PYOMYOSITIS

Introduction
Background

Pyomyositis is an inflammation of muscle tissue, usually of voluntary muscles that results in pus production. Once considered a tropical disease, it is now seen in temperate climates as well. The pathogenesis is unclear, but trauma, infections (S. aureus, S. pneumoniae), and malnutrition have been implicated. Although most cases of pyomyositis occur in healthy individuals, other pathogenetic factors include nutritional deficiency and associated parasitic infection in tropical climates. In the temperate climates, pyomyositis is seen most commonly in patients with diabetes, HIV infection, and malignancy.
Clinical Presentations

Presentation with painful, tender, localized swelling over muscle Fever Epidural abscess

Complications

Life-threatening complications include sepsis and toxic shock syndrome.

Diagnosis

CT scan or MRI demonstrates muscle abscess. Aspiration of abscess (by surgery or CT/US guided) yields pus, usually yielding S. aureus. Bacteremia may accompany.

Treatment
Medical Care

Promptly administer systemic antibiotics. This could eliminate the need for surgical drainage in selected cases. The choice of antibiotic is determined by identification of the causative organism. Antibiotics initially are given intravenously until clinical improvement is noted, followed by oral antibiotics for a total course of 3 weeks (eg, cefazolin or ceftriaxone IV followed by cephalexin PO).

Surgical Care

During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be required. Surgical drainage is especially necessary for large abscesses. Complicated cases may require fasciotomies and debridement.

Prognosis

Prompt administration of antibiotics can result in complete resolution.

Specific Objectives:
Define Pyomyositis. Identify the signs and symptoms manifested by the patient. Distinguish the precipitating and predisposing factors that trigger this development. Trace the pathogenesis based on the signs and symptoms manifested by the patient. Determine appropriate medical and nursing management for the patient. Use the nursing process as the framework for the care of the patient.

Significance of the Study in Nursing Field:

Shall have critical thinking skills necessary for providing safe and effective nursing care. Shall have a comprehensive assessment and implement care base on our knowledge and skills of the condition. Shall have familiarized with effective interpersonal skills to emphasize health promotion and illness prevention. Shall have imparted the learning experience from direct patient care.

PATIENTS PROFILE
Name: Baby Dyein Sex: Female Birthday: October 2007 Age: 2 - 3 y/o Religion: Roman Catholic Civil Status: Single Nationality: Filipino Date of Admission: July 27, 2010 Time of Admission: 8:40 PM Admission Diagnosis: Pyomyositis Left Scapular Area Attending Physician: Dr. De Guzman A. Family Background Baby Dyein is the youngest among the four siblings. B. Educational and Socio - Economic Status She does not go to school yet. The rest of the siblings are funded for their educational expenses by one of their mothers rich customers as a laundry woman, except that the eldest child does not go to school anymore as she decided to stop studying and just help work. C. Lifestyle and Diet She eats three times a day and drinks 5-6 glasses of water a day though mostly breastfeed on her mother. D. Family Health History No family history of pyomyositis, diabetes, hypertension, tuberculosis, diabetes, nor any other diseases reported. E. Immunization Record With complete record of immunization. F. Past Health History Had cough, colds and fever but is only hospitalized once now due to pyomyositis. G. Present Health History One month prior to consultation, patient together with her older brother had a fall as she was given a piggy backride. Patient fell on her left scapular area and complained of pain. Her mother had her massaged by a so-called manghihilot. Three weeks prior to consultation, patient still complained of pain and endured of fever and localized swelling on the left scapular area. Another hilot session was done and patient was given TSB. But as the swelling and fever still persevered, patient was brought to the nearest clinic. Patient was given Paracetamol and was referred to Philippine Orthopedic Center. Patient was admitted.

ANATOMY AND PHYSIOLOGY

The scapula or shoulder blade is the bone that connects the humerus (arm bone) with the clavicle (collar bone). The scapula forms the posterior located part of the shoulder girdle. It is a flat bone, roughly triangular in shape, placed on a posterolateral aspect of the thoracic cage.

LEFT

SCAPULA

. LATERAL SURFACE

CORACOID PROCESS - bony projection on the shoulder blade GLENOID CAVITY holds the head of the humerus SUPRAGLENOID TUBERCLE rounded protuberance above the glenoid cavity INFRAGLENOID TUBERCLE rounded protuberance below the glenoid cavity SPINE a bony projection from the glenoid to acromion ACROMION - bony projection from the outer end of the spine of the shoulder blade, to which the collar bone is attached AXILLARY BORDER near to armpit INFERIOR ANGLE - gives greater strength to the body of the bone by its arched form

OSSIFICATION OF SCAPULA The larger part of the scapula undergoes membranous ossification. Some of the outer parts of the scapula are cartilagenous at birth, and would therefore undergo endochondral ossification. The head, processes, and the thickened parts of the bone, contain cancellous tissue; the rest consists of a thin layer of compact tissue. The central part of the supraspinatous fossa and the upper part of the infraspinatous fossa, but especially the former, are usually so thin as to be semitransparent; occasionally the bone is found wanting in this situation, and the adjacent muscles are separated only by fibrous tissue.

PATHOGENESIS
Fell on her left scapular Area from a Piggy Backride

Inflammatory Response

Trauma: Pressure by hilot

Vascular Response

Chemical Response

Systemic Response

Vasodilatation

Redness Heat

Pain

Leukocytosis Infiltration

PR and RR

Increased Membrane Permeability

Swelling

Increased ESR

Fever

Abscess Formation

PYOMYOSITIS

IF NOT TREATED: Toxic Shock Syndrome Sepsis

IF TREATED: Good Prognosis Recovery

DIAGNOSTIC EXAMS
COMPLETE BLOOD COUNT Results Hemoglobin 107 Normal Values 110 - 158 g/L Interpretations Bone marrow suppression or iron deficiency anemia Iron deficiency anemia Tissue injury Tissue injury Tissue injury Trauma Iron deficiency anemia Iron deficiency anemia Iron deficiency anemia Iron deficiency anemia Nursing Responsibilities

Hematocrit Leukocyte Count Differential Count Segmenters Lymphocytes Platelet Count Indices MCV MCH MCHC ESR

0.34 22.4 0.75 0.19 513 69.9 21.9 31 128

0.37 - 0.54 4.5 - 10 x 109/L 0.50 - 0.70 0.20 - 0.40 150 - 400 x 109/L 82 - 92 28 - 32 32 - 38 0 - 10mm/hr

Iron deficiency anemia: > Diet. Foods rich in iron.

Tissue Injury and Trauma: > Monitoring of VS. > Wound Care > Diet. Foods rich in protein and Vit. C. > Administration of prescribed medications. > Avoid pressure on the affected area.

MUSCULOSKELETAL SONOGRAPHY There is a 5.0 x 1.2 cm complex mass in the left scapular area. Remainder is unremarkable. Impression: PYOMYOSITIS

DRUG STUDY
Drugs Name Generic Name: Ibufropen Brand Name: Apo Ibufropen Pharmacologic Class: NSAID Dosage Indication Action 100/s 5ml q8 x 7 > Mild to May inhibit prostaglandin days moderate pain synthesis, to produce anti> Fever inflammatory, analgesic, and antipyretic effects. Adverse Effects CNS: dizziness, headache CV: edema EENT: tinnitus GI: decreased appetite, peptic ulceration GU: acute renal failure Respiratory: bronchospasms Skin: Stevens Johnson Syndrome > Mild pain or Blocks pain impulses by Hepatic: jaundice fever inhibiting synthesis of Metabolic: hypoglycemia prostaglandin in the CNS or Skin: rash, urticaria of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. > Skin infection Inhibits cell wall synthesis, CV: phlebitis promoting osmotic instability. GI: diarrhea, N/V, anorexia Skin: rashes, urticaria Nursing Considerations > NSAID may mask S/S of infection > It may take 1 or 2 wks before full anti inflammatory effects occur > Take with meals > Use with aspirin may increase risk of GI adverse reaction > Report for S/S of GI bleeding > Given for T>38.0C > Monitor V/S

Generic Name: Acetaminophen Brand Name: Paracetamol Pharmacologic Class: Para-aminiohenol derivative Generic Name: Cefuroxime Brand Name: Ceftin Pharmacologic Class: 2nd gen. cephalosphorin

80 mg q4 IV

250mg IV q8

> Perform skin test (ANST) > Give if ANST (-) > Take with meals > Monitor for signs of infection

Generic Name: Ceftazidime Brand Name: Tazicef Pharmacologic Class: 3rd gen. cephalosphorin

22 in 50ml IV

> Bacteremia and Inhibits cell wall synthesis, CNS: seizures, headache skin infection promoting osmotic instability. CV: phlebitis GI: diarrhea, N/V Skin: rashes, urticaria

> Perform skin test (ANST) > Give if ANST (-) > Take with meals > Monitor for signs of infection

NURSING CARE PLAN

Assessment Subjective Cue: Objective Cues: >Flushed skin > Warm to touch > With lab results as follows: - Leukocyte Ct: 22.4 x 109/L (NV: 4.5 -10 x 109/L) - Segmenters: 0.75 (NV: 0.50 0.70) - Lymphocytes: 0.19 (NV: 0.20 0.40) - Impression of Pyomyositis on Sonography > with VS taken as ff: T: 38.2 C P: 82 bpm R: 20 cpm Nursing Diagnosis Hyperthermia r/t trauma 2 underlying disease Scientific explanation Trauma has been implicated to cause Pyomyositis, an inflammation of a muscle tissue. Due to inflammatory process, vasodilatation occurs leading to increase body metabolism and elevated body temperature.
Ref: Brunner and Suddarths Textbook of Medical Surgical Nursing

Planning After 2-3 hours of nursing intervention, patients temperature would be within normal range.

Intervention Established rapport both with the mother and the patient. Monitored V/S.

Rationale To gain cooperation and trust.

Evaluation After 2 hours, patients temperature was within normal range AEB temperature of 37.5C.

To review alterations of V/S as affected by patients condition, and progress as given with interventions. Age can directly impact ability to regulate temperature. Hyperthermia may cause dehydration. To identify potential internal causes of temperature imbalances. To provide cooling measures.

Noted clients age.

Monitored I & O.

Reviewed laboratory values.

Provided fans as indicated.

Asked mother to dress the baby with light loose clothing. TSB done.

To promote comfort.

To provide cooling measures. To prevent cross contamination and transmission of MCOs. For additional booster of patients immunity.

Emphasized handwashing.

Promoted maintenance of proper breastfeeding. Administered due medications as prescribed.

To protect from identified risk factors and intervene with pyrexia.

NURSING CARE PLAN

Assessment Subjective Cue: Medyo masakit po ang likod ko Objective Cues: - Facial grimace - Guarding on the left scapular area - Restlessness - With facial pain scale of 4/10 - V/S taken as follows: T: 38.2 C P: 82 bpm R: 20 cpm Nursing Diagnosis Acute pain related to trauma on the left scapular area Scientific explanation As a a vascular anti-inflammatory response, body releases antiinflammatory mediators causing pain. Reference: http://www.who.int/ csr/resources/ publications/ pyomyositis/01 223.pdf Planning Within 4 hours of effective nursing interventions patients pain will be relieved. Intervention Established rapport both with the mother and the patient. Monitored V/S Rationale To gain cooperation and trust Evaluation After 4 hours of rendering effective nursing interventions patient had reported of Pain may cause less pain AEB less alterations in V/S guarding on her left scapular area and had To improve quality, been smiling more frequency & location of frequently. pain. To alleviate pain.

Performed a comprehensive assessment of pain

Provided nonpharmacologic management like change of position & applying cold or warm compress as indicated Encouraged diversional activities Encouraged rest period Administered medications as ordered by physician.

To divert his attentions to the pain To prevent fatigue To alleviate pain.

DISCHARGE SUMMARY
M E T H
edications. Compliance on the prescribed take home medications with the right generic name, right dosage and preparation, right route and time of administration. xercise. Active ROM but prevent massaging nor any other traumatic pressure on the affected area. reatment. Compliance on the prescribed treatment. Cover the affected area with a wound gauze as pt has underwent surgery. Instructed proper wound care. ealth teachings. Emphasized proper handwashing and encouraged non pharmacological measures for fracture once re encountered (Rest, Ice or Cold Compress, Compression bandage, Elevate affected part) utpatient follow up visit. Attend on the scheduled outpatient follow up visit. iet. Consume foods rich in Vitamin C such as fruits for boosting of immunity, protein such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy products for bone growth.

O D

REFERENCES
http://hopkins-abxguide.org/diagnosis/soft_tissue/pyomyositis.html?contentInstanceId=255446 Zafar, Mohammed. Infectious Myositis. http:// www.yahoo.com// May 18, 2010 Scapula. http:// www. wikipedia.com// Lippincott. Nursing 2008 Drug Handbook. 28th Edition. 2008 Doenges, M. et al. Nurses Pocket Guide. 11th Edition. 2008

Saint Michaels College of Laguna

School of Nursing and Midwifery

Old National Highway, Platero, City of Binan, Laguna AY 2010-2011
[Year]

In Partial Fulfillment for the requirements in NCM 104 RLE

PYOMYOSITIS
Case Study

Submitted to: MRS. ELLA R. ASTETE, RN MAN

Built In Clinical Instructor Supervisor, Philippine Orthopedic Center

Submitted by: COSICO, Marineth April A.

BSN4A, SMCL

Saint Michaels College of Laguna

School of Nursing and Midwifery

Old National Highway, Platero, City of Binan, Laguna AY 2010-2011
[Year]

In Partial Fulfillment for the requirements in NCM 104 RLE

POTTS DISEASE

Submitted to: MRS. ELLA R. ASTETE, RN MAN

Built In Clinical Instructor Supervisor, Philippine Orthopedic Center

Submitted by: COSICO, Marineth April A.

BSN4A, SMCL

POTTS DISEASE
Synonyms: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease Pott's disease is named after Percival Pott (1714-1788), an eighteenth century surgeon who was considered an authority in issues related to the back and spine in London. Potts disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Potts disease is the most common site of bone infection in TB; hips and knees are also often affected. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. . The commonest area affected is T10 to L1. Epidemiology Pott's disease in developing countries it represents about 2% of cases of tuberculosis and 40 to 50% of musculoskeletal tuberculosis. Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting richer ones. The disease affects males more than females in a ratio of between 1.5 and 2:1. Risk factors Endemic tuberculosis. Poor socio-economic conditions. Historical exposure on infections Mortality/Morbidity Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (35-45%). In other series, proportions are similar but favor lumbar spine involvement Approximately 10% of Pott disease cases involve the cervical spine. Pathophysiology Pott disease is usually secondary to an extraspinal source of infection. The source of infection is usually outside the spine. It is most often spread from the lungs via the blood. The basic lesion involved in Pott disease is a combination of osteomyelitis and arthritis that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected. Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site. If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as it is avascular and cannot receive nutrients. Progressive bone destruction leads to vertebral collapse and kyphosis or Potts curvature. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. The kyphotic deformity is caused by collapse in the

anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin. Clinical Manifestations The onset is gradual. Localised back pain Paravertebral swelling may be seen Systemic signs and symptoms of tuberculosis may be present (fever, night sweats, anorexia, weight loss) Neurological signs may occur, leading to paraplegia. o Cervical spine tuberculosis causes severe neurologic complications characterized by pain and stiffness, dysphagia or stridor, retropharyngeal abscess, torticollis, hoarseness, and neurologic deficits. o Lumbar spine tuberculosis is characterized with hip flexion. o Lower thoracic tuberculosis causes chest pain, and patient tends to have stiff spine, erected gait and dislikes sitting. Back pain is localised. May include kyphosis, gibbus or Potts curvature (pathognomonic sign) A psoas abscess may present as a lump in the groin and resemble a hernia: o There is a tender swelling below the inguinal ligament and they are usually apyrexial. Nursing Assessments The examination should include the following: o Careful assessment of spinal alignment o Inspection of skin, with attention to detection of sinuses o Abdominal evaluation for subcutaneous flank mass o Meticulous neurologic examination Alert for abscess. Monitor patients body weight and appetite record. May provide some diversional therapies. Diagnostic Exams The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). Strongly positive Mantoux skin test. Tuberculin skin test (purified protein derivative [PPD]) results are positive. Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space. MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present.

Medical Management Duration of antituberculosis treatment (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol): o If debridement and fusion with bone grafting are performed, treatment can be for six months o If debridement and fusion with bone grafting are NOT performed a minimum of 12 months treatment is required. Immobilisation of the spine is usually for 2 or 3 months (bed rest, Taylor Brace, head halter, pelvic strap). Paraplegia resulting from the active disease causing cord compression usually responds well to chemotherapy (6-9 months). Surgical Management Anterior Decompression Spinal Fusion. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression. Prevention As for all tuberculosis, BCG vaccination. Improvement of socio-economic conditions.

References:
http://www.bsac.org.uk/pyxis/Bone%20and%20joint/Potts%20disease/Potts%20disease.htm http://www.wisegeek.com/what-is-potts-disease.htm