Fatal pneumococcal septic shock in a patient with ulcerative colitis.

contiguous skin and soft-tissue infections or abscesses, or direct inoculationof bacteria intomusclewith or without vasoconstrictive materials [1, 2, 7, 8]. In intravenous drug abusers (IVDAs), impaired cellular and humoral immunity and defective bactericidal activities of neutrophils, as well as abnormal skin bacterial colonization due to repeated skin punctures and the accompanying introduction of nonsterile diluents, contribute to the susceptibility of skeletal muscle to infection [8, 9]. Table I summarizes data on pyomyositis in 12 IVDAs; malespredominated, andnonehad a definite history of recent travel to or immigration from tropical countries. Of the 9 patients whose underlying conditions were mentioned, 5 (42%) had AIDS (including one who also had diabetes mellitus and liver cirrhosis), I (8%) had AIDSrelated complex, and 3 (25%) hadnootherobvious immunosuppressive diseases. Antecedent muscle injury has been described in 20%-70% ofpatients withtropical pyomyositis andin 39%ofpatients fromNorth America [1,2]. Sucha history wasnotedin four(36%)of our reviewed cases; two patients had direct muscle injury due to injection of insulin andcocaine, respectively. Concurrent skin infection was foundin three patients; however, its relation to the development of pyomyositis was obscure. The lower-extrernity muscle was involved in sevenpatients. Multiple muscle involvement was found in three patients (25%). In otherseries [1,2]15%-50% of patients had multiple muscle involvement Mortality in tropical areas is low (0.5%-2%) compared with that (10"10) in temperate climates [1, 2]. In the II previously reported cases, mostpatients were clinically cured following appropriate drainage procedures and antimicrobial therapy, exceptfor one patient(9%) who died of endotoxic shock. A variety of bacteria were included as etiologic agents of pyomyositis [1, 2]. It is of interest that pyomyositis due to mixed aerobes and anaerobes, which is rarely seen in non-IVDAs, was found in two (18%) of the II previously described IVDAs. Five of the remaining nine patients (56%) had concurrent bacteremia. This finding contrasts sharply with the rates (5%-30%) reported in cases ofnon-IVDAs [1, 2]. F. indologenes, previously designated as Flavobacterium aureum CDC group lIb, is an indole-positive, saccharolytic, strongly pigmented bacterium. This organism is widely distributed in nature, particularly in water and soil, and is occasionally recovered from various clinical specimens [10]. Like other species of flavobacteria, strains of F. indologenes are commonly resistant to many antimicrobial agents,including aminoglycosides. Its pathogenic role in humans is infrequently described, although in a small number of cases, this