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Type 2 Diabetes Complicated by Multiple Pyomyositis Masayasu Yonedaand Kiyoshi Oda

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Type 2 Diabetes Complicated by Multiple Pyomyositis Masayasu Yonedaand Kiyoshi Oda å¡ CASE REPORT å¡ Type 2 Diabetes Complicated by Multiple Pyomyositis Masayasu YONEDAand Kiyoshi Oda Abstract He had not undergone a routine medical check-up and his diabetes had not been detected. He felt pain in the left scapu- A40-year-old manwas hospitalized due to fever, mus- lar region from the beginning of August 2001 but left it un- cular swelling and pain. He had poorly controlled diabe- treated. From mid-August 2001, he developed pain in the left tes with many dental caries and repeated periodontitis. medial femoral region and right gluteal region with a fever CT revealed multiple intramuscular abscesses; adminis- of 38°C and decrease in body weight (10 kg per 2 weeks); he tration of antibiotics and pus drainage were performed. visited a neighborhood hospital on August 21. He was pre- Intraoral infection was suspected as the route of infection scribed nonsteroidal anti-inflammatory drugs (NSAIDs) but of pyomyositis, and a total of six teeth was extracted. In exhibited no improvement, and then visited our neurology the clinical treatment of diabetic patients, it is important department. There were no neurologically abnormal find- to instruct patients to routinely check for the presence of ings, but a gradually increasing mass was found in the region traumatic injuries of the lower extremities, and to have of the left breast with a casual blood glucose value of 380 routine check-ups and dental care to check for dental mg/dl. Therefore, he visited our outpatient department on caries or periodontitis. August 27, and was hospitalized on August 31 for detailed (Internal Medicine 42: 174-177, 2003) examination and treatment. Physical findings on admission: He was lucid with a Keywords: intramuscular abscess, intraoral infection, dental height of 173 cm, body weight of 58.1 kg, blood pressure of caries 114/70 mmHg, pulse of 72 beats/min (regular), body tem- perature of 37.2°C, no palpable body surface lymph nodes, and tender, palpable masses in the left scapular region, left medial femoral region, region of the left breast and right Introduction gluteal region. He had a normal heart sound or respiratory sound, and no abdominal region abnormalities, no edema of Diabetes mellitus is a systemic disease which mayde- the legs, normal deep tendon reflexes, and no abnormal find- velop various complications involving the eyes, kidneys, ings on chest X-ray. nerves, large vessels, etc. Infection is often a major problem, Laboratory findings on admission (Table 1): General in- especially in diabetic patients with poorly controlled blood flammatory findings such as elevated WBCand CRPand in- glucose. Weencountered a case of diabetes complicated by creased blood sedimentation rate were observed. He had multiple pyomyositis, a relatively rare complication of diabe- poorly controlled type 2 diabetes with a casual blood glucose tes which is uncommonin temperate regions like Japan. value of 633 mg/dl, hemoglobin Ale (HbAlc) of 10.5%, and urinary-connecting peptide reactivity (U-CPR) of 68.4|ug/ day, and anti-glutamic acid decarboxylase (GAD) antibody Case Report was negative. Examination for other autoantibodies revealed A 40-year-old manhad the chief complaints of muscular negative findings for antinuclear antibody and anti-DNA an- pain, left breast mass, fever and body weight loss. In his tibody. Examination revealed HBs-Agx2,560, HBs-Ab nega- family history, his father and paternal aunt had diabetes, and tive, HBe-Ag negative, HBe-Ab positive, HBV-DNA(TMA) his mother and maternal aunt had breast cancer. Hehad been below 3.7 LGE/ml, HCV-Ab negative, a-fetoprotein of 3.4 diagnosed hepatitis B virus-positive when he was in his ng/ml and hyaluronic acid of 20 ng/ml, indicating that he twenties. He had had many dental caries and often had re- was a HBVcarrier. peated periodontitis from his youth, but had left it untreated. Clinical course (Fig. 1): Chest CT (Fig. 2) examination From the Department of Internal Medicine, Metabolism and Endocrinology, Chugoku Rosai General Hospital, Kure Received for publication August 6, 2002; Accepted for publication November 22, 2002 Reprint requests should be addressed to Dr. Masayasu Yoneda, the Department of Internal Medicine, Metabolism and Endocrinology, ChugokuRosai General Hospital, 1-5-1 Hirotagaya, Kure, Hiroshima 737-0193 174 Internal Medicine Vol. 42, No. 2 (February 2003) Type 2 Diabetes Complicated by Multiple Pyomyositis Table 1. Laboratory Findings on Admission administration of the antibiotic was changed from intrave- C B C : nous drip infusion to oral administration. Since CT per- W B C 1 6 , 3 9 0 / u l A S T 2 1 IU /Z formed on Day 27 of hospitalization revealed that these N e u t . 8 2 . 4 % A L T 1 8 iu /z abscesses were decreased in size but remained in each mus- L y m . 1 3 .0 % L D H 1 6 7 IU /Z cle, administration of the antibiotics was continued. Intraoral M o n o . 3 . 9 % B U N 1 8 m g / d l infection was suspected as a route of infection, as no trau- E o s . 0 . 2 % C re 0 . 6 4 m g/ d l matic injuries were observed on the body but manydental B a s o . 0 . 5 % N a 1 3 0 -m E q /Z caries were observed. With relief from muscular pain and R B C 4 3 8 x l O 7 u l K 5 . 4 m E q // improvement of general condition, six teeth (right upper 7, H b 1 4 . 8 g / d l T -c h o 1 1 5 m g / d l H t 4 2 . 4 % T G 1 0 2 m g / d l right lower 7, left upper 6, left lower 4, 7, 8), which were im- P it 3 1. 6 x l O 7 u l C K 3 0 I U /Z possible to be preserved, were extracted, and intraoral irriga- E S R : 8 7 m m / h Uri naly sis : tion and disinfection wereperformed. Diabetic complications Bl o o d c h e m i st r y : g lu c o s e (+ + ) (retinopathy, nephropathy, and neuropathy) were not found. G l u 6 3 3 m g / d l p r o te in (- ) For treatment of diabetes, insulin therapy was introduced H b A l c 1 0 . 5 % o c cu lt (- ) using biphasic isophane insulin (Novolin 30R® or Pen fill C R P 1 7 . 9 m g / d l k eto n (ｱ ) 30R®), which was then switched to isophane insulin (Pen fill T P 8 . 6 g / d l U -C P R 6 8 . 4 u g / d a y N®). Finally by subcutaneous injection of isophane insulin A l b 3 . 4 g / d l U -A lb 2 8 . 3 m g / d a y (Pen fill N®) (24 units in the morning and 12 units in the eve- T - b i 1 0 . 7 m g / d l 2 4 h C cr 1 5 0 . 1 m l/m in ning), the patient achieved good control of blood glucose (fasting blood glucose of 100-120 mg/dl, 2-hr postprandial CBC: complete blood count, Neut; neutrophil, Lym.: Lym- blood glucose of 110-150 mg/dl, and 10/9 HbAlc of 6.3%) phocyte, Mono.: Monocyte, Eos.: Eosinocyte, Baso.: Baso- cyte, Ht: hematocrit, Pit: platelet, ESR: erythrocyte sedimen- and was discharged from the hospital on October 12. tation rate, Glu: glucose, TP: total protein, Alb: albumin, T- bil: total bilirubin, AST:aspartate aminotransferase, ALT: Discussion alanine aminotransferase, LDH:lactate dehydrogenase, BUN: blood urea nitrogen, Cre: creatinine, Na: natrium, K: potas- Pyomyositis is bacterial myositis occurring in skeletal sium, T-cho: total cholesterol, TG: triglyceride, CK: creatine muscle. This myositis is called "Tropical Pyomyositis" and kinase, U-Alb: urinary-albumin, 24hCcr: 24h creatinine clear- is commonin tropical regions but is relatively rare in tem- ance. perate regions (1,2). Muscle is normally resistant to bacteria and rarely infected by bacteria even in the case of bacte- remia, provided there is no injury to it (1). performed on the day of hospitalization (Day 1 of hospital- As for the cause of disease and underlying diseases, in- ization) revealed cystic lesions the interior of which had volvement of region specificity, traumatic injuries, malnutri- slightly low density and contrast-enhanced borders in the fol- tion, parasite, and infection by virus and spirochete have lowing regions, suggestive of intramuscular abscesses: left been suggested (2). Morerecently, this disease has been re- pectoralis major muscle (2.5x2.5x7 cm), left infraspinatus ported in patients with autoimmune diseases, blood diseases muscle (4.5x3x13 cm), right erector spinae muscle (1.5x and the acquired immunodeficiency syndrome (AIDS) (3, 4). 1.5x5 cm), and right subscapularis muscle (diameter of 3 Diabetic patients are knownto tend to be infected because cm). Immediately, pus drainage by dissection of four masses of neutrophil dysfunction, decreased antibody production, (left thoracic region, left scapular region, right gluteal region tissue metabolism disorders, blood flow disorders, and ner- and left medial femoral region) was performed. The wounds vous system disorders. Diabetic patients with poorly con- were left open and the patient was treated topically with trolled blood glucose are easily complicated by infectious Gentamicin and systemically by intravenous drip infusion of diseases involving the respiratory system, urinary tract, and Panipenem Betamipron. Culture of the pus detected Staphy- skin, etc. As the present patient had not undergone routine lococcus aureus. On Day 5 of hospitalization, CT from the medical check-ups, the period of occurrence of diabetes is head to the pelvic region (Fig.
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