Infectious Myositis

Overview
Background:
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. For a
detailed discussion of HIV-associated myopathies, refer to HIV-1 Associated Myopathies.
Pathophysiology:
Single or multiple muscle groups in the limbs can be involved, a notable exception
being trichinosis, which commonly involves orbital muscles. In most instances,
involvement of proximal muscles is predominant. Characteristic myopathic features
and findings of polymyositis, including inflammatory infiltrates, may be seen.
- Viruses:
Viruses implicated in the pathogenesis of myositis include HIV-1, human T
lymphotrophic virus 1 (HTLV-1), influenza, coxsackieviruses, and echoviruses. As in
the nonHIV-infected population, HIV-associated polymyositis is most likely
autoimmune in origin. Influenza myositis could be due to direct viral invasion or
autoimmune response.
- Pyomyositis:
The pathogenesis is unclear, but trauma, viral infection, 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.
- Lyme borreliosis:
Musculoskeletal manifestations are noted frequently in Lyme borreliosis. The disease
is transmitted by the bites of ticks of the Ixodes genus that carry the spirochete (see
image below). The animal reservoirs are the white-footed mouse in the Eastern
United States and the wood rat in California. Human infection results from the bite of
infected ticks in the late spring and early summer. Lyme myositis may result from
direct invasion of muscle by the spirochete Borrelia burgdorferi or by autoimmune
mechanisms.
- American trypanosomiasis:
The causative organism is a protozoan, Trypanosoma cruzi. The insect vectors are reduviid
bugs such as Rhodnius prolixus ("vinchuca"), Triatoma infestans, and Panstrongylus megistus. The insect
defecates on the host's 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). The parasite reproduces asexually 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.
- Cysticercosis:
Myositis 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. Another mode of infection is by contamination of
food and water by feces containing the eggs of the tapeworm. The larvae migrate
throughout the body and may form fluid-filled cysts in a variety of tissues, including
muscle.
Epidemiology
Pyomyositis : Approximately 676 cases have been reported in the US literature since
1971.
Lyme disease
: Endemic areas include the Northeast, mainly Connecticut,
Massachusetts, Maryland, and New York; the North-Central region, mainly Wisconsin
and Minnesota; and the West Coast, especially Northern California.

In eastern Uganda, 400-900 cases of tropical myositis occur per year; it is rare in
western Kenya.
Cysticercosis is most prevalent in India, Eastern Europe, Central America, and
Mexico.
In endemic areas of Latin America, 8% of the population is seropositive for American
trypanosomiasis.
Mortality/Morbidity : A potentially life-threatening complication of pyomyositis is
toxic shock syndrome.
Rhabdomyolysis can complicate influenza and, rarely, coxsackievirus myositis.
Race : In Hawaii, muscle abscesses were noted to be confined to the Polynesians.In
the French Pacific islands, the disease is not seen in the French settlers.
Sex : Infectious myositis has a male predominance.
Age : Infectious myositis typically is seen in young adults.

Clinical Presentation
-

Risk factors for Staphylococcus aureus pyomyositis - Strenuous activity, muscle trauma, skin
infections, infected insect bites, illicit drug injections, connective tissue disorders,
and diabetes
Overseas travel
Consumption of poorly cooked meats (especially pork products in the case of
trichinosis or cysticercosis)
Tick bites
Pyomyositis ,Fever and malaise
Psoas abscess - Subtle symptoms such as fever and flank and hip pain; may manifest
as pyrexia of unknown origin
Trichinosis -Myalgia, periorbital swelling, and fever . Depending on site of involvement
- Diplopia, dysarthria, dysphagia, dyspnea
Lyme myositis -Pain and weakness of the proximal muscle groups.Symptoms in the
vicinity of skin lesions or in limb muscles
Cysticercosis with myositis - Fever, myalgias
Trypanosomiasis with myositis
Acute stage :: May be asymptomatic or characterized by fever.Myositis
occurring in the early stage of infection - Symptoms such as muscle weakness and
myalgias mimicking those of polymyositis
Chronic stage:: Myalgias
Toxoplasma myositis - Fever, myalgias, and muscle weakness
Influenza myositis - Childhood and adult forms recognized
Childhood form :Fever, malaise, and rhinorrhea followed 1-7 days later by
severe pain, especially in the calves.Muscle pain worse with movement,
especially with walking.Symptoms of myositis - Generally last 1-7 days
Adult form :: Fever, myalgias, generalized weakness.Muscle swelling in some
patients
Acute coxsackievirus myositis
Group A virus infection - Myalgias, weakness
Group B virus infection - Causes epidemic pleurodynia (Bornholm disease or
epidemic myalgia), which is considered a form of myositis .This is an acute, febrile
disorder with abrupt onset of pain in the abdomen or lower thoracic region.Pain can
be referred to the back and shoulders.Pain is worse with movement, breathing, or
coughing.
Fungal myositis ::Most often seen in severely immunosuppressed patients.Clinical
presentation is similar to pyomyositis
Cryptococcal myositis -Rare cause of myositis.Most involve immunocompromised
patients.Symptoms overlap those of bacterial myositis.Often present with lower
extremity pain and swelling.May involve the paraspinal musculature

 Physical
- Pyomyositis : Muscles are painful, swollen, tender, and indurated.Quadriceps muscle
is involved most commonly.The second most common location is the psoas muscle,
followed by the upper extremities.
Depending on the site of involvement, it may mimic appendicitis (psoas muscle),
septic arthritis of the hip (iliacus muscle), or epidural abscess (piriformis muscle).
This may be difficult to distinguish clinically from inflammatory myopathy.Findings
may be subtle in immunocompromised persons requiring a high index of suspicion
for diagnosis.
- Trichinosis -Involvement of orbital muscles can result in diplopia and
strabismus.Dysarthria or dysphagia can result when tongue and pharyngeal muscles
are affected.Limb muscles usually are mildly involved.
Other manifestations include myocarditis and dyspnea from diaphragmatic
involvement.
- Lyme myositis -Weakness and atrophy of the proximal muscle groups can occur,
accompanied by local swelling and tenderness.Muscle weakness may be a major
presenting feature of this disease.
Rarely, late ocular involvement, including orbital myositis may occur.
-

Cysticercosis with myositis -The most common sites of involvement are the skeletal
and cardiac muscle, brain, and eyes.When skeletal muscles are involved, palpable
cysticerci (mature larvae) appear in subcutaneous tissues.A notable feature of this
type of myositis is muscle pseudohypertrophy, which may be seen in the tongue or
calf muscles.During the acute stage of disease, patients may have fever and muscle
tenderness.
Trypanosomiasis with myositis -The acute stage of the disease may be characterized
by fever, lymphadenopathy, and hepatosplenomegaly.At the site of the insect bite,
local inflammation (involving subcutaneous tissues and muscle) results in a swelling
known as a chagoma. Contamination of the eyes produces unilateral periocular and
palpebral edema with conjunctivitis and preauricular lymphadenopathy (Romaa).
Extraocular involvement is rare. It may present with features of subacute orbital
myositis and may mimic an orbital tumor.During the acute parasitemic stage,
intense infection of the myocardium may occur, producing severe myocarditis and
disturbances of cardiac conduction.
Clinical manifestations in the early stage of myositis include muscle weakness,
tenderness, and erythema mimicking those of polymyositis and dermatomyositis.
Skeletal muscle may be involved in the chronic stage as well and can last for
decades.
Toxoplasma myositis -Muscle invasion by Toxoplasma gondii usually is seen in
immunocompromised individuals with disseminated toxoplasmosis.The clinical
features are similar to those of polymyositis, with manifestations of fever and muscle
weakness.Polymyositis is a prominent feature even in the congenital form of
toxoplasmosis.
Influenza myositis -Muscle weakness, tenderness, and swelling .More severe in adults
Proximal muscles are affected predominantly.In children, involvement of the
gastrocnemius-soleus muscles causes calf pain and difficulties with walking( toewalking, wide-based gait) .Complications include myocarditis and respiratory
dysfunction.
Acute coxsackievirus myositis
Group A virus -These viruses can cause an acute, diffuse inflammatory
myopathy.This may progress to rhabdomyolysis and myoglobinuria, leading to
renal failure.
Group B virus infection (epidemic myalgia)- Muscle tenderness and swelling
may be noted in some patients.Relapses can occur 2 weeks to a few months
after the initial presentation.
Fungal myositis -Clinically presents with fever, rash, and muscle tenderness

Lower extremities are commonly involved.

Causes
Known pathogens include the following:
1- Viral - HIV-1 (one of the most common causes of myositis), HTLV-1, cytomegalovirus,
group B coxsackievirus (epidemic myalgia), influenza
2- Bacterial -S aureus (most common, 70%); Streptococcus viridans; Streptococcus pyogenes; Streptococcus
pneumoniae[5] ; Salmonella enteritidis; Klebsiella pneumoniae; Clostridium freundii; Bartonella; gram-negative
organisms including Escherichia coli,Pseudomonas aeruginosa, Neisseria species , Yersinia species ,
Morganella morganii, and Citrobacter species
3- Spirochetal -B burgdorferi
4- Mycobacterial -Mycobacterium avium-intracellulare complex
5- Parasitic -T gondii, Trichinella spiralis, Trichinella nativa (from eating bear meat), T nelsoni, T britovi, T pseudospiralis,
Echinococcus granulosus, T solium, T cruzi, microsporidia
6- Fungal -Cryptococcus neoformans, Candida species (especially Candida tropicalis, Candida krusei, Candida
albicans) , Histoplasma capsulatum, Coccidioides species , Aspergillus species , Pneumocystis jiroveci, Fusarium
species, and Actinomyces species; less common are mucormycosis, Sporothrix schenckii, and
Blastomyces dermatitidis

Differential Diagnoses
Acute Inflammatory Demyelinating Polyradiculoneuropathy
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Dermatomyositis/Polymyositis
Femoral Mononeuropathy
HIV-1 Associated Myopathies
HIV-1 Associated Neuromuscular Complications (Overview)
Metabolic Myopathies
Paraneoplastic Autonomic Neuropathy

Work-up

Laboratory StudiesLeukocytosis
Elevated erythrocyte sedimentation rate (ESR)
Serum creatine kinase (CK) and aldolase usually normal
Blood culture results generally negative
Purulent material for Gram stain, anaerobic and aerobic cultures, antimicrobial
sensitivity testing
Trichinosis :: Eosinophilia is suggestive of the diagnosis.Laboratory tests may also
reveal leukocytosis, elevated immunoglobulin E, and increased muscle enzymes.A
rising antibody titer is highly suggestive of the disease.Serology of Viral IgM and IgG
titers.
Toxoplasmal antibodies
Lyme antibody titer: If enzyme-linked immunosorbent assay (ELISA) screening test
result is positive, confirm with a Western blot test.
Cysticercosis Electrocardiogram
HTLV-1 infection - Serological tests to detect HTLV-1 antibodies in serum
Trypanosomiasis :: Serological tests - ELISA (highly sensitive) or direct agglutination
test
Influenza myositis :: Elevated CK, mostly consisting of the MM (muscle) isoenzyme,
as high as 500 times normal
Urine myoglobin - May be positive

Liver enzymes (aspartate aminotransferase [AST] and lactate dehydrogenase [LDH])

- May be elevated
Detection of virus with polymerase chain reaction (PCR) testing of nasopharyngeal
specimens
Coxsackievirus myositis :: Rising coxsackievirus IgG antibody titers
Isolation methods for group B coxsackievirus - Include inoculation of cell cultures
Cryptococcal myositis :: Muscle biopsy may reveal intracytoplasmic organisms
Alcian blue or mucicarmine stains may identify polysaccharide capsule.Serology Positive cryptococcal serum antigen
Fungal myositis - Fungal stain and culture

Imaging Studies
- Pyomyositis ::
MRI is the imaging modality of choice for the diagnosis of pyomyositis. MRI is helpful
in differentiating pyomyositis from osteomyelitis. It is especially useful in
differentiating early muscle inflammation from abscess formation. MRI is also the
best imaging modality for evaluation of pelvic infections. [6]
CT scanning may show hypertrophy of involved muscle groups and effacement of the
fat planes. Contrast enhancement may indicate abscess formation. CT is also useful
for distinguishing tumors and hematomas from abscess.
Ultrasound or MRI also may be used to localize involved muscle.
Gallium scan is useful for localization in the early stages of illness.
-

Tuberculous pyomyositis -MRI: Findings are consistent with an abscess (ie, low signal
intensity on T1-weighted images and high signal intensity on T2-weighted images of
affected muscles). Following gadolinium infusion, peripheral rim enhancement is
noted. This is indicated by subtle hyperintensity on T1-weighted images and
hypointensity on T2-weighted images.
Cysticercosis with orbital involvement: Multiplanar imaging with MRI may be
obtained to identify a cyst with a mural nodule. With gadolinium, a nodule shows
intense enhancement.
Trichinosis :: Imaging of soft tissue or muscles may demonstrate the calcified lesions
with classic "puffed rice" or "spindle-shaped" radiographic appearance. MRI, CT, and
ultrasonography may show a clear cyst with a scolex.MRI is superior at
demonstrating the cysts in the soft tissues.Calcifications are best visualized on CT
scans.
Trichinosis: Skin test with trichinellar antigen is unreliable.

Procedures
- HIV polymyositis: Electromyography (EMG) findings are similar to those of idiopathic
polymyositis.
Short-duration motor unit potentials.Low-amplitude polyphasic motor unit
potentials.Fibrillations
- Trichinosis: EMG may reveal fibrillation potentials.
- Lyme myositis: Changes of denervation may be seen in the involved muscles.
- Pyomyositis: Needle aspiration is useful for the detection of purulent material and for
microbiologic identification of the causative organism.
Histologic Findings
- Trichinosis-Muscle biopsy is required to confirm diagnosis. Findings in the acute stage
of larval invasion of the muscles include segmental necrosis and interstitial infiltrates
composed mainly of eosinophils. The Trichinella species larvae sometimes can be seen
in the muscle biopsy. However, encapsulated cysts (without larvae), granulomas, and
focal calcification are more likely to be encountered.

Pyomyositis-Widespread necrosis of muscle fibers, perimysium, and blood vessels is

noted. Pleomorphic inflammatory response consisting of both neutrophils and
lymphocytes is noted.
Cysticercosis-The viable larvae produce little or no tissue reaction. However, rupture
or death of a cysticercus (mature larva) evokes an acute inflammatory response with
a pleomorphic exudate composed of neutrophils and eosinophils. Over time, fibrous
tissue encapsulates the cysts. A chronic granulomatous response may surround the
cysts.
Lyme myositis-Muscle biopsy shows atrophic fibers and an infiltrate consisting of
lymphocytes, plasma cells, and macrophages. Borrelia burgdorferi can be detected in
muscle fibers by the modified Dieterle silver stain method.
Trypanosomiasis-Sections of infected tissues may reveal clusters of amastigotes in
muscle cells surrounded by acute or chronic inflammation.
Influenza myositis-Muscle fiber necrosis without inflammatory change is observed.
Influenza viral particles have been identified in muscle fibers under electron
microscopy. Muscle fiber regeneration is seen in some, with an inflammatory
response consisting of mononuclear and polymorphonuclear leukocytes.
Fungal myositis-Muscle biopsy is needed to confirm diagnosis. Budding yeast and
pseudohyphae may be seen.

Treatment

Medical Care-All medical care should be provided in conjunction with an infectious

disease specialist and the primary care physician.
- HIV polymyositis: Corticosteroids remain the mainstay of treatment of polymyositis.
- Trichinosis :Thiabendazole is effective if administered within 24 hours of infection. It
has minimal effect in established infection.Optimal dosage has not been
established.It can be combined with prednisone 40-60 mg/day in patients with
severe pain and weakness.
- Trypanosomiasis :Benznidazole is a trypanocidal drug that is quite effective in the
acute phase of the illness.It reduces cardiac complications and parasitemia and has
been found to be beneficial in the early chronic phase.Successful treatment is
evinced by serological tests remaining negative for at least 1 year after conclusion of
treatment.
- Viral myositis -Treatment comprises bed rest, intravenous fluids, and symptomatic
management with antipyretics and analgesics.Antiviral agents such as amantadine
could be considered in adults.
- Pyomyositis -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).
- Fungal myositis: Use an antifungal agent such as amphotericin B or an echinocandin
such as caspofungin.
Surgical Care
- Pyomyositis: During the suppurative phase, abscess aspiration under ultrasonic or CT
guidance may be required. Surgical drainage is especially necessary for large
abscesses.
- Fungal myositis: Focal fungal abscesses may require surgical drainage/debridement.
- Medication Summary-Treat the underlying cause of infectious myositis. Use
appropriate antibiotics for pyomyositis. Prednisone may be effective to treat HIV-1
associated polymyositis.[7]
- Corticosteroids-These agents decrease inflammatory reactions by reversing
increased capillary permeability and suppressing PMN activity.Can be used for HIV-1
associated polymyositis. Use in combination with thiabendazole for trichinosis.

Anthelmintic-Parasite biochemical pathways are sufficiently different from those of

the human host to allow selective interference by chemotherapeutic agents in
relatively small doses. Treats trichinosis infections; inhibits helminth-specific
mitochondrial fumarate reductase; alleviates symptoms of trichinosis during invasive
phase. Little value in disease that spreads beyond lumen of intestines; absorption
from GI tract is poor. May be useful in early stages of trichinosis. Causes worm death
by selectively and irreversibly blocking uptake of glucose and other nutrients in
susceptible adult intestine where helminths dwell.
- Antibiotics-Empiric antimicrobial therapy must be comprehensive and should cover
all likely pathogens in the context of the clinical setting.
For treatment of Lyme myositis. Treats gram-positive and gram-negative organisms
as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial
protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Drug of
choice for most neurologic manifestations of Lyme disease; third-generation
cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against
gram-positive organisms; higher efficacy against resistant organisms. Arrests
bacterial growth by binding to penicillin-binding proteins. Can be used for treatment
of pyomyositis. Semisynthetic cephalosporin effective against: S aureus (including
penicillinase-producing strains), Staphylococcus epidermidis, group A beta-hemolytic
streptococci, and other strains of streptococci.
For treatment of severe infections caused by methicillin-resistant (beta-lactamresistant) staphylococci; and for treatment of staphylococcal infection in individuals
allergic to penicillin or cephalosporins.

Deterrence/Prevention
Prevent trichinosis and cysticercosis by adequately processing pork.When traveling
in endemic areas of Latin America, apply insect repellents such as N -diethyl-metatoluamide (DEET) to avoid American trypanosomiasis. Pyrethrin insecticides also
may be used to kill insect vectors. Using bed nets to keep away insects is advisable.
Complications
Influenza, echovirus, Legionella, and, rarely, coxsackievirus myositis can be complicated
by rhabdomyolysis.
Pyomyositis: Life-threatening complications include sepsis and toxic shock
syndrome.
Gas gangrene usually follows penetrating injuries complicated by clostridial
pyomyositis.
Trichinosis :Heavy infestation may be fatal because of myocarditis and/or
diaphragmatic involvement.
Myocarditis can lead to cerebral embolism.

Prognosis
-

Pyomyositis: Prompt administration of antibiotics can result in complete resolution.

Trichinosis: Most patients with myopathic involvement recover after several weeks.
Infection may be fatal if severe and involving other organs systems (eg, cardiac,
pulmonary, CNS).