Endgames Case Review

A young goalkeeper with buttock pain and fever

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2400 (Published 08 June 2017) Cite this as: BMJ 2017;357:j2400
  1. Valentina Moressa, trainee paediatrician1,
  2. Serena Pastore, paediatrician2,
  3. Samuele Naviglio, paediatrician1,
  4. Alessandro Ventura, professor of paediatrics1 2
  1. 1Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy
  2. 2Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
  1. Correspondence to Valentina Moressa valemorex{at}gmail.com

A previously healthy 13 year old boy presented to the emergency department with pain in the right buttock and fever. Five days earlier he had fallen diving to catch a ball during a football match, and two days later had a fever of up to 39°C and had started to complain of buttock pain. Physical examination on presentation was unremarkable except for pain on abduction of the right hip, with limited range of motion. Radiography of the pelvis was normal. Oral ketoprofen was prescribed for pain and he was discharged. Three days later the pain had worsened and he was still feverish. He returned to the emergency department. Physical examination was unchanged from the previous visit. Ultrasonography was performed on the right hip, which was normal. Laboratory findings included elevated C reactive protein (155.4 mg/L, normal values <5) and erythrocyte sedimentation rate (56 mm/h, normal values <20), and leucocytosis (leucocyte count 17 × 109/L (normal range 4.0-10.5 × 109/L), with 88% neutrophils (normal range 50-65%)), with normal haemoglobin and platelet count. Creatine kinase levels were within the normal range and blood cultures were negative. Magnetic resonance imaging (MRI) of the pelvis was performed (fig 1).

Fig 1 Magnetic resonance imaging of the pelvis after gadolinium infusion (T1 weighted, turbo spin echo with fat suppression)

Questions

  1. What is the most likely diagnosis?

  2. What complications can arise?

  3. How is this condition managed?

1. What is the most likely diagnosis?

Short answer

Pyomyositis of the right gluteus maximus muscle. There are no specific laboratory tests for pyomyositis; MRI is the gold standard for diagnosis.

Discussion

MRI shows marked enhancement of the right gluteus maximus muscle, with distortion of the muscular fibres (fig 2

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