Anisau, Aliaksandr

Vanhoenacker, Filip

English

Ghent University Academic Bibliography

Case 15211 Osteomyelitis pubis with bilateral muscle abscessesAliaksandr Anisau 1, 2Filip M. Vanhoenacker 1, 2, 31. General Hospital AZ Sint-Maarten Duffel-Mechelen, Leopoldstraat 2, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium; Email:filip.vanhoenacker@telenet.be University Hospital Antwerp  Musculoskeletal System Section: 2017, Nov. 22 Published: 55 year(s), malePatient:Clinical HistoryA 55-year-old man, with known type 2 diabetes mellitus, presented withincreasing pubalgia since 2 weeks.Laboratory examination revealed moderately elevated ESR, CRP and white blood cell count.Imaging FindingsRadiographs of the pelvis showed widening of the pubic joint and subchondral bone erosions(figure 1a and 1b), which were confirmed on subsequent CT of the pelvis (figure 2a and 2b). Inaddition, CT showed soft tissue swelling adjacent to the symphysis in the adductor and rectusabdominis muscles (figure 2c and 2d). MRI of the pelvis revealed bone marrow oedema in theiliopubic rami (figure 3a and 3b). After administration of gadolinium contrast, bilateralrim-enhancing collections extending from the symphysis pubis were seen along the adductor andrectus abdominis muscles (figure 3c, 3d and 3e). The shape of collections along the adductormuscles resembled a butterfly (figure 3a and 3b).DiscussionOsteomyelitis pubis is an infection of the pubic bone and joint, most frequently caused by S. aureus(1). It's a rare condition accounting for less than 1% of all cases of osteomyelitis (1).The exact pathogenesis is unclear, but the infection usually arises from hematogenous disseminationand more rarely by extension of an adjacent infectious focus (2, 3). This condition has also beencalled septic arthritis of the symphysis pubis, but osteomyelitis a more correct term, because theprimary site of infection is the pubic bone adjacent to the joint. The infection starts in one pubicbone and later crosses the joint to affect the contralateral pubic bone, analogous to the course ofspondylodiscitis. Potential risk factors are invasive pelvic procedures, pregnancy or delivery, gracilis-adductortendinopathy and the presence of infectious foci elsewhere in the body which can spreadhematogenously (1, 2).The presenting symptoms and signs are nonspecific (3). The patient complains of graduallyincreasing pubic pain, radiating to the groin, perineum, buttock or genital region (2). Antalgic gaitmay be present as hip motion aggravates the pain (1, 3). Inflammatory parameters are usuallyelevated, but their absence does not exclude the diagnosis (2). Bacteraemia may be present (2).Pelvic radiographs are insensitive and are normal in the early stages of the disease (1, 3). Diastasisof the symphysis and progressive bony destruction will initially appear in one pubic ramus, whilethe process crosses the joint space at a later stage (3). Diastasis is suspicious for abscess formationin the joint (3). CT scan is more sensitive, but its false negative rate remains 10% (2). MRI is theimaging modality of choice, with a sensitivity that approaches 100% (2). Typical findings are jointsurface irregularities, subchondral bone destruction, bone marrow oedema in the iliopubic rami, softtissue oedema adjacent to the pubic symphysis and pus in a widened symphysis (1, 2). Afteradministration of gadolinium contrast, there is enhancement of the infected pubic bone and jointsurface. In later stages, a soft tissue abscess will appear as a collection with peripheralenhancement. The abscesses in the adductor muscles may have a characteristic butterflymorphology (1).Therapy of osteomyelitis pubis consists of long term intravenous administration of antibiotics (1).In case of failure of conservative treatment, surgery may be indicated (4, 5). Follow-up imaging isoften required (3).Our patient was successfully treated with antibiotics and follow-up was uneventful. No surgery wasrequired.Final DiagnosisOsteomyelitis pubis with bilateral hip adductor and rectus abdominis abscesses.Differential Diagnosis ListGracilis-adductor tendinopathy (aka Osteitis Pubis"), Subpubic cystFiguresFigure 1 Pelvic radiographWidening of the symphysis (red circle). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: Conventional radiography;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Erosions in both pubic bones, larger at the left side (red arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: Conventional radiography;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Figure 2 Contrast-enhanced CT of the pelvisWidening of the symphysis. Subchondral erosion in the left pubic ramus (pink arrow). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Widening of the symphysis. Subchondral erosion in the left pubic ramus (pink arrow). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Widening of the symphysis. Intra-articular collection extending anteriorly into the softtissues, with subtle enhancement at the margins of the collection (orange arrow). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Abscess; Arthritides; Infection;Bilateral collections along the adductor muscles with butterfly morphology and subtle rimenhancement (orange arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Abscess; Arthritides; Infection;Figure 3 MRI of the pelvisT1. Widening of the symphysis. Low T1 signal intensity in the pubic rami (red arrows)representing bone marrow oedema surrounding the erosions. Soft tissue extension along theadductor muscles (purple arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Abscess; Arthritides; Infection;T2 PD, TSE, fs. Widening of the symphysis. Bone marrow oedema in the pubic rami (redarrows). Pus in the symphysis pubis, extending along the adductor muscles (purple arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Abscess; Arthritides; Infection;T1, fs, Gd. Contrast enhancement of the articular surface (blue arrow), both pubic rami(green arrows) and the soft tissues (yellow arrow). Lymph nodes (small white arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Infection; Inflammation;T1, fs, Gd. Bilateral adductor muscle abscesses (black arrows) with rim enhancement(orange arrows). Enhancement of the adjacent muscle tissue (yellow arrows). Enlargedinguinal lymph nodes (small white arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Infection; Inflammation; T1, fs, Gd. Subtle rim-enhancing abscess (black arrow) in the right rectus abdominis muscle(orange arrow). Enhancement of the adjacent muscle tissue (yellow arrow). Enlargedinguinal lymph nodes (small white arrows). © AZ Sint-Maarten Mechelen, Department of Radiology. Area of Interest: Musculoskeletal bone; Musculoskeletal joint; Musculoskeletal soft tissue;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Abscess; Arthritides; Infection;References[1] Alqahtani SM, Jiang F, Barimani B, Gdalevitch M. (2014) Symphysis pubis osteomyelitis withbilateral adductor muscles abscess Case Rep Orthop[2] Yax J, Cheng D. (2014) Osteomyelitis pubis: a rare and elusive diagnosis West J Emerg Med15(7):880[3] Knoeller SM, Uhl M, Herget GW. (2006) Osteitis or osteomyelitis of the pubis? A diagnosticand therapeutic challenge: report of 9 cases and review of the literature. Acta Orthop Belg72(5):541[4] Pauli S, Willemsen P, Declerck K, Chappel R, Vanderveken M. (2002) Osteomyelitis pubisversus osteitis pubis: a case presentation and review of the literature. Br J Sports Med 1;36(1):71-3[5] Pham DV, Scott KG. (2007) Presentation of osteitis and osteomyelitis pubis as acute abdominalpain. Perm J 11(2):65-8CitationAliaksandr Anisau 1, 2Filip M. Vanhoenacker 1, 2, 31. General Hospital AZ Sint-Maarten Duffel-Mechelen, Leopoldstraat 2, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium; Email:filip.vanhoenacker@telenet.be (2017,Nov. 22)  Osteomyelitis pubis with bilateral muscle abscesses {Online}URL: http://www.eurorad.org/case.php?id=15211

Osteomyelitis pubis with bilateral muscle abscesses

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Osteomyelitis pubis with bilateral muscle abscesses

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