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PubMed2004

Musculoskeletal disorders associated with HIV infection and AIDS. Part I: infectious musculoskeletal conditions.

The musculoskeletal system can be affected by a variety of abnormalities in association with human immunodeficiency virus (HIV) infection. Although not as common as complications involving other organ systems, such as the pulmonary and the central nervous systems, HIV-associated musculoskeletal disorders are sometimes the initial presentation of the viral illness. Knowledge of the existence and the characteristic appearance of the conditions affecting bone, joint, and muscle in HIV-infected patients is valuable to radiologists for diagnosis and to clinicians for detection and appropriate treatment. We reviewed recent literature to provide a comprehensive assessment of the HIV-associated musculoskeletal disorders, and present radiologic examples from our own collection. This article is divided into two parts. In the first part we review the infectious musculoskeletal disorders associated with HIV illness and AIDS, including cellulitis, abscesses, pyomyositis, septic bursitis, septic arthritis, osteomyelitis, and bacillary angiomatosis. We also present a comprehensive spectrum of mycobacterial infections, consisting of tuberculous spondylitis and spondylodiskitis, arthritis, osteomyelitis, and tenosynovitis, as well as infections caused by atypical mycobacteria. Part II of this review will concentrate on non-infectious musculoskeletal conditions, including rheumatic disorders and neoplasms.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Iliopsoas myositis mimicking appendicitis: MRI diagnosis.

Myositis of the truncal muscles can closely mimic acute appendicitis. Myositis is the early stage of muscular infection. It is characterized by diffuse muscular pain and swelling without a distinct mass. Early diagnosis of myositis improves the outcome and surgical debridement is usually avoided. Pyomyositis, the advanced stage of the disease, can be diagnosed by MRI examination. We present a case of early bacterial myositis that was diagnosed by MRI.

Acute Disease↗
PubMed1996

Orthopaedic surgery and HIV disease in Africa.

Human immunodeficiency virus (HIV) infection has radically changed African orthopaedic practice within a decade. In Lusaka, a third of adults are infected, but most have no physical signs of the disease. Early experience showed that closed fractures healed normally, the risk of sepsis during osteosynthesis was increased and most open fractures became septic. Major orthopaedic surgery in HIV-positive patients has increased risks of sepsis which rise steeply in those with physical signs of HIV disease. Musculoskeletal infections such as tropical pyomyositis, adult haematogenous long-bone osteomyelitis, and late haematogenous infection of implants, appear as immune competence wanes. There is a dual epidemic of tuberculosis and HIV, and bone and joint tuberculosis is now common. Atypical features suggest that traditional diagnostic criteria for spinal tuberculosis may be inadequate. Rheumatoid diseases, especially reactive arthritis, are common and serious complications of HIV disease. The risk of transmission of HIV between patient and surgeon is small, especially if recommended precautions are universally applied.

Africa↗
PubMed2004

Ultrasonography of musculoskeletal infections in children.

Ultrasonography is an important modality for evaluation of musculoskeletal infections in children because it is rapid, nonionising and very sensitive for (infectious) fluid collections and joint effusions. Moreover, the images are not degraded by metallic or motion artefacts (as with CT and MRI) and finally, ultrasonography offers the possibility of fine-needle aspiration to confirm the infectious nature of a fluid collection without unnecessary contamination of adjacent anatomical compartments. Ultrasonography should be combined with radiography because both imaging techniques are complimentary. The purpose of this article is to emphasise the role of ultrasonography in the diagnosis of various diseases in childhood, including cellulitis, subcutaneous abscess, necrotizing fasciitis, pyomyositis, infectious bursitis and arthritis, osteomyelitis, foreign bodies and infectious lymphadenitis. Along with conventional radiography, ultrasonography is a very valuable modality for early diagnosis and follow-up of musculoskeletal infections in children.

Acute Disease↗
PubMed2004

Soft tissue and joint infection.

Soft tissue infection may be acute or chronic and may be introduced by the haematogenous route, or by inoculation, including surgical infection, or spread from other areas. The spectrum of infecting organism differs in primary infection, in immunodeficiency or when foreign bodies, including prostheses, are present. Bacterial infections are usually more rapid than those due to fungi or atypical organisms. Inflammation usually begins as cellulitis, proceeding through necrosis to cavitation and abscess formation, sometimes complicated by haemorrhage. Imaging, apart from MRI in selected cases, is rarely helpful in the early stages, but early diagnosis of pyomyositis and necrotizing fasciitis is mandatory. When infection is established, US, CT and MRI all have individual value in diagnosis, including biopsy, and in directing therapy, including percutaneous or surgical drainage or debridement. Both MRI and CT are best suited to monitoring progress. Septic arthritis presents as rapidly progressive, destructive arthritis, and early diagnosis is essential to prevent long-term morbidity. Ultrasound offers the best method of detecting early joint effusion and synovial thickening, but aspiration is usually required for diagnosis. In more advanced stages CT is valuable for revealing destructive changes, and MRI for documenting intra-articular changes and detecting inflammation in surrounding bone.

Arthritis, Infectious↗
PubMed2000

Primary pyogenic psoas abscess in children.

Primary pyogenic psoas abscess, although quite a common condition, particularly in the tropics, is often overlooked as a clinical entity, probably because a psoas abscess has been traditionally associated with tuberculous spondylitis. The abscess is easily diagnosed by ultrasonography (US). Treatment by open drainage and antibiotics effective against Staphylococcus aureus results in complete reversal of symptoms and signs. In our series of 55 cases in the pediatric age group (0-12 years), pain and flexion at the hip were the most frequent clinical features at presentation. US was diagnostic in all cases in which it was performed. All except 1 patient showed complete resolution with extraperitoneal drainage, antibiotics, and skin traction. Although 4% of the cases were associated with suppurative external-iliac lymphadenitis, the remaining ones arose de novo in the psoas sheath, suggesting a primary pyomyositis of the psoas muscle.

Anti-Bacterial Agents↗
PubMed1999

AIDS-related myopathy.

Infection with the human immunodeficiency virus (HIV) is often associated with the acquired immunodeficiency syndrome (AIDS), and wasting is one of the defining clinical features of AIDS. Muscular weakness due to myopathy may develop at any stage of HIV infection. We report two illustrative cases of HIV-associated myopathies. One was due to inflammatory myosits most likely directly related to the HIV infection, and the other was most likely the result of mitochondrial damage due to zidovudine, a nucleoside analogue commonly used in treating HIV infection. Biopsies from both patients showed alterations of myofiber structures, of varying severity, culminating in necrosis, lipid droplets, and lymphoplasmocytic inflammatory response. The zidovudine-treated patient also showed distinctive mitochondrial changes, predominantly enlargement, variation in shape and size, and disorganization of the cristae. These two types of HIV-associated inflammatory myopathies are reviewed, along with other HIV-associated myopathies, including HIV wasting syndrome, nemaline rod myopathy, pyomyositis, rhabdomyolysis, cardiomyopathy, and other miscellaneous myopathies associated with HIV infection.

Journal Article↗
PubMedDate not supplied

Magnetic resonance imaging of osteoarticular infections in children.

Magnetic resonance imaging has become a common tool for the diagnosis and management of osteoarticular infections in children. We retrospectively review the MRI findings in 57 children (age range 4 months to 16 years; mean 6.3 years) diagnosed with osteoarticular infection. Thirty-eight cases were osteomyelitis, 4 were septic arthritis, 6 were spondylodiscitis, 7 were soft-tissue infections, 2 were pyomyositis, and 2 were chronic multifocal osteomyelitis. The pathogenesis and classification of osteoarticular infections are briefly discussed. Currently available imaging techniques are reviewed, and advantages and disadvantages are discussed. Magnetic resonance imaging indications and findings are shown. The most adequate magnetic resonance imaging sequences, as well as the usefulness of intravenous contrast material, are stressed.

Arthritis, Infectious↗
PubMed2005

Musculoskeletal infections: ultrasound appearances.

Musculoskeletal infections are commonly encountered in clinical practice. This review will discuss the ultrasound appearances of a variety of musculoskeletal infections such as cellulitis, infective tenosynovitis, pyomyositis, soft-tissue abscesses, septic arthritis, acute and chronic osteomyelitis, and post-operative infection. The peculiar sonographic features of less common musculoskeletal infections, such as necrotizing fasciitis, and rice body formation in atypical mycobacterial tenosynovitis, and bursitis will also be presented.

Abscess↗
PubMed2006

Skin and soft tissue infections.

Primary skin infections (ie, pyodermas) typically are initiated by some breach in the epidermis, resulting in infection by organisms, such as Streptococcus pyogenes and Staphylococcus aureus, that normally colonize the skin. Host-associated factors, such as immunosuppression, vasculopathy, neuropathy, or decreased lymphatic drainage, may predispose to skin infection. The clinical syndromes associated with skin infections are often characteristic and are defined most simplistically by anatomic distribution. Although often mild and self-limited, skin infections can be more aggressive and involve deeper structures, including fascia and muscle. This article discusses skin and soft tissue infections, including impetigo, hair follicle-associated infections (ie, folliculitis, furuncles, and carbuncles) erysipelas, cellulitis, necrotizing fasciitis, pyomyositis, septic bursitis, and tenosynovitis.

Journal Article↗
PubMed2006

Tropical dermatology: bacterial tropical diseases.

UNLABELLED: Bacterial infections are common in tropical parts of the world and can include those species also seen regularly in temperate climates. Many tropical bacterial infections, however, are rarely diagnosed in temperate parts of the world and include bartonellosis, tropical ulcer, tropical pyomyositis, granuloma inguinale, lymphogranuloma venereum, yaws, pinta, melioidosis, and glanders. Some tropical bacterial diseases, eg, plague and anthrax, are associated with high mortality rates and are of potential use in bioterrorism. Some tropical bacterial diseases are closely associated with specific activities such as hunting (ie, tularemia) or eating raw seafood (Vibrio vulnificus infection). The bacterial diseases having the most severe medical impact in the tropics are those caused by members of the Mycobacterium genus. Millions of persons throughout the world suffer from tuberculosis and leprosy; Buruli ulcers are common causes of morbidity in many tropical countries. Because of the increasing frequency of travel to tropical parts of the world for tourism and work as well as the increasing number of immigrants and adoptees from these areas, it is imperative that physicians practicing in temperate climates be able to recognize the signs and symptoms of tropical bacterial diseases, carry out the proper diagnostic tests, and initiate appropriate therapy and prevention. LEARNING OBJECTIVE: At the completion of this learning activity, participants should be familiar with the clinical presentations, epidemiologies, diagnoses, therapies, and preventions of bacterial tropical diseases.

Bacterial Infections↗
PubMed2006

Isolated obturator externus muscle abscess presenting as hip pain.

The case of a 20-year-old diabetic male with 2 weeks of hip pain, diagnosed with an isolated obturator externus muscle abscess, is reported. Pyomyositis, or abscess formation deep within a large striated muscle, is a rare but potentially life-threatening disease.

Abscess↗
PubMed2005

Musculoskeletal infections in children.

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

Arthritis, Infectious↗
PubMed1997

Primary muscle lymphoma.

Primary muscle lymphoma is rare. Less than 50 cases have been described. The clinical and radiological features of muscle lymphoma are presented in this series of six cases. Most patients present with solitary or multiple masses which may be painful. Clinical presentation varies from the indolent to the rapidly progressive. Systemic symptoms occur in a minority. In most cases, ultrasound shows an ill-defined hypoechoic mass but apparent coarsening of fibroadipose septa and swelling of muscle bundles may occur. CT shows an iso/hypo dense mass. On MR the mass appears iso/minimally hyperintense to muscle on T1W and enhances, and hyperintense on T2W, proton density and fat suppression sequences. Infiltration of the subcutaneous fat is a striking feature in a majority of cases on CT and MR. The diagnosis can be established by ultrasound guided biopsy and should be performed urgently in HIV positive patients to exclude pyomyositis.

AIDS-Related Opportunistic Infections↗
PubMedDate not supplied

Prevalence and indicators of HIV and AIDS among adults admitted to medical and surgical wards in Blantyre, Malawi.

Despite high seroprevalence there are few recent studies of the effect of human immunodeficiency virus (HIV) on hospitals in sub-Saharan Africa. We examined 1226 consecutive patients admitted to medical and surgical wards in Blantyre, Malawi during two 2-week periods in October 1999 and January 2000: 70% of medical patients were HIV-positive and 45% had acquired immune deficiency syndrome (AIDS); 36% of surgical patients were HIV-positive and 8% had AIDS. Seroprevalence rose to a peak among 30-40 year olds; 91% of medical, 56% of surgical and 80% of all patients in this age group were HIV-positive. Seropositive women were younger than seropositive men (median age 29 vs. 35 years, P < 0.0001). Symptoms strongly indicative of HIV were history of shingles, chronic diarrhoea or fever or cough, history of tuberculosis (TB), weight loss and persistent itchy rash (adjusted odds ratios [AORs] all > 5). Clinical signs strongly indicative of HIV were oral hairy leukoplakia, shingles scar, Kaposi's sarcoma, oral thrush and hair loss (AORs all > 10). Of surgical patients with 'deep infections' (breast abscess, pyomyositis, osteomyelitis, septic arthritis and multiple abscesses), 52% were HIV-positive (OR compared with other surgical patients = 2.4). Severe bacterial infections, TB and AIDS caused 68% of deaths. HIV dominates adult medicine, is a major part of adult surgery, is the main cause of death in hospital and affects the economically active age group of the population.

Acquired Immunodeficiency Syndrome↗
PubMed2000

23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults: double-blind, randomised and placebo controlled trial.

BACKGROUND: Infection with Streptococcus pneumoniae is a frequent and serious problem for HIV-immunosuppressed adults. Vaccination is recommended in the USA and Europe, but there are no prospective data that show vaccine efficacy. METHODS: 1392 (937 female) HIV-1-infected adults in Entebbe, Uganda, were enrolled. 697 received 23-valent pneumococcal polysaccharide vaccine and 695 received placebo. The primary endpoint was first event invasive pneumococcal disease. Secondary endpoints included vaccine serogroup-specific invasive disease, all (probable and definite) pneumococcal events, all-cause pneumonia, and death. FINDINGS: First invasive events occurred in 25 individuals (24 bacteraemias, one pyomyositis), 15 in the vaccine arm and ten in the placebo arm (hazard ratio [HR] 1.47; 95% CI 0.7-3.3). 22 isolates (88%) were of vaccine-specific serogroups with 15 events in the vaccine arm compared with seven in the placebo arm (HR 2.10; 0.9-5.2). All pneumococcal events had a similar distribution (20 vs 14; HR 1.41; 0.7-2.8) though all-cause pneumonia was significantly more frequent in the vaccine arm (40 vs 21; HR 1.89; 1.1-3.2). Mortality was unaffected by vaccination. INTERPRETATION: 23-valent pneumococcal polysaccharide vaccination is ineffective in HIV-1-infected Ugandan adults and probably has little, or no, public health value elsewhere in sub-Saharan Africa. Increased rates of pneumococcal disease in vaccine recipients may necessitate a reappraisal of this intervention in other settings.

AIDS-Related Opportunistic Infections↗
PubMed1994

Serious group A beta-hemolytic streptococcal infections complicating varicella.

STUDY OBJECTIVE: To alert practicing emergency physicians to an important and possibly increasing relationship between life-threatening group A beta-hemolytic streptococcal (GABHS) infections and children recovering from varicella. DESIGN: A case series of six patients managed from January through March 1993. SETTING: A university-affiliated pediatric specialty emergency department. TYPE OF PARTICIPANTS: Six previously healthy immunocompetent children between 1 and 5 years of age seen in our ED over a nine-week period. RESULTS: Six children had onset of varicella two days to two weeks before developing a serious life-threatening GABHS infection. Children presented with clinical symptoms of invasive GABHS infection with bacteremia (one patient); streptococcal toxic shock syndrome with negative blood culture (two), pneumonia with pleural effusion and streptococcal toxic shock syndrome (one), pneumonia with pleural effusion (one), and pyomyositis of the thigh (one). Four of six patients required intensive care admissions and aggressive support of vital signs. All six survived. CONCLUSION: Emergency physicians should be aware of the association between varicella and serious GABHS infections and be prepared to recognize and aggressively manage serious complications should they occur.

Cellulitis↗
PubMed1999

Acute swelling of the limbs: magnetic resonance pictorial review of fascial and muscle signal changes.

OBJECTIVE: This pictorial review analyzes the magnetic resonance (MR) fascial/muscular changes in 69 patients referred as emergencies with acute swelling of the limbs (ASL) from various causes. METHODS AND MATERIAL: A prospective MR imaging (MRI) study of 69 patients referred as emergencies for ASL was performed. Our population consisted of 45 patients with skin and soft-tissue infections (cellulitis and necrotizing fasciitis, and pyomyositis), six patients with soft-tissue inflammatory diseases (dermatomyositis, graft-versus-host disease), 11 patients with acute deep venous thrombosis, three patients with rhabdomyolysis, one patient with acute denervation and three other patients with rare diseases. Hematomas, tumorous or infectious bone involvement and soft-tissue tumors were excluded. All studies included spin echo T1-weighted images and spin echo T2-weighted images. Gadolinium-enhanced spin echo T1-weighted images were obtained when an abscess was suspected on T2-weighted images. Selective fat-saturated T1- and T2-weighted sequences were also used. MRI analysis was performed to obtain a compartmentalized anatomical approach according to the location of signal abnormalities in subcutaneous fat, superficial and deep fascia and muscle. RESULTS: In all patients with ASL, MRI demonstrated soft-tissue abnormalities involving subcutaneous fat, superficial fascia, deep fascia, or muscle. Although MR findings were non-specific, MRI appears sensitive for detecting subtle fascial and muscle signal changes. CONCLUSIONS: In skin and soft-tissue infections, MRI can be helpful for therapeutic management by determining the depth of soft-tissue involvement, particularly within fasciae and muscles, which is partly related to the severity of cellulitis with severe systemic manifestations. MRI can also aid the surgeon in diagnosing abscesses. In inflammatory diseases, MRI can determine the best site for biopsy and also monitor therapeutic response.

Adolescent↗