infectious myositis is an acute, subacute, or chronic infection of skeletal muscle.

Once considered a
tropical disease, it is now seen in temperate climates as well, particularly with the emergence of HIV
infection.
1,2
In addition to HIV, other viruses, bacteria including mycobacteria!, fungi, and parasites can
cause myositis. "or a detailed discussion of HIV#associated myopathies, refer to e$edicine article HIV#1
%ssociated $yopathies.
Pathophysiology
&ingle or multiple muscle groups in the limbs can be involved, a notable e'ception being trichinosis, which
commonly involves orbital muscles. In most instances, involvement of pro'imal muscles is predominant.
(haracteristic myopathic features and findings of polymyositis, including inflammatory infiltrates, may be
seen.
Viruses) Viruses implicated in the pathogenesis of myositis include HIV#1, human * lymphotrophic virus 1
H*+V#1!, influen,a, co'sackieviruses, and echoviruses. %s in the non-HIV#infected population, HIV#
associated polymyositis is most likely autoimmune in origin. Influen,a myositis could be due to direct viral
invasion or autoimmune response.
.yomyositis) *he pathogenesis is unclear, but trauma, viral infection, and malnutrition have been
implicated. %lthough 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.
+yme borreliosis) $usculoskeletal manifestations are noted fre/uently in +yme borreliosis. *he disease is
transmitted by the bites of ticks of the Ixodes genus that carry the spirochete see image below!. *he
animal reservoirs are the white#footed mouse in the 0astern 1nited &tates and the wood rat in (alifornia.
Human infection results from the bite of infected ticks in the late spring and early summer. +yme myositis
may result from direct invasion of muscle by the spirochete Borrelia burgdorferi or by autoimmune
mechanisms.
2
Ixodes scapularis (dammini), tick vector for Lyme disease. Courtesy of Centers for Disease
Control and Prevention.
%merican trypanosomiasis) *he causative organism is a proto,oan, Trypanosoma cruzi. *he insect
vectors are reduviid bugs such as Rhodnius prolixus 3vinchuca3!, Triatoma infestans, and Panstrongylus
megistus. *he insect defecates on the host4s skin as it feeds, contaminating the bite wound with feces
containing the parasites. T cruzioccurs in 2 forms in humans, the intracellular amastigote and the
trypomastigote form in blood, which is ingested by the insects see image below!. *he parasite
reproduces ase'ually and migrates to the hindgut. In humans, the parasite loses its flagellum and
transforms into the amastigote form, which may enter muscle and multiply, resulting in myositis.
rypanosoma cru!i in "lood smear. Courtesy of Centers for Disease Control and Prevention.
(ysticercosis) $yositis also can occur in cysticercosis, which represents an infection by the larval stage of
the intestinal tapeworm Taenia solium. Human infection results from ingestion of raw or incompletely
cooked pork. %nother mode of infection is by contamination of food and water by feces containing the
eggs of the tapeworm. *he larvae migrate throughout the body and may form fluid#filled cysts in a variety
of tissues, including muscle.
#re$uency
%nited &tates
.yomyositis) %ppro'imately 565 cases have been reported in the 1& literature since 1761.
+yme disease) 0ndemic areas include the 8ortheast, mainly (onnecticut, $assachusetts,
$aryland, and 8ew 9ork: the 8orth#(entral region, mainly ;isconsin and $innesota: and the
;est (oast, especially 8orthern (alifornia.
International
In eastern 1ganda, <==#7== cases of tropical myositis occur per year: it is rare in western >enya.
(ysticercosis is most prevalent in India, 0astern 0urope, (entral %merica, and $e'ico.
In endemic areas of +atin %merica, ?@ of the population is seropositive for %merican
trypanosomiasis.
'ortality('or"idity
% potentially life#threatening complication of pyomyositis is to'ic shock syndrome.
Ahabdomyolysis can complicate influen,a and, rarely, co'sackievirus myositis.
)ace
In Hawaii, muscle abscesses were noted to be confined to the .olynesians.
In the "rench .acific islands, the disease is not seen in the "rench settlers.
&ex
Infectious myositis has a male predominance.
*ge
Infectious myositis typically is seen in young adults.
Clinical
+istory
>ey historical points should be confirmed.
o Aisk factors for Staphylococcus aureus pyomyositis # &trenuous activity, muscle trauma,
skin infections, infected insect bites, illicit drug inBections, connective tissue disorders,
and diabetes
o Overseas travel
o (onsumption of poorly cooked meats especially pork products in the case of trichinosis
or cysticercosis!
o *ick bites
.yomyositis
o "ever and malaise
o .soas abscess # &ubtle symptoms such as fever and flank and hip pain: may manifest as
pyre'ia of unknown origin
*richinosis
o (ardinal features # $yalgia, periorbital swelling, and fever see following image!
o
* patient ,ith trichinosis and ocular involvement. Courtesy of Centers for
Disease Control and Prevention and Dr. homas #. &ellers, -r.
o Cepending on site of involvement # Ciplopia, dysarthria, dysphagia, dyspnea
+yme myositis
o .ain and weakness of the pro'imal muscle groups
o &ymptoms in the vicinity of skin lesions or in limb muscles
(ysticercosis with myositis # "ever, myalgias
*rypanosomiasis with myositis
o %cute stage
$ay be asymptomatic or characteri,ed by fever
$yositis occurring in the early stage of infection # &ymptoms such as muscle
weakness and myalgias mimicking those of polymyositis
o (hronic stage # $yalgias
*o'oplasma myositis # "ever, myalgias, and muscle weakness
Influen,a myositis # (hildhood and adult forms recogni,ed
o (hildhood form
"ever, malaise, and rhinorrhea followed 1#6 days later by severe pain, especially
in the calves
$uscle pain worse with movement, especially with walking
&ymptoms of myositis # Denerally last 1#6 days
o %dult form
"ever, myalgias, generali,ed weakness
$uscle swelling in some patients
%cute co'sackievirus myositis
o Droup % virus infection # $yalgias, weakness
o Droup E virus infection # (auses epidemic pleurodynia Eornholm disease or epidemic
myalgia!, which is considered a form of myositis
*his is an acute, febrile disorder with abrupt onset of pain in the abdomen or
lower thoracic region.
.ain can be referred to the back and shoulders.
.ain is worse with movement, breathing, or coughing.
(ryptococcal myositis
o Aare cause of myositis
o $ost involve immunocompromised patients
o &ymptoms overlap those of bacterial myositis
o Often present with lower e'tremity pain and swelling
o $ay involve the paraspinal musculature
Physical
.yomyositis
o $uscles are painful, swollen, tender, and indurated.
o Fuadriceps muscle is involved most commonly.
o *he second most common location is the psoas muscle, followed by the upper
e'tremities.
o Cepending on the site of involvement, it may mimic appendicitis psoas muscle!, septic
arthritis of the hip iliacus muscle!, or epidural abscess piriformis muscle!.
o *his may be difficult to distinguish clinically from inflammatory myopathy.
o "indings may be subtle in immunocompromised persons re/uiring a high inde' of
suspicion for diagnosis.
*richinosis
o Involvement of orbital muscles can result in diplopia and strabismus.
o Cysarthria or dysphagia can result when tongue and pharyngeal muscles are affected.
o +imb muscles usually are mildly involved.
o Other manifestations include myocarditis and dyspnea from diaphragmatic involvement.
+yme myositis
o ;eakness and atrophy of the pro'imal muscle groups can occur, accompanied by local
swelling and tenderness.
o $uscle weakness may be a maBor presenting feature of this disease.
o Aarely, late ocular involvement, including orbital myositis
<
, may occur.
(ysticercosis with myositis
o *he most common sites of involvement are the skeletal and cardiac muscle, brain, and
eyes.
o ;hen skeletal muscles are involved, palpable cysticerci mature larvae! appear in
subcutaneous tissues.
o % notable feature of this type of myositis is muscle pseudohypertrophy, which may be
seen in the tongue or calf muscles.
o Curing the acute stage of disease, patients may have fever and muscle tenderness.
*rypanosomiasis with myositis
o *he acute stage of the disease may be characteri,ed by fever, lymphadenopathy, and
hepatosplenomegaly.
o %t the site of the insect bite, local inflammation involving subcutaneous tissues and
muscle! results in a swelling known as a chagoma.
o (ontamination of the eyes produces unilateral periocular and palpebral edema with
conBunctivitis and preauricular lymphadenopathy AomaGa!.
o 0'traocular involvement is rare. It may present with features of subacute orbital myositis
and may mimic an orbital tumor.
o Curing the acute parasitemic stage, intense infection of the myocardium may occur,
producing severe myocarditis and disturbances of cardiac conduction.
o (linical manifestations in the early stage of myositis include muscle weakness,
tenderness, and erythema mimicking those of polymyositis and dermatomyositis.
o &keletal muscle may be involved in the chronic stage as well and can last for decades.
*o'oplasma myositis
o $uscle invasion by Toxoplasma gondii usually is seen in immunocompromised
individuals with disseminated to'oplasmosis.
o *he clinical features are similar to those of polymyositis, with manifestations of fever and
muscle weakness.
o .olymyositis is a prominent feature even in the congenital form of to'oplasmosis.
Influen,a myositis
o $uscle weakness, tenderness, and swelling
$ore severe in adults
.ro'imal muscles are affected predominantly.
In children, involvement of the gastrocnemius#soleus muscles causes calf pain
and difficulties with walking toe#walking, wide#based gait!
(omplications include myocarditis and respiratory dysfunction.
%cute co'sackievirus myositis
o Droup % virus
*hese viruses can cause an acute, diffuse inflammatory myopathy.
*his may progress to rhabdomyolysis and myoglobinuria, leading to renal failure.
o Droup E virus infection epidemic myalgia!
$uscle tenderness and swelling may be noted in some patients.
Aelapses can occur 2 weeks to a few months after the initial presentation.
Causes
>nown pathogens include the following)
Viral # HIV#1 one of the most common causes of myositis!, H*+V#1, cytomegalovirus, group E
co'sackievirus epidemic myalgia!, influen,a
Eacterial #S aureus most common, 6=@!: Streptococcus viridans: Streptococcus
pyogenes:Streptococcus pneumoniae
H
: Salmonella enteritidis: lebsiella
pneumoniae: !lostridium freundii:Bartonella: gram#negative organisms including "scherichia
coli, Pseudomonas aeruginosa, #eisseriaspecies , $ersinia species , %organella
morganii, and !itrobacter species
&pirochetal #B burgdorferi
$ycobacterial #%ycobacterium avium&intracellulare complex
.arasitic #T gondii, Trichinella spiralis, Trichinella nativa 'from eating bear meat(, T nelsoni, T
britovi, T pseudospiralis, "chinococcus granulosus, T solium, T cruzi, microsporidia
"ungal #!ryptococcus neoformans, !andida species , )istoplasma capsulatum,
!occidioides species , *spergillus species , Pneumocystis +iroveci, ,usarium species , and
actinomyces
La"oratory &tudies
.yomyositis
o +eukocytosis
o 0levated erythrocyte sedimentation rate 0&A!
o &erum creatine kinase (>! and aldolase usually normal
o Elood culture results generally negative
o .urulent material for Dram stain, anaerobic and aerobic cultures, antimicrobial sensitivity
testing
Imaging &tudies
.yomyositis
o $AI is the imaging modality of choice for the diagnosis of pyomyositis. $AI is helpful in
differentiating pyomyositis from osteomyelitis. It is especially useful in differentiating early
muscle inflammation from abscess formation. $AI is also the best imaging modality for
evaluation of pelvic infections.
5
o (* scanning may show hypertrophy of involved muscle groups and effacement of the fat
planes. (ontrast enhancement may indicate abscess formation. (* is also useful for
distinguishing tumors and hematomas from abscess.
o 1ltrasound or $AI also may be used to locali,e involved muscle.
o Dallium scan is useful for locali,ation in the early stages of illness.
.yomyositis
o .romptly administer systemic antibiotics. *his could eliminate the need for surgical
drainage in selected cases.
o *he choice of antibiotic is determined by identification of the causative organism.
o %ntibiotics initially are given intravenously until clinical improvement is noted, followed by
oral antibiotics for a total course of 2 weeks eg, cefa,olin or ceftria'one IV followed by
cephale'in .O!.
&urgical Care
.yomyositis) Curing the suppurative phase, abscess aspiration under ultrasonic or (* guidance may be
re/uired. &urgical drainage is especially necessary for large abscesses.
Consultations
8eurologist
*reat the underlying cause of infectious myositis. 1se appropriate antibiotics for pyomyositis.
.rednisone may be effective to treat HIV#1-associated polymyositis.
6
Corticosteroids
*hese agents decrease inflammatory reactions by reversing increased capillary permeability and
suppressing .$8 activity.
What is pyomyositis?
Pyomyositis is a bacterial infection of the skeletal muscles. Abscesses form that are filled with pus
caused by a staph infection. More specifically, the bacteriumStaphylococcus aureus is the major
problem.
Pyomyositis can affect any skeletal muscle. Large muscle groups such as thequadriceps (muscles
along the front of the thigh), iliopsoas (muscle deep inside the pelvic cavity that flexes the hip),
orgluteal (buttock) muscles are commonly affected.
Pyomyositis is rare in healthy individuals. Trauma (sometimes just minor trauma) can start the
process that results in pyomyositis. Any immune system problems already present can prevent the
body from responding to overcome this infection. People with human immunodeficiency virus
infection (HIV), diabetes mellitus, cancer, connective-tissue diseases, and cirrhosis of the liver are at
increased risk.
Treatment is important. In fact, this is one time when the use of antibiotics early on is especially
important. The abscess within the muscle may need to be drained. This can be
donepercutaneously (through the skin) or with open surgery. Percutaneous aspiration (drawing the
pus and fluids out) is done through the guidance of computed tomography (CT) imaging. Draining
the abscess is a must if the antibiotic treatment is unsuccessful in clearing up the infection.
.athophysiology
&ingle or multiple muscle groups in the limbs can be involved, a notable e'ception being trichinosis, which
commonly involves orbital muscles. In most instances, involvement of pro'imal muscles is predominant.
(haracteristic myopathic features and findings of polymyositis, including inflammatory infiltrates, may be
seen.
Viruses) Viruses implicated in the pathogenesis of myositis include HIV#1, human * lymphotrophic virus 1
H*+V#1!, influen,a, co'sackieviruses, and echoviruses. %s in the non-HIV#infected population, HIV#
associated polymyositis is most likely autoimmune in origin. Influen,a myositis could be due to direct viral
invasion or autoimmune response.
.yomyositis) *he pathogenesis is unclear, but trauma, viral infection, and malnutrition have been
implicated. %lthough 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.
+yme borreliosis) $usculoskeletal manifestations are noted fre/uently in +yme borreliosis. *he disease is
transmitted by the bites of ticks of the Ixodes genus that carry the spirochete see image below!. *he
animal reservoirs are the white#footed mouse in the 0astern 1nited &tates and the wood rat in (alifornia.
Human infection results from the bite of infected ticks in the late spring and early summer. +yme myositis
may result from direct invasion of muscle by the spirocheteBorrelia burgdorferi or by autoimmune
mechanisms.
I2J
I'odes scapularis dammini!, tick vector for +yme disease. (ourtesy of (enters for
Cisease (ontrol and .revention.
%merican trypanosomiasis) *he causative organism is a proto,oan, Trypanosoma cruzi. *he insect
vectors are reduviid bugs such as Rhodnius prolixus 3vinchuca3!,Triatoma infestans, and Panstrongylus
megistus. *he insect defecates on the host4s skin as it feeds, contaminating the bite wound with feces
containing the parasites. T cruzi occurs in 2 forms in humans, the intracellular amastigote and the
trypomastigote form in blood, which is ingested by the insects see image below!. *he parasite
reproduces ase'ually and migrates to the hindgut. In humans, the parasite loses its flagellum and
transforms into the amastigote form, which may enter muscle and multiply, resulting in myositis.
*rypanosoma cru,i in blood smear. (ourtesy of (enters for Cisease (ontrol and
.revention.
(ysticercosis) $yositis also can occur in cysticercosis, which represents an infection by the larval stage of
the intestinal tapeworm Taenia solium. Human infection results from ingestion of raw or incompletely
cooked pork. %nother mode of infection is by contamination of food and water by feces containing the
eggs of the tapeworm. *he larvae migrate throughout the body and may form fluid#filled cysts in a variety
of tissues, including muscle.