Challenging case of tropical Pyomyositis with metastatic MRSA infection in a De Novo HIV Patient

Harish M M and team

Director-Institute of Critical Care Medicine, Kauvery Hospital, Marathahalli

Case Presentation

we have treated an obese (with undiagnosed OSA), middle-aged doctor who was previously fit. He travelled to Kumbh Mela around two months back. After 15 days of return, he started having pain around right shoulder joint with restricted movements, local neurologist diagnosed it to be having brachial plexus neuritis/GB syndrome and started on pulse dose steroid.

After couple of days, pain persisted and started having swelling around right deltoid. Ultrasound showed collection for which incision and drainage done from local surgeon. Post that, in the next 48 hours, he started having a right thigh pain.

Then they worried and reached us for infectious disease consultation.

Initial Management

First differential diagnosis came to us was tropical Pyomyositis (secondary to metastatic staphylococci aureus infection).

We done a whole body MRI (it was challenging since he had OSA, hypoxia and it took around 8 hr to complete the scan) which showed collection in his right deltoid region, left acromioclavicular joint, left gluteal region and right hip joint with right thigh involving anterior compartment with the around 600 to 700 ml of collection.

Intervention

Immediately planned for surgical intervention with good coverage for gram positive including the MRSA organism. In the due course, he had hypotension, persistent tachycardia and due to his rapid clinical deterioration we suspected underlying immunocompromised status and investigated appropriately, unfortunately it came positive for HIV.

Done with his CD4 count (140 cells/mm³) and his HIV viral load (significantly high >1 lac per ml).

Surgical Management for the patient with HIV

The real challenge was, it is a De novo detected HIV in critically ill patient which is having very poor outcome in terms of morbidity and mortality.

With all due explanation to the relatives he was been posted for surgery. After initial control of the source, we followed up his culture, as expected it grown MRSA in both pus and blood. So, it is a metastatic MRSA infection that is because of tropical Pyomyositis.

We ruled out infective endocarditis with echocardiography. He required multiple sessions of surgical interventions and followed up with multiple MRIs.

After a week we started him on antiretroviral therapy, but he had drug interactions, hyponatremia, acute kidney injury, persistent vomiting and decrease in appetite. We withheld ART, re looked into the source and definitive control has been achieved with satisfactory wound closure.

Conclusion

He was reinitiated on antiretroviral therapy and discharged home. This successful outcome is a shining example of exceptional team effort and patient-centered care. This case reminds us of the power of collaboration, vigilance, and perseverance in managing complex infections in immunocompromised patient.

Acknowledgement

  1. Gaurishankar for outstanding surgical management
  2. Entire team of anaesthesiology
  3. Satish and the radiology team for their detailed imaging support
  4. Prerana for psychological support to both the patient and family
  5. All ICU and Ward Team (Doctors, Lab Staff, Nurses, Physio, RT) Admin Team

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