KP1 Parasitologi blok 17 Sistem Muskuloskeletal ta 2018/2019

Parasitic Infections in the

Musculoskeletal system

Trichinella Spiralis, sediaan otot tekan:

tampak larva melingkar dalam kista yang terdapat dalam jaringan otot

Forman Erwin Siagian

Dept. of Parasitology FKUKI
Email: forman.siagian@uki.ac.id
Monday, 05/06th/2019
In this lesson, you’ll learn about:
Epidemiology of

Pathophysiology and
pathogenesis of

Clinical signs and

symptoms of

Management of
 Characteristics of
a typical Parasitic Infection

(1) Different
stages of life cycle

(2) Tendency to
become chronic

(3) Ability to evade

Host’s immune
response
 definition
Myositis:
inflammation of the muscles, especially
voluntary muscles, characterized by
localized or diffuse pain, tenderness on
movement or palpation, swelling and or
weakness.
Can be caused by non-infectious and
infectious (e.g, bacteria, viruses, fungi and
parasites)
El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Epidemiology
• Exact number unknown, iceberg phenomenon
• Parasitic agent responsible for causing myositis:
- Trichinella spp  Trichinosis
- Taenia spp  cysticercosis
- Toxoplasma gondii  toxoplasmosis

• Fungal Myositis (uncommon), e.g candidiasis,

cryptococcosis, coccydioidomycosis, Aspergillosis
• Other parasitic myositis  myasis, severe malaria
falciparum causing rhabdomyolisis
El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Mechanism by which parasites/fungal
agent produced myositis
Direct invasion of the musculature

Induction of auto-immune mediated

reactions that lead to myositis

Transmission of other pathogens that produce

myositis as in the migration of parasite (e.g
Toxocara canis)

El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Trichinella spp
• Nematode, causing trichinosis/trichinellosis
• Raw/undercooked meat contains larvae
• Disemination occurs via lymphatic or
bloodstream to striated muscles
• Chronic infections, capsule
formation/calcification made from
collagenous wall and cellular components

El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Trichinella Spiralis, sediaan otot tekan:
tampak larva melingkar dalam kista yang
terdapat dalam jaringan otot

Trichinella Spiralis, sediaan potong otot

(jaringan otot dengan pemeriksaan
histopatologi): tampak potongan cacing dalam
dinding kista di jaringan otot
 Diagnosis of trichinosis
Suggested by,
 Clinical history
 The presence of eosinophilia, IgE, elevated
muscle enzyme
 Serologic tests (specific anti-Trichinella antibodies
in the serum)
Confirmed by biopsies

El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Taenia spp
• Cestode, its cysticercus (larvae) causing myositis
• Infection occurs via ingestions of T. Solium eggs;
its larvae predilection: CNS, eye, subcutanoeus
tissue and muscle
• Suggestion can be made by imaging soft tissue
and muscle (MRI and CT)
• Confirmation made from serologic testing
(ELISA)

El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Cysticercus cellulosa (Taenia solium):
Tampak gelembung dengan skoleks berbatil isap dan
mempunyai rostelum (kait-kait) pada potongan otot
 Toxoplasma gondii
• Protozoa, intracellular parasite
• Infection occurs via:
- ingestions of raw/undercooked/
contaminated meat/food
- inhalation (congenitally)
- blood transfusion
- organ transplant recipients
• Immunocompromised patients
• Dx: serologic tests IgG antibodies
 Toxocara canis
• Dog tapeworm, acquired by human via accidental
ingestion of Toxocara eggs
• Children most commonly affected
• Cutaneous larvae migrans predisposisng for
bacterial pyomyositis
• Eosinophilia present
• Dx made by serologic testing

El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Trypanosoma cruzii
• Chagas disease, latin America (Bolivia and
Brazil)
• Acquired via the bite of Reduviid bug, blood
transfussion, or congenital
• Smooth and striated muscle with the most
important visceral involvement is the heart.
• Subclinical, might be overshadowed by other
symptoms
• Reactivation among AIDS patients
El-Beshbishi et al, Parasitic infections and myositis. Parasitol Res, 2011
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Trypanosoma cruzii
bentuk amastigot
Sediaan otot jantung
 Pneumocystis jirovecii
• Pneumocystis carinii  pneumonia in AIDS
patients
• Myositis presented as inramuscular mass in
an AIDS patients

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev. 2008, 21(3)
 Malaria
• protozoa darah kelas haemosporozoa
• Species yang menginfeksi manusia (sbg
hospes perantara): Plasmodium falciparum,
P. vivax, P. ovale, P. malariae
• Ditularkan oleh nyamuk Anopheles spp
betina (sbg. hospes definitif)
• Daur hidup: dlm tubuh nyamuk fase
seksual, dlm tubuh manusia aseksual
 Rhabdomyolisis in severe
falciparum Malaria
• Complication of severe malaria
• Its origin is unclear. Severe myalgia,darkned
urine, swelling soft tissues paradigmatic
sympthoms of rhabdomyolysis.
• A determinant role in skeletal muscle damage
is played by red cells sequestration in muscle
capillaries and parasite’s toxins.
 ARF & Rhabdomyolysis
• Acute renal failure is a common complication in malaria
infection. This can be the result of multiple mechanisms
[1]: hypovolaemia, excessive haemolysis, disseminated
intravascular coagulation or impaired microcirculation due
to a high level of parasitized erythrocytes.
• Rhabdomyolysis (mechanism unknown) is another
uncommon way of inducing renal failure in malaria
infection. The diagnosis is based on high serum level of
muscular enzymes; Creatine Phosphokinase (CPK) and
clinical symptoms like myalgias.
• To our knowledge, only limited cases of rhabdomyolysis
complicated by acute renal failure during malaria infection
have been described
Reynaud et al. Rhabdomyolysis and acute renal failure in Plasmodium falciparum malaria.
Nephrol Dial Transplant (2005) 20: 847–855
 Fungal Myositis
Candida spp, Cryptococcus spp, Histoplasma spp,
Coccidioides spp, Aspergillus spp

Fungal involvement of the musculature is uncommon but has been

described in case reports. Most have involved immunocompromised
patients; occasionally fungal myositis has been reported in
immunocompetent persons. Given the rising prevalence rates of
immunocompromised hosts due to advanced therapies for cancer
and rheumatologic conditions, as well as the aging of the population,
and so in consequences the number of fungal myositis cases may increase.

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
 Candida myositis
• The most commonfungal myositis Candida spp.
• Myositis may develop in the setting of systemic candidiasis.
• The first case was described in the 1970s in a patient with
acute lymphoblastic leukemia which involved diffuse myositis
• Risk Factors include severe granulocytopenia and long-term
broadspectrum antibiotics; in addition, some have suggested
that chemotherapeutic agents (e.g., vinca alkaloids) and
steroid
• Dx: anamnesis, physical examination, and biopsy
• therapy may induce a subclinical myopathy which may
predispose patients to a subsequent infectious myositis
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
 Cryptococcus Myositis
• Rare, Most infections are asymptomatic;
• Cases of myositis usually occur in the setting
• of disseminated cryptococcal disease, but
focal infections within the muscle have been
reported
• Most cases occurs in immunocompromised
patients
• Dx: anamnesis, physical examination, and
biopsy
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
 Histoplasma myositis
• endemic to some region
• Infection is via inhalation of the dimorphic fungal
• microconidia into the lungs
• Case reports of: (1) nodular myositis in an AIDS patient,
(2) fulminant necrotizing myofascial infections, which
occurred in a transplant recipient and (3) a patient with
a rheumatologic condition on immunosuppressive agents
• Diagnosis has been made by biopsy, with histopathology
showing ovoid yeast cells using the Gomori-methenamine
or Grocot silver stain and growth of the fungus on
culture.

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
 Coccidiodes Myositis
• Endemic, route of infection is inhalation
• manifest as pneumonia; 1 to 2% develop disseminated
disease to the bones, skin, or CNS.
• Muscle involvement is rare, e.g a case involving a cardiac
transplant recipient manifested as a rash, severe
myositis, and arthropathy.
• muscular infections may involve the muscle body or occur
as abscesses between muscle groups
• Diagnosis is by biopsy of the involved muscles, which
shows pathognomonic spherules filled with endospores and
grows Coccidioides spp. on culture.
• Serology and complement fixation testing are available
and are usually positive in disseminated disease.
Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
 Aspergillus Myositis
• occurs most commonly among immunocompromised
persons.
• Can be disseminated disease or as a focal infection
• One case involved an elderly man receiving systemic
corticosteroids for myelodysplastic syndrome who
developed Aspergillus fumigatus myositis of the calf
• Route of infection mainly hematogenous, although
direct inoculation during steroid injection due to lack
of disinfection was hypothesized
• Dx: biposy and culture

Crum-Cianflone. Bacterial, fungal, Parasitic and viral myositis. Clin Microbiol Rev.
2008, 21(3)
Other parasites causing myositis
• Myasis caused by dipterous larvae (true flies), which, at
least for a certain period, feed on the host’s dead or
living tissue, liquid body substances, or ingested food
• Clinically, myiasis is classified according to the anatomic
site
• Myiasis should be suspected in any case with residence
or travel history to myiasis-endemic areas, supported by
extraction of the larvae and identification according to
morphological criteria. Sometimes, one has to breed
those larvae to identify the adult stages (Goddard
2009).
• Specific serologic analyses can identify infected patients
• Treatment is by removal of the larvae. Surgical
exploration should be carried out when tissue
destruction presents