Pyomyositis is a primary bacterial infection of the striated muscle. The sternocleidomastoid muscle (SCM) is rarely
involved in pyomyositis because of its excellent blood supply from the branches of the external carotid artery. In this
study, we present the report of a 67-year-old male with an uncommon case of pyomyositis of the sternocleidomastoid
muscle who had been taking methylprednisolone and isoniazid for rheumatoid arthritis and latent tuberculosis,
respectively. The infection in the SCM occurred after the drainage of an abscess in the left submandibular and sublingual
space that appeared after extraction of a tooth. Although pyomyositis of the head and neck area is rare, it can lead to
severe complications, and even death, if treated improperly. It is also known that patients with reduced immunity are
susceptible to these infections. Therefore, if cervical edema or redness is observed in immunocompromised patients, a
more intensive clinical and radiographic examination is recommended for differential diagnosis of pyomyositis.ope

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Pyomyositis is a primary bacterial infection of the striated muscle. The sternocleidomastoid muscle (SCM) is rarely
involved in pyomyositis because of its excellent blood supply from the branches of the external carotid artery. In this
study, we present the report of a 67-year-old male with an uncommon case of pyomyositis of the sternocleidomastoid
muscle who had been taking methylprednisolone and isoniazid for rheumatoid arthritis and latent tuberculosis,
respectively. The infection in the SCM occurred after the drainage of an abscess in the left submandibular and sublingual
space that appeared after extraction of a tooth. Although pyomyositis of the head and neck area is rare, it can lead to
severe complications, and even death, if treated improperly. It is also known that patients with reduced immunity are
susceptible to these infections. Therefore, if cervical edema or redness is observed in immunocompromised patients, a
more intensive clinical and radiographic examination is recommended for differential diagnosis of pyomyositis.ope

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105J Korean Academy of Advanced General Dentistry 2020;9:105-108INTRODUCTIONPyogenic myositis (pyomyositis) is a primary bacterial infection of the striated muscles1-3, usually caused by Staph-ylococcus aureus and predominantly occurring in the trop-ics3. It is more common in immunocompromised patients, such as those with diabetes mellitus, acquired immune defi-ciency syndrome, hematopoietic disorders, autoimmune dis-eases, or chronic liver diseases. Patients treated with drugs, such as prednisolone and azathioprine, are also susceptible to infectious complications2,4-6.Reports of pyomyositis of the head and neck areas are scarce3,7. Infections in this location comprise approximately 0.5~4% of all cases, with the most frequent causes being dental and tonsil infections and trauma8. It is exception-ally rare for the sternocleidomastoid muscle (SCM) to be involved in pyomyositis because of its excellent blood sup-ply from the branches of the external carotid artery; these branches include the sternocleidomastoid branch of the superior thyroid artery and the sternocleidomastoid branch of the occipital artery3,9. Herein, we present an uncommon case of pyomyositis of the sternocleidomastoid muscle with a literature review.CASE REPORTIn February 2018, a 67-year-old man visited the Depart-Pyomyositis of the Sternocleidomastoid Muscle after  Tooth Extraction: A Case ReportHae-Seong Yong1, Dae-Hoon Kim2, Jong-Ki Huh3, Jae-Young Kim4,*1D.D.S., Resident, Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital,  Yonsei University College of Dentistry, Seoul, Korea 2D.D.S., MSD, Ph.D., Clinical and research assistant professor, Department of Oral and Maxillofacial Surgery,  Gangnam Severance Hospital, Yonsei University College of Dentistry, Seoul, Korea 3D.D.S., MSD, Ph.D., Professor, Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital,  Yonsei University College of Dentistry, Seoul, Korea 4D.D.S., MSD, Ph.D., Assistant professor, Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital, Yonsei University College of Dentistry, Seoul, KoreaABSTRACTPyomyositis is a primary bacterial infection of the striated muscle. The sternocleidomastoid muscle (SCM) is rarely involved in pyomyositis because of its excellent blood supply from the branches of the external carotid artery. In this study, we present the report of a 67-year-old male with an uncommon case of pyomyositis of the sternocleidomastoid muscle who had been taking methylprednisolone and isoniazid for rheumatoid arthritis and latent tuberculosis, respectively. The infection in the SCM occurred after the drainage of an abscess in the left submandibular and sublingual space that appeared after extraction of a tooth. Although pyomyositis of the head and neck area is rare, it can lead to severe complications, and even death, if treated improperly. It is also known that patients with reduced immunity are susceptible to these infections. Therefore, if cervical edema or redness is observed in immunocompromised patients, a more intensive clinical and radiographic examination is recommended for differential diagnosis of pyomyositis.Key words :  Pyomyositis, Abscess, Sternocleidomastoid muscleCorrespondence : Jae-Young KimDepartment of Oral and Maxillofacial Surgery, Gangnam Severance Hospital, Yonsei University College of Dentistry, 211 Eonju-Ro, Gangnam-gu, Seoul 06273, Republic of KoreaTel: +82-2-2019-3576, fax: +82-2-2019-1318E-mail: KJY810927@yuhs.acReceived: June 23, 2020; Revised: August 26, 2020; Accepted: September 16, 2020JOURNAL OF KOREAN ACADEMY OF ADVANCED GENERAL DENTISTRY106ment of Oral and Maxillofacial Surgery in Gangnam Sever-ance Hospital complaining of persistent pain that appeared after the extraction of his lower left second premolar at a dental clinic 11 days earlier. He underwent the tooth ex-traction, due to persistent pain after the root-canal treatment, and was given antibiotics after the surgery. Clinical exam-ination revealed the formation of granulation tissue and pus draining from the extraction socket. The patient reported taking methylprednisolone and isoniazid for rheumatoid ar-thritis and latent tuberculosis, respectively.After the initial visit, the patient did not return for his fol-low-up appointment; however, he revisited the hospital six days later, complaining of facial swelling and odynophagia. A clinical examination showed moderate swelling, indu-ration, and tenderness of the left submandibular area. His ability to open his mouth was limited to 20 mm, and the pa-tient complained of chills. Laboratory findings revealed an elevated white blood cell count (23,810/μL, normal range: 4,000~10,800/μL), neutrophil percentage (89.7%, normal range: 40~73%) and C-reactive protein levels (239.7 mg/L, normal range: 0.1~6.0 mg/L) (Table 1). We performed con-trast-enhanced computed tomography (CT), which revealed pus aggregation in the sublingual and submandibular spaces (Fig 1), indicating an abscess. We performed an intra-oral incision and drainage of the abscess under local anesthesia and had a specimen cultured. The culture showed the pres-ence of Gram-positive α-Streptococcus. Antibiotic therapy was administered (Flumarin, Flomoxef, 2nd generation ceph-alosporin, Ildong Pharmaceutical Co., Ltd.), and copious irrigation was done daily.Six days after the initial incision and drainage procedure, obvious swelling and pain appeared in the patient’s left neck area (Fig 2). A repeat contrast-enhanced CT revealed an ab-Table 1. Laboratory findings of inflammatory markersInitial visit13 days after initial incision and drainage (Prior to discharge)White blood cell count (/µL) 23,810 10,800Neutrophil percentage (%) 89.7 65.0C-reactive protein levels (mg/L) 239.7 6.6A B CFigure 1. Computed tomography images demonstrating pus collection in the left sublingual space (A) and submandibular space (B). No abnormalities were observed in the sternocleidomastoid muscle area (C). Figure 2. Six days after the first incision and drainage, swelling and redness were observed in the left sterno­cleidomastoid muscle area.Yong et al. Pyomyositis of the SCM after Tooth Extraction: A Case Report107scess affecting the entire length of the left sternocleidomas-toid muscle (Fig 3). Under general anesthesia, an incision about 1 cm in length was made at the most fluctuant area of the SCM. At that time, a large quantity of a purulent dis-charge was drained. A culture of this drainage revealed the presence of Strep-tococcus constellatus, a Gram-positive coccus that is sensi-tive to second-generation cephalosporins. Daily dressings and antibiotic therapy (Flumarin, Flomoxef, Ildong Phar-maceutical Co., Ltd.) were continued for 13 days after the initial incision and drainage. Prior to patient discharge, his ability to open his mouth increased gradually to 46 mm, Additional laboratory testing found improved white blood cell count (9,470/μL, normal range: 4,000~10,800/μL), neutrophil percentage (65.0%, normal range: 40~73%) and C-reactive protein levels (6.6 mg/L, normal range: 0.1~6.0 mg/L) (Table 1). The patient has recovered well.DISCUSSIONHerein, we present an uncommon case of pyogenic myo-sitis (pyomyositis) of the sternocleidomastoid muscle. Pyo-genic myositis (pyomyositis) is a primary bacterial infection of the striated muscle, typically affecting the extremities1-3. According to Gosnell et al., such an infection in the sterno-cleidomastoid muscle is infrequent, with about seven cases reported over the last two decades3. Pyomyositis is more common in immunocompromised patients, and it is known that patients being treated with drugs such as prednisolone and azathioprine are more sus-ceptible2,4,5. In this case, the patient had been taking methyl-prednisolone for rheumatoid arthritis and isoniazid because of latent tuberculosis. Despite being treated with antibiotics, a sublingual and submandibular space abscess was found after a simple extraction of a mandibular premolar. Six days after the incision and drainage, pyomyositis was found in the left sternocleidomastoid muscle area. This may have been due to the patient’s reduced immunity. On the 4th day after the incision and drainage, a bacterial culture of the left SCM showed that Streptococcus constel-latus was the causative agent. This bacterium is endogenous to the normal flora of the oral cavity, urogenital region, and intestinal tract. However, it is known that it can frequently cause purulent infections in other parts of the body10. It can be assumed that oral bacteria were infiltrated during the extraction due to the patient’s reduced immunity, and the spread of this bacterium caused pyomyositis of the left ster-nocleidomastoid muscle.According to the literature, the etiology of myositis is associated with temporary bacteremia in the location of muscle damage. S. aureus is known to be the most common causative agent, while streptococci are known as the second most common cause1,2,11. Therefore, we recommend the administration of broad-spectrum antibiotics covering S. au-reus and streptococci before the acquisition of the bacterial culture results.Pyomyositis of the head and neck area is rare, but if treat-ed improperly, it can lead to death through internal jugular vein thrombosis and sepsis3. Therefore, if cervical edema or redness is observed in immunocompromised patients, a A BFigure 3. Coronal (A) and axial (B) computed tomography images demonstrating pus collection throughout the left sternocleidomastoid muscle.JOURNAL OF KOREAN ACADEMY OF ADVANCED GENERAL DENTISTRY108differential diagnosis of pyomyositis through active clinical and radiographic examination is recommended. After diag-nosis, appropriate antibiotic administration is recommended, and surgical intervention should be performed for patients with evidence of pus collection.DISCLOSURE OF INTERESTThe authors declare that they have no competing interests.REFERENCES1.  Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 2008;21:473-94.2.  Crum NF. Bacterial pyomyositis in the United States. Am J Med 2004;117:420-8.3.  Gosnell EJ, Anwar B, Varadarajan V, Freeman S. Sternocleido-mastoid pyomyositis. Eur Ann Otorhinolaryngol Head Neck Dis 2016;133:273-5.4.  Collier S, Vig N, Collier J. Two cases of tropical pyomyositis of the sternocleidomastoid muscle occurring in the UK. Br J Oral Maxillofac Surg 2010;48:216-7.5.  Soleh M, Mohamad I. Sternocleidomastoid pyomyositis mimic-king parotid abscess. Bangladesh J Med Sci 2010;9:238-40.6.  Rimell F, Dohar J, Niehans G, Goding GS. Cervical “tropical” pyomyositis. Otolaryngol Head Neck Surg 1992;106:104-7.7.  Bickels J, Ben-Sira L, Kessler A, Wientroub S. Primary pyomyositis. J Bone Joint Surg Am 2002;84:2277-86.8.  González-Márquez R, Morato M, Suárez-Nieto C, Rodrigo JP. [Sternocleidomastoid pyomyositis in an immunocompetent patient]. Acta Otorrinolaringol Esp 2014;65:202-4.9.  Kierner AC, Aigner M, Zelenka I, Riedl G, Burian M. The blood supply of the sternocleidomastoid muscle and its clinical implications. Arch Surg 1999;134:144-7.10.  Whiley RA, Beighton D, Winstanley TG, Fraser HY, Hardie JM. Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infections. J Clin Microbiol 1992;30:243-4.11.  Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patie-nts. Am J Surg 1979;137:255-9.

Pyomyositis of the Sternocleidomastoid Muscle after Tooth Extraction: A Case Report

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Pyomyositis of the Sternocleidomastoid Muscle after Tooth Extraction: A Case Report

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