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 eMedicine article 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 non–HIV-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.3

Ixodes scapularis (dammini), tick vector for Lyme disease. Courtesy of Centers for Disease
Control and Prevention.

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 cruzioccurs 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.
Trypanosoma cruzi in blood smear. Courtesy of Centers for Disease Control and Prevention.

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.

Frequency
United States

• 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.

International

• 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

History

• Key historical points should be confirmed.

o Risk factors for Staphylococcus aureus pyomyositis - Strenuous activity, muscle trauma,
skin infections, infected insect bites, illicit drug injections, connective tissue disorders,
and diabetes
o Overseas travel
o Consumption of poorly cooked meats (especially pork products in the case of trichinosis
or cysticercosis)
o Tick bites
• Pyomyositis
o Fever and malaise
o Psoas abscess - Subtle symptoms such as fever and flank and hip pain; may manifest as
pyrexia of unknown origin
• Trichinosis
o Cardinal features - Myalgia, periorbital swelling, and fever (see following image)
o

A patient with trichinosis and ocular involvement. Courtesy of Centers for

Disease Control and Prevention and Dr. Thomas F. Sellers, Jr.

o Depending on site of involvement - Diplopia, dysarthria, dysphagia, dyspnea

• Lyme myositis
o Pain and weakness of the proximal muscle groups
o Symptoms in the vicinity of skin lesions or in limb muscles
• Cysticercosis with myositis - Fever, myalgias
• Trypanosomiasis with myositis
o 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
o Chronic stage - Myalgias
• Toxoplasma myositis - Fever, myalgias, and muscle weakness
• Influenza myositis - Childhood and adult forms recognized
o 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
o Adult form
 Fever, myalgias, generalized weakness
 Muscle swelling in some patients
• Acute coxsackievirus myositis
o Group A virus infection - Myalgias, weakness
o 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.
• Cryptococcal myositis
o Rare cause of myositis
o Most involve immunocompromised patients
o Symptoms overlap those of bacterial myositis
o Often present with lower extremity pain and swelling
o May involve the paraspinal musculature

Physical

• Pyomyositis
o Muscles are painful, swollen, tender, and indurated.
o Quadriceps muscle is involved most commonly.
o The second most common location is the psoas muscle, followed by the upper
extremities.
o Depending on the site of involvement, it may mimic appendicitis (psoas muscle), septic
arthritis of the hip (iliacus muscle), or epidural abscess (piriformis muscle).
o This may be difficult to distinguish clinically from inflammatory myopathy.
o Findings may be subtle in immunocompromised persons requiring a high index of
suspicion for diagnosis.
• Trichinosis
o Involvement of orbital muscles can result in diplopia and strabismus.
o Dysarthria or dysphagia can result when tongue and pharyngeal muscles are affected.
o Limb muscles usually are mildly involved.
o Other manifestations include myocarditis and dyspnea from diaphragmatic involvement.
• Lyme myositis
o Weakness and atrophy of the proximal muscle groups can occur, accompanied by local
swelling and tenderness.
o Muscle weakness may be a major presenting feature of this disease.
o Rarely, late ocular involvement, including orbital myositis4 , may occur.
• Cysticercosis with myositis
o The most common sites of involvement are the skeletal and cardiac muscle, brain, and
eyes.
 o When skeletal muscles are involved, palpable cysticerci (mature larvae) appear in
subcutaneous tissues.
o A notable feature of this type of myositis is muscle pseudohypertrophy, which may be
seen in the tongue or calf muscles.
o During the acute stage of disease, patients may have fever and muscle tenderness.
• Trypanosomiasis with myositis
o The acute stage of the disease may be characterized by fever, lymphadenopathy, and
hepatosplenomegaly.
o At the site of the insect bite, local inflammation (involving subcutaneous tissues and
muscle) results in a swelling known as a chagoma.
o Contamination of the eyes produces unilateral periocular and palpebral edema with
conjunctivitis and preauricular lymphadenopathy (Romaña).
o Extraocular involvement is rare. It may present with features of subacute orbital myositis
and may mimic an orbital tumor.
o During the acute parasitemic stage, intense infection of the myocardium may occur,
producing severe myocarditis and disturbances of cardiac conduction.
o Clinical manifestations in the early stage of myositis include muscle weakness,
tenderness, and erythema mimicking those of polymyositis and dermatomyositis.
o Skeletal muscle may be involved in the chronic stage as well and can last for decades.
• Toxoplasma myositis
o Muscle invasion by Toxoplasma gondii usually is seen in immunocompromised
individuals with disseminated toxoplasmosis.
o The clinical features are similar to those of polymyositis, with manifestations of fever and
muscle weakness.
o Polymyositis is a prominent feature even in the congenital form of toxoplasmosis.
• Influenza myositis
o 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( toe-walking, wide-based gait)
 Complications include myocarditis and respiratory dysfunction.
• Acute coxsackievirus myositis
o Group A virus
 These viruses can cause an acute, diffuse inflammatory myopathy.
 This may progress to rhabdomyolysis and myoglobinuria, leading to renal failure.
o 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.

Causes
Known pathogens include the following:

• Viral - HIV-1 (one of the most common causes of myositis), HTLV-1, cytomegalovirus, group B
coxsackievirus (epidemic myalgia), influenza
• Bacterial -S aureus (most common, 70%); Streptococcus viridans; Streptococcus
pyogenes;Streptococcus pneumoniae5 ; Salmonella enteritidis; Klebsiella
 pneumoniae; Clostridium freundii;Bartonella; gram-negative organisms including Escherichia
coli, Pseudomonas aeruginosa, Neisseriaspecies , Yersinia species , Morganella
morganii, and Citrobacter species
• Spirochetal -B burgdorferi
• Mycobacterial -Mycobacterium avium-intracellulare complex
• Parasitic -T gondii, Trichinella spiralis, Trichinella nativa (from eating bear meat), T nelsoni, T
britovi, T pseudospiralis, Echinococcus granulosus, T solium, T cruzi, microsporidia
• Fungal -Cryptococcus neoformans, Candida species , Histoplasma capsulatum,
Coccidioides species , Aspergillus species , Pneumocystis jiroveci, Fusarium species , and
actinomyces

Laboratory Studies

• Pyomyositis
o Leukocytosis
o Elevated erythrocyte sedimentation rate (ESR)
o Serum creatine kinase (CK) and aldolase usually normal
o Blood culture results generally negative
o Purulent material for Gram stain, anaerobic and aerobic cultures, antimicrobial sensitivity
testing

Imaging Studies

• Pyomyositis
o 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
o 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.
o Ultrasound or MRI also may be used to localize involved muscle.
o Gallium scan is useful for localization in the early stages of illness.

• Pyomyositis
o Promptly administer systemic antibiotics. This could eliminate the need for surgical
drainage in selected cases.
o The choice of antibiotic is determined by identification of the causative organism.
o 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
Pyomyositis: During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be
required. Surgical drainage is especially necessary for large abscesses.

Consultations
 • Neurologist
• 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.

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.