Drugs, muscle pallor, and pyomyositis
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CASE REPORT
Drugs, muscle pallor, and pyomyositis Bela Kubat
Accepted: 2 July 2013 Ó Springer Science+Business Media New York 2013
Abstract A 33-year-old athletic male was unexpectedly found dead in his bed. For several days prior to his death he complained of tenderness and swelling of his right buttock. The post-mortem examination revealed unilateral pale gluteal muscles and pustular impetiginized skin lesions of the right lower leg. The muscle histology demonstrated pronounced acute inflammation and limited necrosis of muscle fibers confined to the right gluteal muscles. Vascular occlusion and renal abnormalities were excluded by post-mortem angiography and histology respectively, and the diagnosis of non-tropical pyomyositis, possibly originating from the dermatological infection, was made. Toxicological testing revealed a potentially lethal intoxication with fentanyl and morphine. Pyomyositis is etiologically attributed to an infection and predominantly affects large limb or trunk muscles. Males are affected more frequently than females. Histologically, it is dominated by acute inflammatory infiltrates and may lead to sepsis and subsequent death. Although occurring less frequently, pyomyositis must be considered in the differential diagnosis of macroscopic localized muscle pallor, together with vascular occlusion and rhabdomyolysis. In such cases, only the examination of fresh frozen muscle tissue samples from different locations, together with the histological examination of the internal organs, particularly the kidneys, will facilitate the confirmation of the correct diagnosis. Keywords Pyomyositis Muscle pallor Rhabdomyolysis Gluteal muscles Bacterial myositis
Introduction Pallor of skeletal muscles is a non-specific sign indicative of muscle necrosis, which, aside from compromised blood supply, may initially appear to be caused by rhabdomyolysis, often in cases associated with drug-induced excited delirium [1, 2]. Skeletal muscle histology of rhabdomyolysis reveals extensive muscle fiber necrosis with reactive inflammation. An alternate differential diagnoses when muscle pallor is present includes non-tropical pyomyositis, an acute, infrequent, and potentially life-threatening condition involving a predominantly bacterial infection of a striated muscle. Histologically, it is characterized by acute inflammation of the muscle and subsequent muscle fiber necrosis [3, 4]. Thus, necrosis of muscle tissue occurs in both rhabdomyolysis and in pyomyositis. In rhabdomyolysis, necrosis is widespread and is the primary feature, whereas inflammatory infiltration is reaction to the necrosis. Contrastingly, in pyomyositis, the initial damage is caused by an infection, which induces the inflammation and eventually results in necrosis of muscle fibers. In this paper a case of unexpected death of a drug user is reported where a marked pallor of gluteal muscles was observed at post-mortem examination and appeared to be caused by pyomyositis, possibly originating in impetiginized skin lesions on the lower leg.
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