Good Afternoon

1 year old Male

ACUTE
INFLAMMATION
CHRONIC
INFLAMMATION
Fracture
Dislocation
Soft Tissue
Injury
SOFT TISSUE
INJURY
Compartment Syndrome
Pyomyositis
Acute Compartment Syndrome
Tissue
Pressure
Venous
Pressure
Decreased
Blood Flow
PAIN
Decreased
Sensation
Acute Compartment Syndrome
hypotension on the involved area
pain out of proportion to the injury
pallor of the extremity
pulselessness
paralysis (loss of function) or limitation
of movement

A.O.T.
Pain
Limitation of movement
Good pulses
SOFT TISSUE
INJURY
Compartment Syndrome
Pyomyositis
Pyomyositis
acute bacterial infection of the muscles
severe muscle tenderness in areas with cellulitis
acute bacterial
myositis
tropical
pyomyositis
Streptococci
Staphylococci
M
R
S
A
Swelling of Left Arm
Erythematous
Warm
Pain on movement
XRAY: soft
tissue swelling
Blood Culture:
Staphylococcus
aureus
>90% of cases of skeletal muscle
abscesses Staphylococcus aureus

Micro-abscesses in the
kidneys, liver, or spleen
but never in skeletal
muscles
specific muscles were damaged
by mechanical pinching or
electric current 24 to 48 hours
prior to injection of bacteria


small abscesses
developed within 2
to 28 days at
some of the
injured sites
Muscle
injury
Bacteremia
(staphylococcal)
PYOMYOSITIS
Pyomyositis
May occur in individuals of all ages
Boys > girls
most common site:
Thighs,
Calfs
Arms
Buttocks
no definable immunologic abnormalities

A.O.T.

had no history
of repeated
infection
Pyomyositis
any child with fever and muscle pain, especially
if with history of trauma
Definitive diagnosis: one or more radiologic
procedures
XRAY: soft tissue swelling
scanning with Gallium, or Indium
Ultrasound
CT scan
Pyomyositis
Inflammatory
Response
Increased WBC
Increased
Blood Flow
Hematogenous
Spread
Cytokines
Abscess of skeletal muscles
Increased WBC
Hematogenous
spread of different
microorganisms
from different areas
of the body
formed by the
adjacent healthy cells
in an attempt to keep
the pus from infecting
neighboring
structures
encapsulation tends to
prevent immune cells
from attacking bacteria
in the pus, or from
reaching the causative
organism or foreign
object, resulting in
worsening of the pain
and swelling
ABSCESS
How did
pyomyositis
come
about
Papulovesicular
lesion
secondarily infected
Staphylococcus
aureus inoculated
through skin break
and spreads
hematogenous route
bacteremia
pyomyositis
Differential Diagnosis for a Rash
onset
location
speed or direction of progression
general well-being of the child, including
prodromal illness or fever
infectious contacts
mucosal involvement

Vesicular
VESICULAR RASH
Varicella
Eczema
Herpeticum
HFMD
Eczema Herpeticum
underlying atopic dermatitis or
eczema

lesion is characterized with
umbilication or a crust in the
middle of the vesicle

Hand, Foot and Mouth Disease
Coxsackievirus type A
papulovesicular
eruption but usually
limited on the palms,
soles, mucous
membranes and
sometimes the buttocks

Varicella : most
common cause of
papulovesicular
lesions in children

Maculopapular rash
macule-papule
stage of Varicella
Complications of Varicella
Not common
Possible complications
Pneumonia
Septicemia
Suppurative arthritis
Osteomyelitis or local gangrene
Pyomyositis
Meningitis

Pneumonia by the Varicella
Zoster Virus
Uncommon
2 to 10 days after the rash
with fever
Cough as the first sign
Usually benign
A.O.T.
respiratory distress worsened

fatal forms of pneumonia

Staphylococcus aureus and Klebsiella
pneumoniae
A.O.T.
CSF sugar and protein: normal

CSF Gram Stain: g (-) bacilli
too numerous to count

CSF WBC increased

Acute Bacterial Meningitis
According to Feigin and Cherry,
pyomyositis has been described in
Varicella, presumably caused by
bacteremia resulting from infection of skin
lesions


Paracetamol
and Cefalexin

maculopapular
rashes


allergic reaction
Varicella
Trauma Allergic
Reaction
Systemic
Inflammatory
Response
SIRS: Stage 1
local cytokine
INSULT
inflammatory response
promoting wound repair
and recruitment of the
reticular endothelial system
Infection Trauma
Allergic Reaction
White Blood Cells
Growth Factor Stimulation and the
Recruitment of Macrophages and Platelets
Acute Phase Response
Homeostasis
Stage
1
Stage
2
Reticular Endothelial System
Dysfunction
Cytokine and Mediators
Inflammation and Repair
SIRS: Stage 3
Homeostasis
Not Restored
Significant
Systemic
Reaction Occurs
Cytokine
Release
Activation of the
Reticular Endothelial
System
Activation of
Numerous Humoral
Cascades
END
ORGAN
DAMAGE
Loss of
Circulatory
Integrity
A.O.T.
High grade fever
Tachycardic
Tachypneic MEETS ALL 4 CRITERIA
Leukopenia
A.O.T

Metabolic Acidosis not corrected



Oxacillin and Clindamycin Methicillin
Resistant Staphylococcus aureus.

Septic shock Severe Sepsis Death
Staphylococcus aureus
common cause of skin and
respiratory infections
1970s Penicillin resistance spread
Methicillin, 1960, MRSA identified
in 1961
In 1956, Erythromycin (a
macrolide), Clindamycin (a
lincosamide) resistance reported

According to Feigin et al., invasive strains
of Staphylococcus aureus can cause
severe form of pneumonia
If severe sepsis:
Respiratory compensation becomes
ineffective combination of respiratory and
metabolic acidosis

A.O.T.
Acutely ill and agitated
Poor vital signs only temperature
recorded

Tachycardic
Tachypneic
Hypotensive
Poor peripheral pulses
Poor capillary refill
Septic
shock
Hypersensitivity
Reaction
Trauma
Varicella
superinfection
(Staphylococcus
aureus)
Hematogenous
spread of
bacteria
Pyomyositis
Pneumonia Meningitis
SIRS
Sepsis
1 year Old Male
CC: Left Arm
Swelling
SEPSIS ORGAN Dysfunction
Respiratory Distress
Meningitis

SEVERE
SEPSIS
SEPTIC
SHOCK
DEATH
FINAL DIAGNOSIS

Septic Shock secondary to Severe
Sepsis (Staphylococcus aureus,
probably MRSA)
Varicella
Tropical Pyomyositis
Pneumonia
Meningitis
Hypersensitivity Reaction Secondary to
Cephalexin