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Benign Acute Childhood Myositis


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									Original Article

Benign Acute Childhood Myositis
Sarala Rajajee, S. Ezhilarasi and K. Rajarajan

Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India.

Abstract. Objective: To describe the clinical and laboratory features of benign acute childhood myositis. Methods : 40 children
of BACM were seen during October 2001 to February 2002, 22 (52%) were male with mean age of 5.3 years. Duration of illness
was 3.97 days. Preceding symptoms included fever, leg pain, vomiting and inability to walk. A provisional diagnosis of viral
myositis was made in 26 (66%). Guillian Barre Syndrome was the most common referral diagnosis. Results: 11 (27.5%)
children had leucopenia with lymphocytic response and 16 (40%) had thrombocytopenia. CRP was negative in 32 (80%). CPK
was markedly elevated (more than 1000 IU/l) in 18 (45%) and more than 500IU/l in 11 (27.5%) remaining between 200 to 500IU/
l. Associated features were hepatitis (elevated SGOT & SGPT) in 28 (70%) and shock in 5 (12.5%).Serological test were
indicative of dengue virus (Elisa PAN BIO) in 20 (50%) of which 8 (25%) were primary dengue and 12 (30%) were secondary
dengue. The outcome of therapy mainly supportive were excellent. Conclusion: Benign acute myositis occurs often in
association with viral infection. In the present study, Dengue virus was positive in 20 (50%) children. Benign acute myositis can
be differentiated from more serious causes of walking difficulty by presence of calf and thigh muscle tenderness on stretching,
normal power and deep tendon reflex and elevated CPK. [Indian J Pediatr 2005; 72 (5) : 399-400]
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Key words : Myositis; Dengue virus; Guillian Barre Syndrome

Benign acute childhood myositis (BACM) was first                    pattern were observed, they walked on toes or walked
described in 1957 by Lundberg 1 under the name of                   with wide based, stiff gait. Muscle tenderness was
“Myalgia Cruris Epidemica”. It is characterised by                  recorded in 34 (85%) cases. This was well illustrated by
sudden onset of calf pain and refusal or difficulty to walk.        stretching of the muscle by raising the leg. Similar
Viral agents have been implicated.1,2,3,4 It is followed by         observations were made by Mackary et al.5
rapid recovery within a week. It is rarely reported in                 Eleven children (27.5%) had leucopenia, with
adults. We report 40 cases of BACM between October                  lymphocyte response 16 (40%) had thrombocytopenia.
2001 to February 2002.                                              CRP was negative in 32 (80%). CPK was markedly
                                                                    elevated (more than 1000 IU/litre) in 18 (45%), and more
               MATERIAL AND METHODS                                 than 500 IU/litre in 11 (27.5%) (Fig 1). Serological tests
                                                                    were indicative of dengue virus (Elisa PAN BIO) primary
Inclusion criteria: (i) Children presenting with fever /            Dengue in 8 (25%), secondary Dengue in 12 (30%).
myalgia. (ii) Muscle tenderness demonstrated by straight               Associated features were hepatitis in 28 (70%)
leg raising test (iii) Absence of nuchal rigidity. (iv)             (elevated SGOT and SGPT) shock in 5 (25.5%).
Absence of neurological signs such as altered sensorium                The outcome of the therapy was excellent, everybody
or local deficit.                                                   recovered. Repeat CPK was normal in 10 (25%). Rest of
                                                                    the children were asymptomatic at review after two
                          RESULTS                                   weeks. Therapy was mainly supportive with intravenous
                                                                    fluids as indicated and paracetamol.
Forty cases of BACM were seen. 22 (55%) were male with
mean age of 5.3 years age. All cases were seen between to                                 DISCUSSION
October 2001 – February 2002. Duration of illness was 3.97
days. Preceding symptoms included fever, leg pain,                  After the first reports of BACM in 1957 1, Middleton et al2
headache.                                                           described cases in 1970 and showed elevated CPK in
   A provisional diagnosis of viral myositis was made in            association with influenza B. Since then there have been
26 (65%). Guillian Barre syndrome was the most common               253 cases reported associated with various virus
referral diagnosis in 5 (12.5%). 18 (45%) children were             infections.
unable to walk and in those who walked a characteristic                In the present series 55% of patients were boys. In the
                                                                    report by Mackary et al 84% of patients were boys. This
Correspondence and Reprint requests : Dr. Sarala Rajajee, 19 (New   may be either due to greater levels of activity in boys or a
No 28) Second Main Road, CIT Colony, Chennai – 600 004.
                                                                    genetic predisposition.

Indian Journal of Pediatrics, Volume 72—May, 2005                                                                           399
                                                                  Sarala Rajajee et al

                  20 –                                                        associated with 20 (50%) cases of myositis.
                                                                  18             Muscle biopsies performed in myositis showed non
                  16 –                                                        specific degenerative changes, focal muscle fibre
                                                                              vacuolation and muscle necrosis. The elevation of CPK
 No. of cases

                  12 –           12                                           suggests muscle fibre destruction in keeping with a
                                                  11                          myositic component.
                  8–                                                              Awareness of the possibility of myositis in children
                                                                              presenting with acute myalgia, difficulty in walking in
                  4–                                                          association with elevated CPK may lead to streamlining
                                                                              further tests and unnecessary therapy may be avoided.
                  0–                                                          Contributions
                              135-500       500-999             >1000
                                                                              SR drafted the manuscript. KR collected the data. SE analysed the
                                   CPK levels (IU/litre)
                                                                              data. SR will act as the guarantor of the paper.
                          Fig 1. Creatine Phosphokinase (CPK)
   The mean age of onset of symptoms in our study was                           1. Lundberg A Myalgia cruris epidermica. Acta Paediatr 1957;
5.3 days. The mean duration of prodromal symptoms in                               46 : 18-31.
the present study was 3.97 days. There was associated                           2. Middleton PJ, Alexander RM. Severe myositis during
clinical features of hepatomegaly in 33 (82.5%) cases.                             recovering from influenza. Lancet 1970; 2 : 533-535.
Shock in 5 (12.5%). Resolution was rapid within as week.                        3. Anthony J H, Procopis PG, Ouvier RA. Benign acute
                                                                                   childhood myositis. Neurology 1979; 29 : 1068–1071.
This was similar to the observation of Mackary et al and                        4. Mckinlay IA, Mitchell I. Transient acute myositis in childhood.
Mckinlay et al. Myalgia primarily affected the                                     Arch Dis Child 1976, 51; 135-137.
gastroneomius and hamstring muscles.                                            5. Mackay MT, Kornverg AJ, Shield LK, Dennett X. Benign acute
   Viruses associated with myositis according to several                           childhood myositis. Neurology 1999; 53 : 70.
authors include Influenza A, adenovirus , Coxsackie and                         6. Mark Barasz. Benign acute myositis. Am J Emerg Med 2000;
                                                                                   18 : 35-37.
para influenza. In the present series the Dengue virus was

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