180 Case reports

TECHNIQUES OF REMOVALThere are several methods described to facili-tate removal.23The larva may be removed by enlarging the

central punctum with a cruciate incision underlocal anaesthetic, grasping the larva withforceps, and teasing it out. Care must be takennot to damage the larva and so risk leavingparts behind in the wound, as this may result ina local foreign body reaction. This is the tech-nique we successfully used.

Alternative methods rely on the fact that thelarvae are obligate aerobes. Thus they can becoaxed into the open by occluding their airsupply with adhesive tape, Vaseline, heavymakeup cream, or immersion of the affectedpart in oil. This results in the larvae struggling tothe surface, when removal can be completed bygrasping it with a fine forceps. Perhaps the mostnovel method of removal described is "bacontherapy".4 Multiple strips ofraw bacon are placedover the nodule, with the fat occluding the centralpunctum. The larva migrates into the bacon over aperiod of hours sufficiently to allow its intactremoval with forceps. These latter techniques

minimise scarring. After removal of the larva, thelesions usually heal spontaneously without theneed for routine antibiotic cover

CommentAs areas in south and central America becomemore and more popular as tourist destinations,infestations such as these with Dermatobiahominis which have long larval stages willpresent more frequently to A&E departmentsin the United Kingdom. They are often misdi-agnosed as cellulitis, furunculosis, or infectedsebaceous cysts. Diagnosis should be consid-ered if there is a history of exposure andsuggestive physical findings, as outlined above.Once the diagnosis is made, removal can beaccomplished by the methods outlined.We would like to thank Dr Richard Jennings, The Hospital ofTropical Diseases, London for valuable advice and assistance.

1 Manson-Bahr PEC, Bell DR. Manson's tropical diseases, 19thed. London: Bailliere Tindall, 1987:1463-5.

2 Rooney S, Kerrigan D. Bot fly bite. Postgrad Med J1993;69:411-3.

3 Nunzi E, Rogioletti F, Rebora A. Removal of Dermatobiahominis larvae. Arch Dermatol 1986; 122:140.

4 Brewer TF, Wilson ME, Gonzalez E, Felsenstein D. Bacontherapy and furuncular myiasis. JAMA 1993;270:2087-8.

A case of muscle abscess presenting to an accidentand emergency department

M A Howell, H R Guly

AbstractA case is reported of a patient with acuteprimary muscle abscess who presented tothe accident and emergency departmentwith hip pain. Pyomyositis must be con-sidered as a cause of muscle pain espe-cially around the hip. A briefdiscussion ofthe diagnosis and management ofpyomyo-sitis is also presented.(JAccid Emerg Med 1997;14:180-182)

Keywords: pyomyositis; hip pain

Accident and emergency (A&E) departmentsoften see patients with acute musculoskeletalpain. In this paper we present a case of acutemuscle abscess (pyomyositis) presenting to anA&E department with hip pain and we brieflyreview the published reports on muscle ab-scesses.

Case reportA 46 year old previously healthy civil servantpresented to the A&E department with a fourday history of right hip and groin pain whichhad come on after playing table tennis. Rest

and simple analgesics had been ineffective. Onexamination he had a temperature of 37.6°Cand a tender right hip and pubic symphysis,with a reduced range of movement in the hipand inability to weight bear. Radiographs of thehip were normal, as was an ultrasound scan. Afull blood count was unremarkable but theerythrocyte sedimentation rate (ESR) wasincreased at 32 mm/h. Blood cultures weretaken and the patient admitted under the careof the A&E team for rest and analgesia.The blood cultures grew Staphylococcus

aureus so flucloxacillin 2 g four times daily wasstarted. The general condition of the patientimproved but his reduced hip movementpersisted, as did his pyrexia. The possibility ofa psoas abscess was considered and a furtherultrasound scan was performed four days afteradmission. This showed a 6 cm mass infero-medial to the right inguinal ligament, thoughtby the radiologist to be a strangulated herniathough the general surgeons did not think hehad a hernia clinically. A computerised tomog-raphy (CT) scan the same day showed aninflamed right adductor brevis muscle. Liverfunction tests at this stage were deranged, andthe patient was thought to be septicaemic. A

Accident andEmergencyDepartment,Derriford Hospital,Plymouth PL6 8DHM A HowellH R Guly

Correspondence to:Mr M A Howell, Accidentand Emergency Department,Bristol Royal Infirmary,Marlborough Street, BristolBS2 8HW.

Accepted for publication13 November 1996

on October 9, 2021 by guest. P

rotected by copyright.http://em

j.bmj.com

/J A

ccid Em

erg Med: first published as 10.1136/em

j.14.3.180 on 1 May 1997. D

ownloaded from

Case reports

Figure 1 MRI scan showing the abscess of the patient's right hip.

magnetic resonance imaging (MRI) scan on

the following day (fig 1) showed an abscess inobturator externus, adductor magnus, and adduc-tor brevis, with surrounding oedema and distor-tion of muscle groups. The abscess was

aspirated under ultrasound guidance: 10 ml ofthick pus were removed and a catheter left inthe abscess cavity for seven days. The pus sub-sequently grew staphylococci with the same

sensitivities as that from the original blood cul-tures.The patient completed a four week course of

flucloxacillin and made a complete recovery.

DiscussionAcute primary muscle abscess or pyomyositisis rare in Western countries'2 and its diagnosisoften delayed. It is much more prevalent in thetropics.34 Pyomyositis is relatively more com-mon in children' and has an equal sex distribu-tion.The aetiology of acute muscle abscess is

believed to involve trauma, which is oftentrivial. Subsequent bacteraemia enables bacte-ria to infect this injured muscle. However,minor muscle trauma is common, whereaspyomyositis is rare. Diabetes mellitus,6 steroidtreatment, and immunodeficiency states in-cluding HIV infection7 have been identified aspredisposing factors. Muscle abscess second-ary to intramuscular injections has also beenreported.8The most common muscles affected are

around the hip, including the psoas, piriformis,obturators, adductors, glutei, and quadriceps.Psoas abscesses can also occur secondary tobowel perforation or spinal infection. Upperlimb muscles and even neck muscles are occa-sionally implicated.910 The commonest infect-ing organisms in tropical climates are myco-bacteria," hydatid," and nocardia" species,whereas in temperate zones the main patho-gens are staphylococci,'4 streptococci,'5 hae-mophilus, and coliforms.

Diagnosis is difficult and the differentialdiagnoses are legion, including muscle strain,synovitis, tumour, osteomyelitis, septic arthri-tis, Perthe disease, rheumatoid arthritis,slipped upper femoral epiphysis, strangulatedhernia, venous thrombosis, and thrombophle-bitis. Apart from a history of trauma, oftenminor, there may be non-specific symptomssuch as aches, swelling, chills, and night sweats.Physical findings include local tenderness,masses, erythema, and low grade fever, to-gether with reduced movements of joints actedupon by the affected muscles, most commonlythe hip. Complications may occur, particularlyperipheral nerve palsies.'6 7

Laboratory investigations typically show aleucocytosis and left shift together with raisedESR and C reactive protein. Blood cultures areusually positive and liver function tests de-ranged if septicaemia is present.

Radiological investigations are the mainstayof diagnosis and treatment planning.'8 Plainradiographs may show a soft tissue mass orshadow; ultrasound scanning may reveal anabscess. Radionuclide white cell or galliumscans show increased uptake and may occa-sionally specifically show an abscess. '9 CTscanning may show a mass, localised attenua-tion, and ring enhancement with intravenouscontrast.'0 MRI with gadolinium enhance-ment'o 2 is probably the investigation of choiceat present.The treatment of pyomyositis is drainage of

the muscle abscess, often under ultrasound orCT guidance, together with antibiotics sel-ected on the basis of cultures and antibioticsensitivities. With early diagnosis and treat-ment, prognosis is excellent and full recovery isnormal. Delay in diagnosis and therefore in

181

on October 9, 2021 by guest. P

rotected by copyright.http://em

j.bmj.com

/J A

ccid Em

erg Med: first published as 10.1136/em

j.14.3.180 on 1 May 1997. D

ownloaded from

182 Case reports

treatment can lead to disseminated disease andsystemic complications.22

Primary muscle abscess is a rare conditionbut must be considered as a cause of musclepain especially around the hip.

1 Christin L, Sarosi GA. Pyomyositis in North America: casereports and review. Clin Infect Dis 1992; 15:668-77.

2 Hall RL, Callaghan JJ, Moloney E, Martinez S, HarrelsonJM. Pyomyositis in a temperate climate: presentation, diag-nosis and treatment. J Bone Joint Surg (Am) 1990;72:1240-4.

3 Steinig JP, Odom JW, Jurgenson PF, Williams JS. Tropicalpyomyositis. J Med Assoc Georgia 1992;81:75-6.

4 Gambir IS, Singh DS, Gupta SS, Gupta PR, Kumar M.Tropical pyomyositis in India: a clinico-histopathologicalstudy. J Trop Med Hyg 1992;95:42-6.

5 Renwick SE, Ritterbusch JF. Pyomyositis in children. J Pedi-atr Orthop 1993;13:769-72.

6 Brown RL. Pyomyositis in patients with diabetes. Com-puted tomography as a key to diagnosis. Postgrad Med1989;86:79-81.

7 Rodgers WB, Yodlowski ML, Mintzer CM. Pyomyositis inpatients who have the human immunodeficiency virus.Case report and review of the literature. J Bone Joint Surg(Am) 1993;75:588-92.

8 Rygnestad T, Kvam AM. Streptococcal myositis and tissuenecrosis with intramuscular administration of diclofenac(Voltaren). Acta Anaesthesiol Scand 1995;39: 1128-30.

9 Michaels BM, Orgill DP, Santos AA. Tropical pyomyositispresenting in the upper extremity. Arch Surg 1995;130:446-7.

10 Flory P, Brocq 0, Euller-Ziegler L, Ziegler G. Pyomyositis:cervical localisation. J Rheumatol 1993;20:1411-3.

11 Huang DY. Tuberculous muscle abscess: an unusualpresentation of tuberculosis. Am J Med 1990;88:57-9N.

12 Martin J, Marco V, Zidan A, Marco C. Hydatid disease ofthe soft tissues of the lower limb: findings in three cases.Skel Radiol 1993;22:511-4.

13 Gill MV, Cunha BA. Nocardia asteroides buttock abscess.Infection 1995;23: 126-7.

14 Armstrong DG, D'Amato CR, Strong ML. Three cases ofstaphylococcal pyomyositis in adolescence, including onepatient with neurologic compromise. J Pediatr Orthop1993; 13:452-5.

15 Peetermans WE, Buyse B, Vanhoof J. Pyogenic abscess ofthe gluteal muscle due to Streptococcus pneumoniae[letter; comment]. Clin Infect Dis 1993;17:939.

16 Chen WS. Sciatica due to piriformis pyomyositis. Report ofa case. J Bone Joint Surg (Am) 1992;74: 1546-8.

17 Pai VS, Yee E, Lawson D, Curtis G. Iliacus pyomyositis withinvolvement of lateral cutaneous nerve of the thigh. NZMedJ 1994;107:378-9.

18 Applegate GR, Cohen AJ. Pyomyositis: early detectionutilizing multiple imaging modalities. Magn Reson Imag-ing 1991;9:187-93.

19 Schiff RG, Silver L. Tropical pyomyositis. Demonstration ofextent and distribution of disease by gallium scintigraphy.Clin Nuclear Med 1990; 15:542-4.

20 Gordon BA, Martinez S, Collins AJ. Pyomyositis: character-istics at CT and MR imaging. Radiology 1995;197:279-86.

21 Hopkins KL, Li KC, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletalinfectious processes. Skel Radiol 1995;24:325-30.

22 McGill PE. Bacterial infections: pyomyositis. Baillieres ClinRheumatol 1995;9:193-200.

Malignant hypertension presenting as blurredvision in a 43 year old intravenous drug abuser

G Walters, T R Dabbs

AbstractA 43 year old intravenous drug abuserpresented to the accident and emergencydepartment with a three week history ofbilateral visual loss and frontal headaches.Fundoscopy revealed bilateral retinal cot-

ton wool spots and haemorrhages and anophthalmic opinion was requested. Hisblood pressure was subsequently found tobe 210/140. A diagnosis of malignanthypertension was made and blood pres-sure was gradually controlled on oralantihypertensives. This case illustrates theimportance of checking the blood pres-sure of all patients presenting with visualloss.(JAccid Emerg Med 1997;14:182-183)

Keywords: malignant hypertension; visual loss

Case reportA 43 year old man presented to the accidentand emergency (A&E) department with a threeweek history of bilateral blurred vision andfrontal headaches. He was a long standingintravenous heroin abuser and attended be-cause of difficulty in seeing to inject. In his pasthistory he had received a brain contusioninjury after a road traffic accident two yearspreviously. He had recently been found to behepatitis C positive, although he had notreceived any treatment for this. He wasotherwise well.On examination in the A&E department, his

vision was found to be reduced to 6/24 in theright eye and 6/36 in the left eye (normal 6/6 or

Figure 1 Retinal photograph of the left eye showing optic disc swelling, arteriolarattenuation, arteriovenous nipping, prominent cotton wool spots, and haemorrhages.

Department ofOphthalmology, StJames' UniversityHospital, BeckettStreet, Leeds LS9 7TFG WaltersT R Dabbs

Correspondence to:Mr G Walters.

Accepted for publication6 February 1997

on October 9, 2021 by guest. P

rotected by copyright.http://em

j.bmj.com

/J A

ccid Em

erg Med: first published as 10.1136/em

j.14.3.180 on 1 May 1997. D

ownloaded from