1. CASE PRESENTATION
An 8‐year‐old girl with a history of juvenile idiopathic arthritis taking adalimumab reported progressive right leg pain, erythema, and fever. She sustained a laceration 6 days prior and progressively developed a fever with pain and swelling of her right lower extremity. Initial physical examination revealed right lower extremity erythema and edema with a well‐healed laceration. Laboratory results revealed elevated inflammatory markers (C‐reactive protein, 12.7; erythrocyte sedimentation rate, 38) without leukocytosis. Point‐of‐care ultrasound and magnetic resonance imaging were done (Figures 1, 2, 3).
FIGURE 1.
Point‐of‐care ultrasonography in axial view comparing the sonographic appearance of the affected muscle (red asterisk) with the contralateral side (yellow asterisk). An anechoic collection is seen (red arrow) adjacent to medial tibia (red and yellow squares)
FIGURE 2.
Axial magnetic resonance imaging view showing medial right anterior tibialis intramuscular abscess
FIGURE 3.
Coronal magnetic resonance imaging view showing abnormal signal and edema in the muscles of the anterior compartment versus normal contralateral side
2. DIAGNOSIS
2.1. Pyomyositis, subperiosteal abscess, and osteomyelitis secondary to methicillin‐resistant Staphylococcus aureus
Operative incision and drainage produced thick purulent material in the anterior compartment and tibial periosteum. She was treated with clindamycin for a total of 6 weeks of therapy. Pyogenic bacterial infections are infrequent but known adverse effects of adalimumab. 1 Hematogenic spread of bacteria is a common mechanism for the development of osteomyelitis and pyomyositis. Once established, an infection may expand and develop into an abscess within the subperiostum. 2 , 3 S. aureus is the most commonly implicated pathogen. Drainage of any identified abscess is critical to management. Antibiotic therapy should be tailored to local drug resistance patterns, and long‐term treatment is necessary. 4
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Philip V, Radomski MA. Deep tissue infection in a girl with juvenile idiopathic arthritis. JACEP Open. 2021;2:e12505. 10.1002/emp2.12505
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