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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 1175-1178
An unusual clinical presentation of tuberculous pyomyositis in a renal allograft recipient


Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India

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Date of Submission09-Sep-2018
Date of Decision10-Oct-2018
Date of Acceptance11-Oct-2018
Date of Web Publication4-Nov-2019
 

   Abstract 


We present a renal allograft recipient with pulmonary tuberculosis presenting with multiple subcutaneous abscesses involving left forearm, left thigh, suture site and left loin, which on later evaluation revealed to be due to Mycobacterium tuberculosis.

How to cite this article:
Khandalvalli P, Nazneen S, Yadla M. An unusual clinical presentation of tuberculous pyomyositis in a renal allograft recipient. Saudi J Kidney Dis Transpl 2019;30:1175-8

How to cite this URL:
Khandalvalli P, Nazneen S, Yadla M. An unusual clinical presentation of tuberculous pyomyositis in a renal allograft recipient. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 21];30:1175-8. Available from: http://www.sjkdt.org/text.asp?2019/30/5/1175/270277


Soft-tissue infections are rare in organ transplant recipients. These may be caused by typical and atypical organisms including Grampositive organisms to tuberculous bacilli, fungus, Nocardia, etc. Often, skin and soft-tissue infection may be one of the manifestations of underlying systemic infection. Prompt identification and diagnosis are important in the management of these infections. Soft-tissue infections include subcutaneous abscess, pyoderma, necrotizing fasciitis, pyomyositis, etc. Pyomyositis is purulent inflammation of muscle and commonly occurs due to Gram-positive organisms. Pyomyositis due to Mycobacterium tuberculosis is unusual. The diagnosis of pyomyositis is made based on the radiological and microbiological evaluation.


   Case Report Top


Informed consent was obtained from the patient before presenting the report.

A 35-year-old woman with presumed native kidney disease of chronic interstitial nephritischronic kidney disease underwent live-related donor renal transplantation. Her father was the donor (HLA: haplomatch, lymphocyte cross match: negative, no induction therapy). She had no previous history of tuberculosis (TB). Posttransplant graft function was good with serum creatinine of 0.9 mg/dL on triple immunosuppression. Two months after transplantation, she developed diabetes which was managed with insulin injections. Six months after transplantation, she presented with cough and fever. She was diagnosed to have pulmonary TB, based on sputum positivity for acid-fast bacillus (AFB). She was started on anti-tuberculous therapy (ATT) for a duration of six months, to which she was noncompliant. One and half years after transplant, she presented with fever and cough. Chest X-ray was normal. Sputum for AFB was negative.

However, she was empirically started on ATT since she was noncompliant to ATT earlier and there was no response to antibiotics. Despite counseling and ensuring compliance, she was again noncompliant to treatment.

Two and half years after transplant, she presented with right loin pain and globular swellings in the left thigh, right side of the neck, left upper limb, and near the graft site [Figure 1]. On examination, her vitals were stable. There was 4 cm × 5 cm firm, nontender mass in the right supraclavicular area, mobile, with overlying skin pinchable. Swelling in the left thigh was 3 cm × 2 cm, firm, nontender, pinchable skin, and no punctum and an increase in the size was noted on standing posture suggesting its location in the subcutaneous area. Swelling in the left upper limb was 2 cm × 2 cm, firm, nontender, and near the elbow joint. Swelling in the right loin was diffuse and bulging, extending from Dil to L3, tender, with elevated temperature. There was no spine tenderness, deformity of the spine, hip joint tenderness or gait abnormality. Multiple swellings of 1 cm × 1 cm were noted along the suture site. These swellings were firm and nontender [Figure 1].
Figure 1a-e: Upper panel: Subcutaneous abscess near graft sutural site (a), in the supraclavicular area (b), left forearm (c). Lower panel: Left paraspinal abscess of 12 cm × 5 cm (d), axial section of computed tomography abdomen showing hypodensity in the left paraspinal muscles (e).

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Investigations showed normal hemogram and serum creatinine was 1 mg/dL. Her liver functions were within the normal limits. Chest X-ray was normal, and the erythrocyte sedimentation rate was 50 mm at the end of 1st h. Color Doppler ultrasound of the graft was within the normal limits. Swellings along the graft site showed hypo-echogenic collections.

High-resolution ultrasound (HRUS) of swelling in the right side of the neck showed matted group of lymph nodes. HRUS of loin swelling showed a hypoechoic collection in the spinal muscles with septations. HRUS of the left thigh and left forearm were consistent with subcutaneous abscesses. Computerized tomography scan of the abdomen with bone windows showed a diffuse collection of 16 cm χ 10 cm in paraspinal muscles [Figure 1]. These findings were consistent with the findings on magnetic resonance imaging (MRI). Computed tomography (CT) scan of the chest showed consolidation in the upper segment of the right lung and infiltrates in the left lower segment.

Fine-needle aspiration cytology of the lymph node swelling from supraclavicular area showed necrotizing cells with mesothelial cells. Suspecting TB, patient was started on ATT (isoniazid, rifampicin, ethambutol, and pyrazinamide). She was started on broad-spectrum antibiotics for paraspinal abscess. Despite this, since there was no improvement in the loin swelling, surgical drainage of the paraspinal abscess was performed. Muscle collection was positive for cartridge based nucleic acid amplification test and showed resistance to rifampicin. Swellings from the suture site were aspirated. Cytology was suggestive of nonspecific inflammation. The patient was added on quinolone drugs. Three weeks after therapy, the paraspinal abscess in the right supraclavicular area and the swelling in the left thigh decreased. She became afebrile. Graft function continued to be normal. A diagnosis of disseminated TB with multiple subcutaneous abscesses due to TB pyomyositis was made.


   Discussion Top


TB pyomyositis is a rare extrapulmonary manifestation of M. tuberculosis. The most common organisms implicated in pyomyositis are Gram-positive organisms such as Staphylococcus aureus Scientific Name Search  and, Group A Streptococcus. M. tuberculosis causing pyomyositis is rare and has been reported in the general population.

Clinically, three stages have been identified in the progression of symptoms. In stage 1, patient may have a fever, muscle pain, and swelling. Stage 2 occurs two to three weeks after the onset of initial symptoms with fever, muscle tenderness, and leukocytosis. During this stage, aspiration of the muscle may reveal purulent material. During the final stage, systemic toxicity is present. Mortality may occasionally be as high as 10%.[1],[2]

The diagnosis of pyomyositis is by HRUS, CT scan, or MRI. Microbiology evaluation would help in confirmation of the organism. Treatment of pyomyositis involves antibiotics and drainage of the pus. In some situations, surgical intervention is needed.

Although organ transplant recipients are prone for infection, soft-tissue infections are rare. Indudhara et al reported TB myositis in left erector Spinae in a renal transplant recipient.[3] Similarly, another case was reported by Johnson et al in a renal transplant recipient.[4]

In our patient, she presented with multiple subcutaneous swellings of which the right supraclavicular mass was lymph nodal mass. Apart from this, the other swellings were abscesses. Although she was managed with antibiotics initially, since the symptoms did not subside, surgical intervention was needed, which revealed M. tuberculosis. With initiation of modified ATT, fever and the swelling subsided.

Pyomyositis due to M. tuberculosis may be due to a) contiguous spread from the adjacent bone or soft tissue or b) due to hematogeneous spread from pulmonary TB. In our patient, it was due to hematogeneous spread since she had a history of sputum positive pulmonary TB.[5]


   Conclusion Top


TB pyomyositis should be considered as one of the differential diagnosis in solid organ transplant recipients with fever and soft-tissue swellings. Prompt diagnosis and timely initiation of the treatment would yield positive results. Disseminated TB with multiple subcutaneous abscesses-pyomyositis is a rare clinical presentation.

Conflict of interest: None declared.



 
   References Top

1.
Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg 1979:137: 255 9.  Back to cited text no. 1
    
2.
Sharma A, Kumar s, Wanchu A, et al. Clinical characteristics and predictors of mortality in 67 patients with primary pyomyositis: A study from North India. Clin Rheumatol 2010:29:45-51.  Back to cited text no. 2
    
3.
Indudhara R, Singh SK, Minz M, Yadav RV, Chugh KS. Tuberculous pyomyositis in a renal transplant recipient. Tuber Lung Dis 1992:73: 239 41.  Back to cited text no. 3
    
4.
Johnson DW, Herzig KA. Isolated tuberculous pyomyositis in a renal transplant patient. Nephrol Dial Transplant 2000:15:743.  Back to cited text no. 4
    
5.
Ahmed J, Homans J. Tuberculosis pyomyosits of the soleus muscle in a fifteen-year-old boy. Pediatr Infect Dis J 2002:21:1169 71.  Back to cited text no. 5
    

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Correspondence Address:
Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana
India
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DOI: 10.4103/1319-2442.270277

PMID: 31696860

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