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TRANSCRIPT
Good Afternoon
1 year old Male
ACUTE INFLAMMATION
CHRONIC INFLAMMATION
Fracture
Dislocation
Soft Tissue Injury
SOFT TISSUE INJURY
Compartment Syndrome Pyomyositis
Acute Compartment Syndrome
Trauma
Trauma
Tissue Pressure
Venous Pressure
Decreased Blood Flow
PAIN Decreased Sensation
Acute Compartment Syndrome
• hypotension on the involved area• pain out of proportion to the injury• pallor of the extremity• pulselessness • paralysis (loss of function) or limitation
of movement
A.O.T.
• Pain• Limitation of movement• Good pulses
SOFT TISSUE INJURY
Compartment Syndrome Pyomyositis
Pyomyositisacute bacterial infection of the muscles
severe muscle tenderness in areas with cellulitis
acute bacterial myositis
tropical pyomyositis
Streptococci Staphylococci
MRSA
Swelling of Left Arm•Erythematous•Warm•Pain on movement
XRAY: soft tissue swelling Blood Culture:
Staphylococcus aureus
• >90% of cases of skeletal muscle abscesses Staphylococcus aureus
Micro-abscesses in the kidneys, liver, or spleen but never but never in skeletal muscles
specific muscles were damaged by mechanical pinching or
electric current 24 to 48 hours prior to injection of bacteria
small abscesses developed within 2 to 28 days at some of the injured sites
Muscle injury
Bacteremia (staphylococcal)
PYOMYOSITIS
Pyomyositis• May occur in individuals of all ages• Boys > girls• most common site:
• Thighs, • Calfs• Arms • Buttocks
• no definable immunologic abnormalities
A.O.T.
had no history of repeated
infection
Pyomyositis• any child with fever and muscle pain, especially
if with history of trauma • Definitive diagnosis: one or more radiologic
procedures– XRAY: soft tissue swelling – scanning with Gallium, or Indium – Ultrasound– CT scan
Pyomyositis
Inflammatory Response
Increased WBC
Increased Blood Flow
Hematogenous Spread
Cytokines
Abscess of skeletal muscles
Increased WBC
Hematogenous spread of different microorganisms from different areas of the body
formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures
encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object, resulting in worsening of the pain and swelling
ABSCESS
How did pyomyositis
come about
Papulovesicularlesion
secondarily infected Staphylococcus aureus inoculated through skin break and spreads
hematogenous route
bacteremia
pyomyositis
Differential Diagnosis for a Rash
• onset • location• speed or direction of progression• general well-being of the child, including
prodromal illness or fever• infectious contacts• mucosal involvement
Vesicular
VESICULAR RASH
Varicella Eczema Herpeticum
HFMD
Eczema Herpeticum
• underlying atopic dermatitis or eczema
• lesion is characterized with umbilication or a crust in the middle of the vesicle
Hand, Foot and Mouth Disease
• Coxsackievirus type A• papulovesicular
eruption but usually limited on the palms, soles, mucous membranes and sometimes the buttocks
Varicella : most common cause of papulovesicular lesions in children
Maculopapular rash macule-papule stage of Varicella
Complications of Varicella
• Not common• Possible complications
– Pneumonia– Septicemia– Suppurative arthritis– Osteomyelitis or local gangrene– Pyomyositis – Meningitis
Pneumonia by the Varicella Zoster Virus
• Uncommon • 2 to 10 days after the rash
with fever• Cough as the first sign • Usually benign
A.O.T.• respiratory distress worsened
• fatal forms of pneumonia
• Staphylococcus aureus and Klebsiella pneumoniae
A.O.T.CSF sugar and protein: normal
CSF Gram Stain: g (-) bacilli too numerous to count
CSF WBC increased
Acute Bacterial Meningitis
According to Feigin and Cherry, pyomyositis has been described in
Varicella, presumably caused by bacteremia resulting from infection of skin
lesions
Paracetamol and Cefalexin
maculopapular rashes
allergic reaction
Varicella Trauma Allergic Reaction
Systemic Inflammatory
Response
SIRS: Stage 1
local cytokine
INSULT
inflammatory response
promoting wound repair and recruitment of the reticular endothelial system
Infection Trauma Allergic Reaction
White Blood Cells
Growth Factor Stimulation and the Recruitment of Macrophages and Platelets
Acute Phase Response
Homeostasis Homeostasis
Stage 1
Stage 2
Reticular Endothelial SystemDysfunction
Cytokine and MediatorsInflammation and Repair
SIRS: Stage 3 Homeostasis Not Restored
Significant Systemic
Reaction Occurs
Cytokine Release
Activation of the Reticular Endothelial
System
Activation of Numerous Humoral
Cascades
END ORGAN
DAMAGE
Loss of Circulatory
Integrity
A.O.T.High grade feverTachycardicTachypneic MEETS ALL 4 CRITERIALeukopenia
A.O.T
• Metabolic Acidosis not corrected
• Oxacillin and Clindamycin Methicillin Resistant Staphylococcus aureus.
Septic shockSevere Sepsis Death
Staphylococcus aureus • common cause of skin and
respiratory infections • 1970’s Penicillin resistance spread • Methicillin, 1960, MRSA identified in
1961• In 1956, Erythromycin (a
macrolide), Clindamycin (a lincosamide) resistance reported
• According to Feigin et al., invasive strains of Staphylococcus aureus can cause severe form of pneumonia
• If severe sepsis:– Respiratory compensation becomes
ineffective combination of respiratory and metabolic acidosis
A.O.T.Acutely ill and agitated
Poor vital signs – only temperature recorded
TachycardicTachypneicHypotensive
Poor peripheral pulsesPoor capillary refill
Septic shock
Hypersensitivity Reaction
Trauma
Varicella superinfection
(Staphylococcus aureus)
Hematogenous spread of bacteria
Pyomyositis
PneumoniaMeningitis SIRS
Sepsis
1 year Old MaleCC: Left Arm
Swelling
SEPSIS ORGAN Dysfunction• Respiratory Distress
•Meningitis
SEVERE SEPSIS
SEPTIC SHOCK
DEATH
FINAL DIAGNOSIS • Septic Shock secondary to Severe Sepsis
(Staphylococcus aureus, probably MRSA)• Varicella • Tropical Pyomyositis• Pneumonia• Meningitis • Hypersensitivity Reaction Secondary to
Cephalexin