Pyomyositis Secondary to Localized Cellulitis in a Dermatomyositis Patient: A Case Report and Review of Infectious Complications in Dermatomyositis

Figures & data

Figure 1 The time course of treatment and states of illness.

Figure 2 (A and D): The cicatrix, fibrocollagenous nodules and multiple calcifications in abdomen and thighs. (B and E): The characteristic features of dermatomyositis: Heliotrope sign, V sign and Gottron sign. (C) (HE×40) and (F) (HE×100): Biopsy of the subcutaneous firm nodules in the trunk revealed localized collagen hyperplasia in the dermis, accompanied by significant mucin deposition, as well as adipose septal fibrosis and hyalinization in the subcutaneous adipose tissue, featuring lipomatous cysts and membranous changes, with a minor infiltration of lymphocytes in the dermis and subcutaneous adipose tissue. (G and H): T1-weighted MR images revealed high signal intensity in sartorius muscle (white arrows) and intermuscular space. (I): The chest CT scan identified subcutaneous calcified nodules (white arrow).

Figure 3 The literature screening flowchart.

Table 1 The Clinical Data and Mortality Rates in Patients with IIM

Diagnosis	Treatment	No. Patients	No. Deaths	No. Deaths (Infection)	Mean Age	Male%	Study
IIM	GCs/ISD/BT	97	24	7(7.2%)	At diagnosis 40.5	25.8%	R	Marta 2016^Citation2
IIM	GCs/ISD/BT	479	114	26(5.4%)	At diagnosis 44.0	26.0%	R	Laura 2017^Citation3
IIM	GCs/ISD/BT	467	113	27(5.7%)	At diagnosis 41.1	26.0%	R	Laura 2017^Citation4
IIM	GCs/ISD/BT	90	13	4(4.4%)	At diagnosis 38.5	28.9%	R	Taborda 2014^Citation5
IIM	GCs/ISD/BT	370	118	26(7.0%)	–	–	R	Limaye 2012^Citation6
IIM	GCs/ISD	158	46	13(8.2%)	At diagnosis 40.8	22.8%	R	Francisca 2023^Citation7
DM	GCs/ISD/BT	100	6	5(5.0%)	In years 50.1	35.0%	R	Nicholas 2015^Citation8
DM	GCs+IVIG	91	9	2(2.2%)	At diagnosis 47.3	33.0%	R	Truzzi 2022^Citation9
DM/PM	GCs/ISD/BT	–	117	81(-)	–	–	R	Vieira 2019^Citation10
DM/PM	GCs/ISD/BT	23	2	1(4.3%)	In years 57.0	26.1%	R	Kenji 2007^Citation11
DM/PM	GCs/ISD	554	36	20(3.6%)	In years 49.2	36.3%	R	Lao 2023^Citation12

Abbreviations: IIM, idiopathic inflammatory myositis; DM, dermatomyositis; PM, polymyositis; GCs, Glucocorticosteroid; ISD, Immunosuppressive drug; BT, Biologic therapy; IVIG, Intravenous immunoglobulin; R, Retrospective.

Table 2 The Clinical Data and Prevalence of Infections in Patients with Different IIM Subtypes

Diagnosis	Treatment	No. Patients	No. Infections	Mean Age	Male%	Study
IIM	GCs/ISD/BT	1026	7(0.7%)	In years 61.8	33.4%	R	Shirley 2021^Citation13
	GCs/ISD/BT	214	121(56.5%)	At diagnosis 38.7	20.9%	Cohort study	Naveen 2021^Citation14
	CYC	14	7(50.0%)	In years 51.1	–	R	Sangmee 2018^Citation15
	GCs/ISD/BT	204	13(6.4%)	–	–	R	Redondo 2018^Citation16
	–	106	56(52.8%)	–	–	R	Xiao 2017^Citation17
	RTX	30	8(26.7%)	In years 52.5	30.0%	R	Marion 2011^Citation18
	RTX	30	3(10.0%)	In years 56.0	26.7%	R	Edoardo 2023^Citation19
	CTX	11	2(18.2%)	–	–	Clinical Trial	Cronin 1989^Citation20
	GCs/ISD/BT	97	32(33.0%)	At diagnosis 40.5	25.8%	R	Marta 2016^Citation2
	RTX/GCs/ISD/BT	20	2(10.0%)	In years 49.2	25.0%	R	Casals 2010^Citation21
	–	957	124(13.0%)	In years 59.0	43.0%	R	John 2017^Citation1
	–	66	33(50.0%)	In years 49.5	31.8%	R	Lu 2023^Citation22
DM	GCs/ISD/BT	89	58(65.2%)	At diagnosis 40	28.1%	Cohort study	Naveen 2021^Citation14
	GCs/ISD	105	22(21.0%)	At diagnosis 51.5	19.6%	R	Nuno 2019^Citation23
	–	91	48(50.0%)	At diagnosis 47.3	33.0%	R	Truzzi 2022^Citation9
Juvenile DM	MMF+GCs	50	41(82.0%)	In years 12.2	24.0%	R	Kelly 2010^Citation24
	GCs/ISD/BT	19	7(36.8%)	In years 12.5	42.1%	R	Shiva 2013^Citation25
	GCs/ISD/BT	139	33(23.7%)	–	41.0%	Randomized trial	Nicolino 2016^Citation26
	RTX	9	2(22.2%)	At onset 7.6	11.1%	P	Brigitte 2011^Citation27
PM	GCs/ISD/BT	33	14(42.4%)	At diagnosis 38	27.3%	Cohort study	Naveen 2021^Citation14
	GCs/ISD	137	36(26.3%)	At diagnosis 56.1	30.0%	R	Nuno 2019^Citation23
	GCs	115	21(18.3%)	At diagnosis 53.8	28.7%	R	Uchino 2012^Citation28
PM/DM	GCs/ISD/BT	2270	628(27.7%)	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	IVIG	11	3(27.3%)	In years 55.6	46.6%	Clinical Trial	Cherin 1994^Citation30
	RTX	19	7(36.8%)	In years 58	10.5%	R	Unger 2014^Citation31
	–	554	197(35.6)	In years 49.2	36.3%	R	Lao 2023^Citation12
OM/PM/DM	GCs/ISD/BT	332	96(28.9%)	At diagnosis 49.1	22.2%	R	Nuno 2019^Citation23
PM/DM-ILD	TAC and GCs	25	19(76.0%)	In years 55.4	24.0%	Clinical trial	Kazuki 2019^Citation32
ASS-ILD	GCs/ISD/BT	32	11(34.4%)	At diagnosis 55.8	34.4%	P	Tillie 2008^Citation33
Anti-MDA-5^+DM	GCs+TAC or CYC vs GCs+other ISD	42	35(83.3%)	In years 54.8	29.5%	P	Tsuji 2020^Citation34
	TOF+plasma exchange+RTX	33	24(72.7%)	In years 52.0%	18.2%	R	Shirai 2023^Citation35
	–	19	8(42.1%)	At diagnosis 52.5	18.8%	R	Billet 2022^Citation36
Anti-MDA5/ARS/TIF1-γ^+ DM	GCs/ISD/BT	33	17(51.5%)	At diagnosis 55.9	36.3%	R	Kazuki 2020^Citation37
Cancer associated DM	GCs/ISD/BT	7	5(71.4%)	At diagnosis 53	14.3%	Cohort study	Naveen 2019^Citation14

Abbreviations: IIM, idiopathic inflammatory myositis; DM, dermatomyositis; PM, polymyositis; OM, overlap myositis; ASS, Antisynthetase syndrome; MDA5, melanoma differentiation associated gene 5; ARS, Anti-Aminoacyl-tRNA Synthetase; TIF1-γ, Transcription Intermediary Factor 1 Gamma; GCs, Glucocorticosteroid; ISD, Immunosuppressive drug; BT, Biologic therapy; IVIG, Intravenous immunoglobulin; RTX, Rituximab; MMF, mycophenolate mofetil; TOF, Tofacitinib; TAC, Tacrolimus; CYC, Cyclophosphamide; R, Retrospective; P, Prospective; ILD, interstitial lung diseases.

Table 3 The Clinical Data and Prevalence of Infections in Patients with Different Infection Types

Infectious Agents	Diagnosis	No. Patients	No. Infections	Mean Age	Male %	Study
CMV	Anti-MDA5/ ARS/TIF1γDM	33	7	At diagnosis 55.9	36.3%	R	Kazuki 2020^Citation37
	PM/DM	2270	18	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	Anti-MDA-5^+DM-ILD	42	28	In years 54.8	29.5%	P	Tsuji 2020^Citation34
	IMM	204	3	–	–	R	Redondo 2018^Citation16
	DM/PM	554	24	In years 49.2	36.3%	R	Lao 2023^Citation12
CMV pneumonitis	PM/DM-ILD	25	1	In years 55.4	24.0%	Clinical trial	Kazuki 2019^Citation32
Herpes-zoster	Anti-MDA5/ARS/TIF1γ^+DM	33	5	At diagnosis 55.9	36.3%	R	Kazuki 2020^Citation37
	PM/DM-ILD	25	1	In years 55.4	24.0%	Clinical trial	Kazuki 2019^Citation32
	PM/DM	2270	377	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	ASS-ILD	32	8	At diagnosis 55.8	34.4%	P	Tillie 2008^Citation33
	PM/ DM	2023	338	In years 45.9	32.8%	Cohort Study	Tsai 2015^Citation38
	IMM	204	5	–	–	R	Redondo 2018^Citation16
	DM	91	11	At diagnosis 47.3	33.0%	R	Truzzi 2022^Citation9
HSV	PM/ DM	554	5	In years 49.2	36.3%	R	Lao 2023^Citation12
HSV/VZV	Anti-MDA5^+DM-ILD	42	4	In years 54.8	29.5%	P	Tsuji 2020^Citation34
Candidiasis	PM/DM	2270	85	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	Anti-MDA5^+DM-ILD	42	20	In years 54.8	29.5%	P	Tsuji 2020^Citation34
	IMM	204	2	–	–	R	Redondo 2018^Citation16
	DM/PM	554	38	In years 49.2	36.3%	R	Lao 2023^Citation12
PCP	PM/DM	2270	18	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	Anti-MDA5^+DM-ILD	42	5	In years 54.8	29.5%	P	Tsuji 2020^Citation34
	PM/DM-ILD	25	1	In years 55.4	24.0%	Clinical trial	Kazuki 2019^Citation32
	IMM	204	1	–	–	R	Redondo 2018^Citation16
	DM/PM	554	5	In years 49.2	36.3%	R	Lao 2023^Citation12
	–	214	22			R	Liu 2023^Citation39
	Anti-MDA5^+DM	105	13	In years 53.7	24.8%	R	Li 2022^Citation40
Aspergillus	PM/DM	2270	6	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	Anti-MDA-5^+DM-ILD	42	2	In years 54.8	29.5%	P	Tsuji 2020^Citation34
	DM/PM	554	8	In years 49.2	36.3%	R	Lao 2023^Citation12
NTM Nocardiosis	PM/DM	2270	14	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
	PM/DM-ILD	25	1	In years 55.4	24.0%	Clinical trial	Kazuki 2019^Citation32
Cryptococcus	PM/DM	2270	9	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
Salmonellosis	PM/DM	2270	30	In years 47.8	33.5%	Cohort study	Chung 2019^Citation29
Parasites	IMM	204	4	–	–	R	Redondo 2018^Citation16
Upper respiratory infection	Juvenile DM	50	26	In years 12.2	24.0%	R	Kelly 2010^Citation24

Abbreviations: IIM, idiopathic inflammatory myositis; DM, dermatomyositis; PM, polymyositis; ASS, Antisynthetase syndrome; MDA5, melanoma differentiation associated gene 5; ARS, Anti-Aminoacyl-tRNA Synthetase; TIF1-γ, Transcription Intermediary Factor 1 Gamma; R, Retrospective; P, Prospective; CMV, Cytomegalovirus; NTM, Non-tuberculosis mycobacteria; PCP, Pneumocystis carinii pneumonia; HSV, Herpes Simplex Virus; VZV, Varicella-Zoster Virus; ILD, interstitial lung diseases.

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