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 PROFILEName: Baby E.KSex: Female Birthday: August 28.1998Age: 2 - 3 y/oReligion: Roman CatholicCivil Status: SingleNationality: FilipinoDate of Admission: 9/2/10Time of Admission: 3:15PMAdmission Diagnosis: Pyomyositis Left Scapular AreaAttending Physician: Dr. De Guzman

A. Family BackgroundBaby E.K 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 DietShe eats three times a day and drinks 5-6 glasses of water a day though mostly breastfeed

on her mother.

D. Family Health HistoryNo family history of pyomyositis, diabetes, hypertension, tuberculosis, diabetes, nor any

other diseases reported.

E. Immunization RecordWith 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 HistoryOne 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

Vascular Response Chemical Response

Vasodilatation

Increased Membrane

Permeability

Redness

Heat

Swelling

Systemic Response

Pain Leukocytosis Infiltration

Increased ESR

Fever

PR and RR

Trauma: Pressure by hilot

Abscess Formation

PYOMYOSITIS

IF NOT TREATED:Toxic Shock Syndrome

Sepsis

IF TREATED:Good Prognosis

Recovery

DIAGNOSTIC EXAMS

COMPLETE BLOOD COUNT

Results Normal Values Interpretations Nursing Responsibilities

Hemoglobin 107 110 - 158 g/L Bone marrow suppression or iron deficiency

anemiaIron deficiency

anemia:> Diet. Foods rich in

iron.

Tissue Injury and Trauma:

> Monitoring of VS.> Wound Care

> Diet. Foods rich in protein and Vit. C.> Administration of

prescribed medications.

> Avoid pressure on the affected area.

Hematocrit 0.34 0.37 - 0.54 Iron deficiency anemia

Leukocyte Count 22.4 4.5 - 10 x 109/L Tissue injuryDifferential Count

Segmenters 0.75 0.50 - 0.70 Tissue injuryLymphocytes 0.19 0.20 - 0.40 Tissue injuryPlatelet Count 513 150 - 400 x 109/L Trauma

IndicesMCV 69.9 82 - 92 Iron deficiency

anemiaMCH 21.9 28 - 32 Iron deficiency

anemiaMCHC 31 32 - 38 Iron deficiency

anemiaESR 128 0 - 10mm/hr Iron deficiency

anemia

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 ConsiderationsGeneric Name: Ibufropen

Brand Name: Apo – Ibufropen

Pharmacologic Class:NSAID

100/s 5ml q8 x 7 days

> Mild to moderate pain> Fever

May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.

CNS: dizziness, headacheCV: edemaEENT: tinnitusGI: decreased appetite, peptic ulcerationGU: acute renal failureRespiratory: bronchospasmsSkin: Stevens – Johnson Syndrome

> NSAID may mask S/S of infection> It may take 1 or 2 wks before full anti inflammatory effects occur> Take with meals> Use with aspirin may increase risk of GI adverse reaction> Report for S/S of GI bleeding

Generic Name:Acetaminophen

Brand Name:Paracetamol

Pharmacologic Class:Para-aminiohenol derivative

80 mg q4 IV > Mild pain or fever

Blocks pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.

Hepatic: jaundiceMetabolic: hypoglycemiaSkin: rash, urticaria

> Given for T>38.0°C> Monitor V/S

Generic Name:Cefuroxime

Brand Name: Ceftin

250mg IV q8 > Skin infection Inhibits cell wall synthesis, promoting osmotic instability.

CV: phlebitisGI: diarrhea, N/V, anorexiaSkin: rashes, urticaria

> Perform skin test (ANST)> Give if ANST (-)> Take with meals> Monitor for signs of infection

Pharmacologic Class:2nd gen. cephalosphorinGeneric Name:Ceftazidime

Brand Name:Tazicef

Pharmacologic Class:3rd gen. cephalosphorin

22 in 50ml IV > Bacteremia and skin infection

Inhibits cell wall synthesis, promoting osmotic instability.

CNS: seizures, headacheCV: phlebitisGI: diarrhea, N/VSkin: rashes, urticaria

> Perform skin test (ANST)> Give if ANST (-)> Take with meals> Monitor for signs of infection

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale EvaluationSubjective Cue: ø

Objective Cues: >Flushed skin> Warm to touch> With lab results as follows:- Leukocyte Ct: 22.4 x 109/L (NV: 4.5 -10 x 109/L)- Segmenters: 0.75(NV: 0.50 – 0.70)- Lymphocytes: 0.19(NV: 0.20 – 0.40)- Impression of Pyomyositis on Sonography> with VS taken as ff:T: 38.2 °CP: 82 bpmR: 20 cpm

Hyperthermia r/t trauma 2° underlying disease

Trauma has been implicated to cause Pyomyositis, an inflammation of a muscle tissue. Due to inflammatory process, vasodilatation occurs leading to increase body metabolism and elevated body temperature.

Ref: Brunner and Suddarths Textbook of Medical Surgical Nursing

After 2-3 hours of nursing intervention, patient’s temperature would be within normal range.

Established rapport both with the mother and the patient.

Monitored V/S.

Noted client’s age.

Monitored I & O.

Reviewed laboratory values.

Provided fans as

To gain cooperation and trust.

To review alterations of V/S as affected by patient’s condition, and progress as given with interventions.

Age can directly impact ability to regulate temperature.

Hyperthermia may cause dehydration.

To identify potential internal causes of temperature imbalances.

To provide cooling

After 2 hours, patient’s temperature was within normal range AEB temperature of 37.5°C.

indicated.

Asked mother to dress the baby with light loose clothing.

TSB done.

Emphasized handwashing.

Promoted maintenance of proper breastfeeding.

Administered due medications as prescribed.

measures.

To promote comfort.

To provide cooling measures.

To prevent cross contamination and transmission of MCOs.

For additional booster of patient’s immunity.

To protect from identified risk factors and intervene with pyrexia.

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific explanation

Planning Intervention Rationale Evaluation

Subjective Cue:“Medyo masakit po ang likod ko”

Objective Cues:- Facial grimace- Guarding on the left scapular area - Restlessness- With facial pain scale of 4/10- V/S taken as follows:T: 38.2 °CP: 82 bpmR: 20 cpm

Acute pain related to trauma on the left scapular area

As a a vascular anti-inflammatory response, body releases anti-inflammatory mediators causing pain.

Reference: http://www.who.int/csr/resources/publications/pyomyositis/01 2-23.pdf 

Within 4 hours of effective nursing interventions patient’s pain will be relieved.

Established rapport both with the mother and the patient.

Monitored V/S

Performed a comprehensive assessment of pain

Provided nonpharmacologic management like change of position & applying cold or warm compress as indicated

Encouraged diversional activities

Encouraged rest period

Administered medications

To gain cooperation and trust

Pain may cause alterations in V/S

To improve quality, frequency & location of pain. To alleviate pain.

To divert his attentions to the pain

To prevent fatigue

To alleviate pain.

After 4 hours of rendering effective nursing interventions patient had reported of less pain AEB less guarding on her left scapular area and had been smiling more frequently.

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

PYOMYOSITISCase Study

Submitted to:

MRS. Jessica CorpuzBuilt In Clinical Instructor

Submitted by:

Balanay, Randolf Mark P.BSN4A, Wcc-Antipolo

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POTT’S DISEASESynonyms: 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.

PathophysiologyPott 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

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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.htmhttp://www.wisegeek.com/what-is-potts-disease.htm