A 46-year-old female patient complained of mild fever, weakness, left extremity swelling, and fullness of the left inguinal area that became progressively worse over a period of 1 month. She was seen by her primary care physician who did not find any abnormal findings in the physical examination except lymph node enlargement in the inguinal area. He recommended biopsy of the enlarged lymph nodes that was unrevealing. She developed lymphorrhea for about 2 weeks after the procedure.

She acutely complained of higher fevers and more weakness about 2 months after the start of her initial symptoms. She was admitted to the hospital for further management. Physical examination showed left lower extremity swelling and lymph node enlargement in the left inguinal area (Figure 1). Routine laboratory investigation revealed increased white blood cell count (WBC: 20070/mm3, 81,9% neutrophils), C-reactive protein [CRP: 9,1 mg/dl (normal:0-0,5)], and erythrocyte sedimentation rate (ESR:87 mm 1st hour). She was found to have MRSA bacteremia. Imaging of her body with computed tomography (CT) scans revealed abscesses in the left iliopsoas and obturator muscle (pyomyositis) (Figure 2). No other source of active infection was identified, except the findings from the retroperitoneal space. A magnetic resonance imaging (MRI) of the spine and a colonoscopy that included visualization of the terminal ileum were negative. She received intravenous antimicrobial treatment with linezolid (600 mg every 12 hours), clindamycin (600 mg every 8 hours) and rifampicin (600 mg every morning and 300 mg every night) for 4 weeks that improved her condition. Specifically the fever decreased and she felt better. In addition, the laboratory indices of inflammation also improved.

What was the cause of the leg edema?

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