Primary pyomyositis, formerly known as tropical pyomyositis, is an infection that presents with abscess formation in skeletal musculature, mainly in the extremities, hip and pelvis, with Staphylococcus aureus as the main etiologic agent. Among possible complications, we highlight toxic shock syndrome and septic emboli. A 44-year-old Indigenous woman with diabetes and hypertension was admitted to a tertiary hospital in the Center-West region of Brazil with diffuse myalgia, productive cough and multiple skin lesions draining purulent exudate. Symptoms began 1 month earlier with pain in the lower limbs, progressive worsening, intense diffuse pain and the appearance of lesions in the intergluteal region, lateral leg and dorsum of the left foot. She had dressings applied at home with macerated herbs, according to Indigenous rituals. Computed tomography (CT) of the chest, abdomen and lower limbs showed multiple collections in the left gluteal region suggestive of necrotizing involvement, multiloculated confluent lesions in the lower limbs involving bilateral muscular and subcutaneous planes, with peripheral contrast enhancement. Chest CT showed paravertebral intramuscular collections and randomly distributed nodular opacities throughout both lungs, some with cavitary appearance, suggesting hematogenous dissemination. Treatment with ceftriaxone and oxacillin was started. Samples were collected for culture from aspirated secretions and tissue fragments, and S. aureus methicillin-resistant (MRSA) was identified, susceptible to clindamycin, vancomycin, teicoplanin and linezolid. Due to clinical worsening under the initial therapy, antimicrobials were switched to linezolid and meropenem. She required multiple surgical reinterventions, and subsequent cultures yielded new MRSA isolates, as well as ESBL-producing Klebsiella pneumoniae and Kluyvera ascorbata resistant to ceftriaxone. All blood cultures were negative. The patient developed severe hypoxemia and hemodynamic instability during one of the reinterventions, requiring intubation and vasoactive drugs. After this event, she evolved with several healthcare-associated complications: ventilator-associated pneumonia and colitis. There was neurological damage due to hypoxia, and she remains with open gluteal lesions, without surgical conditions and in palliative care.
Guilarde et al. (Sun,) studied this question.