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J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13221
EMP213221
Videos in Emergency Medicine
Videos in Emergency Medicine
Infectious Disease
A transit passenger with unilateral leg pain
FAHEEM et al.
Faheem Ghazala MBBS 1
Rehman Muhammad Abd Ur MBBS 1 mrehman2@hamad.qa

Iqbal Muhammad Junaid MBBS 1
Shahzad Tahir MD 1
1 Department of Emergency Medicine Hamad Medical Corporation Doha Qatar
* Correspondence
Muhammad Abd Ur Rehman, Department of Emergency Medicine, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar.
Email: mrehman2@hamad.qa

23 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1322121 5 2024
24 5 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Qatar National Library 10.13039/100019779 source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:23.09.2024
Faheem G , Rehman MAU , Iqbal MJ , Shahzad T . A transit passenger with unilateral leg pain. JACEP Open. 2024;5 :e13221. 10.1002/emp2.13221
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pmc1 PATIENT PRESENTATION

A 57‐year‐old male transit passenger from an 8‐hour flight presented to the emergency department with severe left posterior thigh pain. He had experienced a traumatic event a few weeks prior, resulting in fractures of the left hip and left lower ribs. Upon examination, he exhibited severe tenderness, warmth, and fluctuation in the left posterior thigh with minimal swelling. He had a low‐grade fever (37.8°C), was markedly tachycardic (heart rate: 125 beats/min), and appeared clinically dehydrated. Blood investigations revealed raised inflammatory markers, elevated creatinine, and high lactate levels (Table 1). Given his clinical presentation and recent surgery combined with the long flight, initial differential diagnoses included deep venous thrombosis (DVT) and sepsis. Point‐of‐care ultrasound (POCUS) ruled out DVT but revealed subcutaneous edema with fluid collection in the hamstring muscles (Figure 1, Video 1).

TABLE 1 Lab investigations.

Blood investigations	Patient's values	Normal range	
White blood cell (× 103/µL)	22.7	4.0–10.0	
C‐reactive protein (mg/L)	340	0.0–5.0	
d‐Dimer (mg/L FEU)	0.33	0.00–0.49	
Creatinine (µmol/L)	151	62–106	
Lactic acid (mmol/L)	5.5	0.5–2.2	
pH	7.11	7.35–7.45	
PCO2 (mmHg)	38	21–69	
PO2 (mmHg)	27	25–40	
HCO3 (mmol/L)	20	23–29	
John Wiley & Sons, Ltd.

FIGURE 1 Showing position of the high‐frequency linear array transducer for thigh ultrasound.

VIDEO 1 Point‐of‐care ultrasound (POCUS) showing subcutaneous edema with fluid collection in muscles

2 DIAGNOSIS

2.1 Pyomyositis with sepsis

Based on laboratory investigations and bedside ultrasound findings, a diagnosis of pyomyositis with sepsis was made. The patient was promptly administered broad‐spectrum antibiotics and surgical consultation was obtained, leading to the incision and drainage of the thigh abscess, with approximately 100 mL of pus drained in the operation room. The patient showed significant clinical improvement and was discharged in stable condition after 3 days. Pyomyositis, a suppurative infection of skeletal muscle often affecting the proximal lower extremities, can lead to abscess formation. 1 , 2 It progresses through three stages. In the first stage, the muscle becomes inflamed and painful, with a “woody” texture but no abscess or erythema, and may show mild leukocytosis. The second stage involves severe pain, swelling, fever, and the formation of a muscle abscess, typically lasting 1–3 weeks. The third stage features systemic toxicity, septicemia, multifocal abscesses, and shock. 3 POCUS enables rapid diagnosis and facilitates prompt surgical consultation following the immediate administration of broad‐spectrum antibiotics in the emergency dt. 4 Ultrasound is cost effective and is highly effective at distinguishing fluid from solid tissue. In musculoskeletal infections, its main use is diagnosing and locating fluid in soft tissues or joints. 5 Early‐stage disease, marked by firm and tender muscle, can be effectively treated with beta‐lactamase‐resistant penicillin, leading to recovery within 2–3 weeks. Later stages or unresolved early stages often produce pus on aspiration and require incision, drainage, and antibiotics. 3

ACKNOWLEDGMENTS

The Qatar National Library funded the open access publication of this article.
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