Mantoux skin test was positive with 20 mm induration. Contrast-enhanced CT revealed an enhancing, bulky temporalis muscle with central low attenuating areas (Fig. 1). The underlying temporal bone was normal (Fig. 2). Chest CT showed mediastinal adenopathy. Fine needle aspiration cytology from the swelling showed caseating granulomas. The patient’s immune status was normal. The patient was started on antituberculous treatment with four drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol). The swelling completely resolved after 6 months and the patient was symptom-free. Follow-up CT showed a normal left temporalis muscle and complete resolution of mediastinal adenopathy.
A 28-year-old male presented with a swelling in the left temporal region of 1-month duration, with pain for the last 2
3. Discussion
∗ Tel.: +91 9810329748; fax: +91 11 2658 8663. Present address: Flat No. 714, Sector 29, Noida, Gautam Budh Nagar, UP 201301, India. E-mail address: [email protected] (A. Seith).
Tuberculosis is a common infectious disease caused by Mycobacterium tuberculosis, but only rarely does it cause skeletal muscle infection even in countries where tuberculosis
1. Introduction Pyomyositis (PM) is a bacterial infection occurring in a skeletal muscle, with no obvious local or adjacent source of infection [1]. Bacterial pyomyositis is often called tropical pyomyositis because it is more common in tropical areas. It is usually caused by staphylococcus aureus [1]. Trauma, tissue parasites, immunodeficiency and malnutrition have been implicated as causative factors [1,2]. The typical presentation is that of a gradually expanding mass in a large muscle, usually the quadriceps or gluteus, accompanied by slowly increasing pain [3]. Skeletal muscle infection due to Mycobacterium tuberculosis in an immunocompetent person is rare, and only few cases of tuberculous myositis have been reported [4]. We present the computed tomography (CT) findings of tuberculous PM of the temporalis muscle in a young nonimmunocompromised male patient as a case report.
1571-4675/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrex.2004.09.014
90
C. Sridhar, A. Seith / European Journal of Radiology Extra 52 (2004) 89–91
Fig. 1. Contrast-enhanced axial (A–C) and coronal (D) CT shows bulky and enhancing temporalis muscle with central areas of low-attenuation.
Fig. 2. The underlying temporal bone appears normal on bone window setting.
is endemic [5]. Tuberculous PM occurs in about 2% of the patients with tuberculosis. Several hypotheses might explain this rarity, including poor oxygen content, high lactic acid concentration; and paucity of reticuloendothelial and lymphatic tissue within skeletal muscle [6]. Tuberculosis may involve the skeletal muscle by various means: (1) direct extension from adjacent structures (bone, joint, tendon, lymph nodes or pleura); (2) hematogenous spread from a distant focus of infection usually pulmonary; (3) traumatic or iatrogenic inoculation, if there is any history of local trauma or surgery. Hematogenous dissemination plays an important causative role in tuberculous myositis. Our patient had tuberculous PM, which was likely due to hematogenous spread, as mediastinal nodes were also present. Tuberculous PM is usually limited to a single large muscle such as the muscles of the thigh, back, buttock, or arm. However, several muscles may be involved [7]. It is rare to involve small muscle like the temporalis, as in our case. Most commonly, tuberculous PM is chronic and slow growing. Pain is rarely a prominent clinical feature in the early stages, and medical care may be delayed for many months. Localized swelling is usually the first complaint [8]. Our patient also presented with swelling followed by mild pain. Pyomyositis is difficult to diagnose clinically because many other pathological processes such as osteomyelitis, fascitis, cellulitis, abscess, polymyositis, hematoma and even neoplasms may produce similar symptoms [9].
C. Sridhar, A. Seith / European Journal of Radiology Extra 52 (2004) 89–91
Due to its non-specific clinical presentation imaging plays an important role in the evaluation of such patients. CT, magnetic resonance imaging (MRI) and sonography have all been reported as diagnostic tools for PM. CT is of value for localization of the lesion, to assess the underlying bone and to differentiate it from a hematoma, cellulitis or deep venous thrombosis [10]. It shows thickening and edema of the involved muscle layers with reticulation of the adjacent subcutaneous fat. Post contrast, the involved muscles show enhancement with central low attenuation areas. Our patient showed similar CT findings. CT is also useful in guiding percutaneous biopsy and/or drainage procedures. Treatment consists of specific antituberculous chemotherapy and drainage if large collections are noted. Our case showed complete resolution of the temporalis muscle inflammation with antituberculous treatment. In conclusion, tuberculous myositis though rare should be considered in the differential diagnosis of muscle inflammation, especially in areas where tuberculosis is endemic. This case has been reported to increase awareness regarding soft tissue tuberculosis, as its incidence is likely to increase in the future.
91
References [1] Gubbay AJ, Isaacs D. Pyomyositis in children. Pediatr Infect Dis J 2000;19:1009–12. [2] Indudhara R, Singh SK, Minz M, et al. Tuberculous pyomyositis in a renal transplant recipient. Tuber Lung Dis 1992;73:239– 41. [3] Editorial. Pyomyositis. Br Med J 2 (1979) 458–459. [4] Yajko DM, Nassos PS, Sanders CA, Mandej J, Hadley WK. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995;20:1576– 7. [5] Bonomo RA, Graham R, Makley JT, Petersilge CA. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995;20:1576–7. [6] Katz R, Herman MA, Katz S. Tuberculosis of muscle. JAMA 1964;190:472–3. [7] Johnson DW, Herzig KA. Isolated tuberculosis pyomyositis in a renal transplant patient. Nephrol Dial Transplant 2000;15:743. [8] Moore DL, Delage G, Labelle H, Gauthier M. peracute streptococcal pyomyositis: report of two cases and review of the literature. J Pediatr Orthop 1986;6:232–5. [9] McLoughlin MJ. CT and percutaneous fine-needle aspiration biopsy in tropical myositis. Am J Roentgenol 1980;134:167–8. [10] Kim JY, Park YH, Choi KH, Park SH, Lee HY. MRI of tuberculosis pyomyositis. J Comput Assist Tomogr 1999;23:454–7.