Good Afternoon

1 year old Male

ACUTE INFLAMMATION

CHRONIC INFLAMMATION

Fracture

Dislocation

Soft Tissue Injury

SOFT TISSUE INJURY

Compartment Syndrome Pyomyositis

Acute Compartment Syndrome

Trauma

Trauma

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

Pyomyositisacute bacterial infection of the muscles

severe muscle tenderness in areas with cellulitis

acute bacterial myositis

tropical pyomyositis

Streptococci Staphylococci

MRSA

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 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

Papulovesicularlesion

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 Homeostasis

Stage 1

Stage 2

Reticular Endothelial SystemDysfunction

Cytokine and MediatorsInflammation 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 feverTachycardicTachypneic MEETS ALL 4 CRITERIALeukopenia

A.O.T

• Metabolic Acidosis not corrected

• Oxacillin and Clindamycin Methicillin Resistant Staphylococcus aureus.

Septic shockSevere Sepsis Death

Staphylococcus aureus • common cause of skin and

respiratory infections • 1970’s 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

TachycardicTachypneicHypotensive

Poor peripheral pulsesPoor capillary refill

Septic shock

Hypersensitivity Reaction

Trauma

Varicella superinfection

(Staphylococcus aureus)

Hematogenous spread of bacteria

Pyomyositis

PneumoniaMeningitis SIRS

Sepsis

1 year Old MaleCC: 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