Painful Thigh — Are We Missing the Diagnosis?

1University of Illinois at Urbana Champaign, Urbana, IL
2University of Illinois at Urbana Champaign, Urbana, IL

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 484

Case Presentation:

A 58‐year‐old white man with no significant medical history presented to the clinic with chief complaint of bilateral thigh pain of 4 weeks' duration. Pain was 10/10 constant, nonradiating, aggravated by walking, no significant relieving factors, associated with intermittent fever and chills. He recently had a few long drives. No history of trauma, sick contacts, or recent illness. Family history was positive for DM in father and sister. On examination, a tender cord‐like structure was palpated on medial left thigh and tenderness elicited over medial right thigh. No regional lymphadenopathy. Distal pulses were normal. Bilateral lower‐extremity duplex ruled out deep venous thrombosis but showed a nonvascular structure suspicious for hematoma or abscess in both thighs. Initial labs were remarkable for glucose of 444 mg/dL. D‐dimer and creatine kinase levels were within normal limits. Magnetic resonance imaging (MRI) of both thighs showed signal characteristics suggestive of intramuscular abscess. He was admitted to the hospital and computed tomography (CT)–guided drainage of the intramuscular abscess was done, which grew Staphylococcus aureus sensitive to methicillin. Glycosylated hemoglobin was 11.4%. Patient responded well to good glycemic control and intravenous antibiotics. Follow up CT scan of thighs showed decrease in size of the abscesses.

Discussion:

Very few cases of pyomyositis as the initial manifestation of DM have been reported. Pyomyositis, also called pyomyositis tropicans due to its endemicity in tropical regions, is increasing in incidence in the temperate regions, with immunosuppression being a significant predisposing factor. Most common site is the thigh (54%), followed by back (13%). It is not always trauma related. Creatine kinase levels are often normal. Between 75% and 90% of cases are caused by Staphylococcus aureus with mortality of up to 10%. CT‐guided drainage helps in optimizing treatment. Painful thigh in patients with DM, immunodeficiency, malignancy, cirrhosis, renal insufficiency, organ transplant, intravenous drug abuse and those on immunosuppressive agents should raise high index of suspicion for pyomyositis.

Conclusions:

Immunosuppression predisposes to a wide variety of infections, some often underdiagnosed due to lack of suspicion. Awareness about such conditions helps in early diagnosis and treatment. Timely use of CT or MRI helps in early diagnosis and initiation of treatment in pyomyositis, thereby preventing significant morbidity and mortality.

To cite this abstract:

Chandra K, Kumar J. Painful Thigh — Are We Missing the Diagnosis?. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 484. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/painful-thigh-are-we-missing-the-diagnosis/. Accessed November 18, 2019.

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