PYOMYOSITIS

Introduction

Background
Pyomyositis is an inflammation of muscle tissue, usually of voluntary muscles that
results in pus production. Once considered a tropical disease, it is now seen in temperate
climates as well. The pathogenesis is unclear, but trauma, infections (S. aureus, S. pneumoniae),
and malnutrition have been implicated. Although most cases of pyomyositis occur in healthy
individuals, other pathogenetic factors include nutritional deficiency and associated parasitic
infection in tropical climates. In the temperate climates, pyomyositis is seen most commonly in
patients with diabetes, HIV infection, and malignancy.

Clinical Presentations

• Presentation with painful, tender, localized swelling over muscle

• Fever
• Epidural abscess

Complications

• Life-threatening complications include sepsis and toxic shock syndrome.

Diagnosis

• CT scan or MRI demonstrates muscle abscess.

• Aspiration of abscess (by surgery or CT/US guided) yields pus, usually yielding S. aureus.
• Bacteremia may accompany.

Treatment

Medical Care

• Promptly administer systemic antibiotics. This could eliminate the need for
surgical drainage in selected cases.
• The choice of antibiotic is determined by identification of the causative
organism.
• Antibiotics initially are given intravenously until clinical improvement is
noted, followed by oral antibiotics for a total course of 3 weeks (eg, cefazolin
or ceftriaxone IV followed by cephalexin PO).

Surgical Care
• During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be
required. Surgical drainage is especially necessary for large abscesses.
• Complicated cases may require fasciotomies and debridement.

Prognosis

• Prompt administration of antibiotics can result in complete resolution.

Specific Objectives:

• Define Pyomyositis.
• Identify the signs and symptoms manifested by the patient.
• Distinguish the precipitating and predisposing factors that trigger this development.
• Trace the pathogenesis based on the signs and symptoms manifested by the patient.
• Determine appropriate medical and nursing management for the patient.
• Use the nursing process as the framework for the care of the patient.

Significance of the Study in Nursing Field:

• Shall have critical thinking skills necessary for providing safe and effective nursing care.
• Shall have a comprehensive assessment and implement care base on our knowledge and skills of
the condition.
• Shall have familiarized with effective interpersonal skills to emphasize health promotion and
illness prevention.
• Shall have imparted the learning experience from direct patient care.
 PATIENT’S PROFILE
Name: Baby Dyein
Sex: Female
Birthday: October 2007
Age: 2 - 3 y/o
Religion: Roman Catholic
Civil Status: Single
Nationality: Filipino
Date of Admission: July 27, 2010
Time of Admission: 8:40 PM
Admission Diagnosis: Pyomyositis Left Scapular Area
Attending Physician: Dr. De Guzman

A. Family Background
Baby Dyein is the youngest among the four siblings.

B. Educational and Socio - Economic Status

She does not go to school yet. The rest of the siblings are funded for their educational
expenses by one of their mother’s rich customers as a laundry woman, except that the eldest
child does not go to school anymore as she decided to stop studying and just help work.

C. Lifestyle and Diet

She eats three times a day and drinks 5-6 glasses of water a day though mostly breastfeed
on her mother.

D. Family Health History

No family history of pyomyositis, diabetes, hypertension, tuberculosis, diabetes, nor any
other diseases reported.

E. Immunization Record
With complete record of immunization.

F. Past Health History

Had cough, colds and fever but is only hospitalized once – now due to pyomyositis.

G. Present Health History

One month prior to consultation, patient together with her older brother had a fall as she
was given a piggy backride. Patient fell on her left scapular area and complained of pain. Her
mother had her massaged by a so-called manghihilot. Three weeks prior to consultation, patient
still complained of pain and endured of fever and localized swelling on the left scapular area.
Another hilot session was done and patient was given TSB. But as the swelling and fever still
persevered, patient was brought to the nearest clinic. Patient was given Paracetamol and was
referred to Philippine Orthopedic Center. Patient was admitted.
 ANATOMY AND PHYSIOLOGY
The scapula or shoulder blade is the bone that
connects the humerus (arm bone) with the clavicle (collar
bone). The scapula forms the posterior located part of the
shoulder girdle. It is a flat bone, roughly triangular in shape,
placed on a posterolateral aspect of the thoracic cage.

LEFT SCAPULA . LATERAL SURFACE

• CORACOID PROCESS - bony projection on the shoulder

blade
• GLENOID CAVITY– holds the head of the humerus
• SUPRAGLENOID TUBERCLE – rounded protuberance
above the glenoid cavity
• INFRAGLENOID TUBERCLE – rounded protuberance below
the glenoid cavity
• SPINE – a bony projection from the glenoid to acromion
• ACROMION - bony projection from the outer end of the spine of
the shoulder blade, to which the collar bone is attached
• AXILLARY BORDER – near to armpit
• INFERIOR ANGLE - gives greater strength to the body of the bone
by its arched form

OSSIFICATION OF SCAPULA

The larger part of the scapula undergoes membranous ossification.

Some of the outer parts of the scapula are cartilagenous at birth, and would
therefore undergo endochondral ossification.
The head, processes, and the thickened parts of the bone, contain
cancellous tissue; the rest consists of a thin layer of compact tissue.
The central part of the supraspinatous fossa and the upper part of the infraspinatous fossa, but
especially the former, are usually so thin as to be semitransparent; occasionally the bone is found
wanting in this situation, and the adjacent muscles are separated only by fibrous tissue.
 PATHOGENESIS

Fell on her left scapular Area from a Piggy Backride

Inflammatory Response Trauma: Pressure by hilot

Vascular Response Chemical Response Systemic Response

Vasodilatation Redness Pain Leukocytosis Infiltration

Heat PR and RR

Increased Swelling Increased ESR

Membrane
Permeability
Fever

Abscess Formation

PYOMYOSITIS

IF NOT TREATED: IF TREATED:

Toxic Shock Syndrome Good Prognosis
Sepsis Recovery
 DIAGNOSTIC EXAMS
COMPLETE BLOOD COUNT

Results Normal Values Interpretations Nursing

Responsibilities
Hemoglobin 107 110 - 158 g/L Bone marrow
suppression or
iron deficiency Iron deficiency
anemia anemia:
Hematocrit 0.34 0.37 - 0.54 Iron deficiency > Diet. Foods rich in
anemia iron.
Leukocyte Count 22.4 4.5 - 10 x 109/L Tissue injury
Differential Count
Segmenters 0.75 0.50 - 0.70 Tissue injury
Tissue Injury and
Lymphocytes 0.19 0.20 - 0.40 Tissue injury
Trauma:
Platelet Count 513 150 - 400 x 109/L Trauma
Indices > Monitoring of VS.
MCV 69.9 82 - 92 Iron deficiency > Wound Care
anemia > Diet. Foods rich in
MCH 21.9 28 - 32 Iron deficiency protein and Vit. C.
anemia > Administration of
MCHC 31 32 - 38 Iron deficiency prescribed
anemia medications.
ESR 128 0 - 10mm/hr Iron deficiency > Avoid pressure on
anemia the affected area.

MUSCULOSKELETAL SONOGRAPHY

There is a 5.0 x 1.2 cm complex mass in the left scapular area. Remainder is
unremarkable.

Impression: PYOMYOSITIS
 DRUG STUDY
Drugs Name Dosage Indication Action Adverse Effects Nursing Considerations
Generic Name: 100/s 5ml q8 x 7 > Mild to May inhibit prostaglandin CNS: dizziness, headache > NSAID may mask S/S of
Ibufropen days moderate pain synthesis, to produce anti- CV: edema infection
> Fever inflammatory, analgesic, and EENT: tinnitus > It may take 1 or 2 wks before
Brand Name: antipyretic effects. GI: decreased appetite, full anti inflammatory effects
Apo – Ibufropen peptic ulceration occur
GU: acute renal failure > Take with meals
Pharmacologic Class: Respiratory: > Use with aspirin may increase
NSAID bronchospasms risk of GI adverse reaction
Skin: Stevens – Johnson > Report for S/S of GI bleeding
Syndrome
Generic Name: 80 mg q4 IV > Mild pain or Blocks pain impulses by Hepatic: jaundice > Given for T>38.0°C
Acetaminophen fever inhibiting synthesis of Metabolic: hypoglycemia > Monitor V/S
prostaglandin in the CNS or Skin: rash, urticaria
Brand Name: of other substances that
Paracetamol sensitize pain receptors to
stimulation. The drug may
Pharmacologic Class: relieve fever through central
Para-aminiohenol action in the hypothalamic
derivative heat-regulating center.
Generic Name: 250mg IV q8 > Skin infection Inhibits cell wall synthesis, CV: phlebitis > Perform skin test (ANST)
Cefuroxime promoting osmotic instability. GI: diarrhea, N/V, anorexia > Give if ANST (-)
Skin: rashes, urticaria > Take with meals
Brand Name: Ceftin > Monitor for signs of infection
Pharmacologic Class:
2nd gen. cephalosphorin
Generic Name: 22 in 50ml IV > Bacteremia and Inhibits cell wall synthesis, CNS: seizures, headache > Perform skin test (ANST)
Ceftazidime skin infection promoting osmotic instability. CV: phlebitis > Give if ANST (-)
GI: diarrhea, N/V > Take with meals
Brand Name: Skin: rashes, urticaria > Monitor for signs of infection
Tazicef

Pharmacologic Class:
3rd gen. cephalosphorin
 NURSING CARE PLAN
Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale Evaluation
Subjective Cue: ø Hyperthermia r/t Trauma has been After 2-3 hours Established rapport To gain cooperation After 2 hours, patient’s
trauma 2° implicated to cause of nursing both with the mother and trust. temperature was within
Objective Cues: underlying disease Pyomyositis, an intervention, and the patient. normal range AEB
>Flushed skin inflammation of a patient’s temperature of 37.5°C.
> Warm to touch muscle tissue. Due to temperature Monitored V/S. To review alterations
> With lab results as inflammatory process, would be within of V/S as affected by
follows: vasodilatation occurs normal range. patient’s condition,
- Leukocyte Ct: 22.4 leading to increase and progress as given
x 109/L body metabolism and with interventions.
(NV: 4.5 -10 x 109/L) elevated body
- Segmenters: 0.75 temperature. Noted client’s age. Age can directly
(NV: 0.50 – 0.70) impact ability to
- Lymphocytes: 0.19 Ref: Brunner and Suddarths regulate temperature.
Textbook of Medical Surgical
(NV: 0.20 – 0.40) Nursing
- Impression of Monitored I & O. Hyperthermia may
Pyomyositis on cause dehydration.
Sonography
> with VS taken as ff: Reviewed laboratory To identify potential
T: 38.2 °C values. internal causes of
P: 82 bpm temperature
R: 20 cpm imbalances.

Provided fans as To provide cooling

indicated. measures.
Asked mother to To promote comfort.
dress the baby with
light loose clothing.

TSB done. To provide cooling

measures.

Emphasized To prevent cross

handwashing. contamination and
transmission of
MCOs.

Promoted For additional booster

maintenance of of patient’s immunity.
proper breastfeeding.

Administered due To protect from

medications as identified risk factors
prescribed. and intervene with
pyrexia.
 NURSING CARE PLAN
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
explanation
Subjective Cue: Acute pain related As a a vascular Within 4 hours Established rapport both To gain cooperation After 4 hours of
“Medyo masakit po to trauma on the anti-inflammatory of effective with the mother and the and trust rendering effective
ang likod ko” left scapular area response, body nursing patient. nursing interventions
releases anti- interventions patient had reported of
Objective Cues: inflammatory patient’s pain Monitored V/S Pain may cause less pain AEB less
- Facial grimace mediators causing will be alterations in V/S guarding on her left
- Guarding on the pain. relieved. scapular area and had
left scapular area Performed a comprehensive To improve quality, been smiling more
- Restlessness Reference: assessment of pain frequency & location of frequently.
- With facial pain http://www.who.int/ pain.
scale of 4/10 csr/resources/
- V/S taken as publications/ Provided nonpharmacologic To alleviate pain.
follows: pyomyositis/01 2- management like change of
T: 38.2 °C 23.pdf position & applying cold or
P: 82 bpm warm compress as indicated
R: 20 cpm
Encouraged diversional To divert his attentions
activities to the pain

Encouraged rest period To prevent fatigue

Administered medications To alleviate pain.

as ordered by physician.
 DISCHARGE SUMMARY

M edications. Compliance on the prescribed take home medications with the right generic
name, right dosage and preparation, right route and time of administration.

E xercise. Active ROM but prevent massaging nor any other traumatic pressure on the
affected area.

T reatment. Compliance on the prescribed treatment. Cover the affected area with a wound
gauze as pt has underwent surgery. Instructed proper wound care.

H ealth teachings. Emphasized proper handwashing and encouraged non pharmacological

measures for fracture once re encountered (Rest, Ice or Cold Compress, Compression
bandage, Elevate affected part)

O utpatient follow up visit. Attend on the scheduled outpatient follow up visit.

D iet. Consume foods rich in Vitamin C such as fruits for boosting of immunity, protein
such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy
products for bone growth.

REFERENCES
http://hopkins-abxguide.org/diagnosis/soft_tissue/pyomyositis.html?contentInstanceId=255446

Zafar, Mohammed. Infectious Myositis. http:// www.yahoo.com// May 18, 2010

Scapula. http:// www. wikipedia.com//

Lippincott. Nursing 2008 Drug Handbook. 28th Edition. 2008

Doenges, M. et al. Nurse’s Pocket Guide. 11th Edition. 2008

 Saint Michael’s College of Laguna
School of Nursing and Midwifery
Old National Highway, Platero, City of Binan, Laguna
AY 2010-2011
[Year]

In Partial Fulfillment for the requirements in NCM 104 – RLE

PYOMYOSITIS
Case Study

Submitted to:

MRS. ELLA R. ASTETE, RN MAN

Built In Clinical Instructor
Supervisor, Philippine Orthopedic Center

Submitted by:

COSICO, Marineth April A.

BSN4A, SMCL
 Saint Michael’s College of Laguna
School of Nursing and Midwifery
Old National Highway, Platero, City of Binan, Laguna
AY 2010-2011
[Year]

In Partial Fulfillment for the requirements in NCM 104 – RLE

POTT’S DISEASE

Submitted to:

MRS. ELLA R. ASTETE, RN MAN

Built In Clinical Instructor
Supervisor, Philippine Orthopedic Center

Submitted by:

COSICO, Marineth April A.

BSN4A, SMCL
 POTT’S DISEASE
Synonyms: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis
secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease

Pott's disease is named after Percival Pott (1714-1788), an eighteenth century surgeon
who was considered an authority in issues related to the back and spine in London. Pott’s disease
is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous
arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Pott’s
disease is the most common site of bone infection in TB; hips and knees are also often affected.
The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. .
The commonest area affected is T10 to L1.

Epidemiology
• Pott's disease in developing countries it represents about 2% of cases of
tuberculosis and 40 to 50% of musculoskeletal tuberculosis.
• Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths
per year.
• Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is
affecting richer ones.
• The disease affects males more than females in a ratio of between 1.5 and 2:1.

Risk factors
• Endemic tuberculosis.
• Poor socio-economic conditions.
• Historical exposure on infections

Mortality/Morbidity
• Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can
cause bone destruction, deformity, and paraplegia.
• Lower thoracic vertebrae is the most common area of involvement (40-50%), followed
closely by the lumbar spine (35-45%). In other series, proportions are similar but favor
lumbar spine involvement
• Approximately 10% of Pott disease cases involve the cervical spine.

Pathophysiology
Pott disease is usually secondary to an extraspinal source of infection. The source of
infection is usually outside the spine. It is most often spread from the lungs via the blood.
The basic lesion involved in Pott disease is a combination of osteomyelitis and arthritis
that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent
to the subchondral plate is area usually affected. Tuberculosis may spread from that area to adjacent
intervertebral disks. In adults, disk disease is secondary to the spread of infection from the
vertebral body. In children, because the disk is vascularized, it can be a primary site.
If only one vertebra is affected, the disc is normal, but if two are involved the disc
between them collapses as it is avascular and cannot receive nutrients. Progressive bone
destruction leads to vertebral collapse and kyphosis or Pott’s curvature. The spinal canal can be
narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord
compression and neurologic deficits. The kyphotic deformity is caused by collapse in the
anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the
lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft
tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral
trigone region and eventually erode into the skin.

Clinical Manifestations
• The onset is gradual.
• Localised back pain
• Paravertebral swelling may be seen
• Systemic signs and symptoms of tuberculosis may be present (fever, night sweats,
anorexia, weight loss)
• Neurological signs may occur, leading to paraplegia.
o Cervical spine tuberculosis causes severe neurologic complications
characterized by pain and stiffness, dysphagia or stridor, retropharyngeal abscess,
torticollis, hoarseness, and neurologic deficits.
o Lumbar spine tuberculosis is characterized with hip flexion.
o Lower thoracic tuberculosis causes chest pain, and patient tends to have
stiff spine, erected gait and dislikes sitting.
• Back pain is localised.
• May include kyphosis, gibbus or Pott’s curvature (pathognomonic sign)
• A psoas abscess may present as a lump in the groin and resemble a hernia:
o There is a tender swelling below the inguinal ligament and they are usually
apyrexial.

Nursing Assessments
• The examination should include the following:
o Careful assessment of spinal alignment
o Inspection of skin, with attention to detection of sinuses
o Abdominal evaluation for subcutaneous flank mass
o Meticulous neurologic examination
• Alert for abscess.
• Monitor patient’s body weight and appetite record.
• May provide some diversional therapies.

Diagnostic Exams
• The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).
• Strongly positive Mantoux skin test. Tuberculin skin test (purified protein derivative
[PPD]) results are positive.
• Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for
changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed
disc space.
• MRI scanning may demonstrate the extent of spinal compression and can show
changes at an early stage. Bone elements visible within the swelling, or abscesses, are
strongly suggestive of Pott's disease rather than malignancy.
• CT scans reveals early lesions and is more effective for defining the shape and
calcification of soft-tissue abscesses.
• Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present.
Medical Management
• Duration of antituberculosis treatment (Rifampicin, Isoniazid, Pyrazinamide,
Ethambutol):
o If debridement and fusion with bone grafting are performed, treatment can be for six
months
o If debridement and fusion with bone grafting are NOT performed a minimum of 12
months’ treatment is required.
• Immobilisation of the spine is usually for 2 or 3 months (bed rest, Taylor Brace,
head halter, pelvic strap).
• Paraplegia resulting from the active disease causing cord compression usually
responds well to chemotherapy (6-9 months).

Surgical Management
• Anterior Decompression Spinal Fusion. Surgery is required if there is spinal
deformity or neurological signs of spinal cord compression.

Prevention
• As for all tuberculosis, BCG vaccination.
• Improvement of socio-economic conditions.

References:
http://www.bsac.org.uk/pyxis/Bone%20and%20joint/Potts%20disease/Potts%20disease.htm
http://www.wisegeek.com/what-is-potts-disease.htm