Osteomyelitis of the pubis in a young athlete revealed by severe abdominal pain

doi:10.4236/ojped.2013.34052

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Open Journal of Pediatrics, 2013, 3, 291-293 OJPed

http://dx.doi.org/10.4236/ojped.2013.34052 Published Online December 2013 (http://www.scirp.org/journal/ojped/)

Osteomyelitis of the pubis in a young athlete revealed by

severe abdominal pain

Lamiae Chater*, Karima Atarraf, Moulay Abderrahmane Afifi

Department of Pediatric Surgery, CHU Hassan II, Fez, Morocco

Email: *[email protected]

Received 31 July 2013; revised 29 August 2013; accepted 7 September 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Acute osteomyelitis is a co mmon condition in children.

Only early diagnosis prevents complications. The lo-

cation at the pubic bones is very rare, even excep-

tional at the pubis symphis. We report a case of os-

teomyelitis of the pubis in a young athlete of 14 years

old whose symptoms were discussing an acute abdo-

men, to illustrate the unusual clinical presenta tion, so

as not to miss the diagnosis and avoid unnecessary

laparotomy.

Keywords: Osteomyelitis; Pubis; Childhood; A thlete;

Acute Abdominal Pain

1. INTRODUCTION

Acute hematogenous osteomyelitis is a bone disease

caused by a germ usually the staphyloccocus aureus. Its

headquarters is fertile metaphysis of long bones near the

knee and far from the elbow. Diagnosis is clinical and

must be as early as possible to initiate treatment quickly,

otherwise the risk of fatal sepsis and especially the evo-

lution to the chronicity is significant [1].

Osteomyelitis of pubis represents less than 1% of lo-

cations. The pathogenesis of this entity is explained by

the location of a secondary bacteremia on undisturbed

bone.

We report a case of pubic osteomyelitis in a young

boy practicing a sporting activity revealed by acute ab-

dominal pain to illustrate the somewhat unusual pre-

sentation.

2. CASE PRESENTATION

A young judoka aged 14 years was admitted to our hos-

pital for severe abdominal pain. The symptoms started it

a week ago, when a history of severe right lower quad-

rant abdominal pain with a fever was developed. There

was a history of local trauma in the pelvic area 20 days

before. The boy reported worsening abdominal and su-

prapubic pain radiating to both groins and preventing

ambulation. He was vomited nonbilious. Physical ex-

amination has obj ectified a fever to 39 ˚C, and abdominal

examination showed right lower quadrant tenderness, but

remains soft. The leukocyte count was 11,400 cells/ml.

The erythrocyte sedimentation rate was 97 mm/h and the

C-reactive protein (CRP) level was 25 mg/l.

A pelvic radiography (Figure 1) showed osteolysis of

the upper inne r angl e of the right pubis wi t hout periost ea l

reaction. Ultrasonography showed a hypoechoic collec-

tion of 10 mm behind the rectus abdominis muscle. A

computed tomography scan of the abdomen and pelvis

revealed a hypodensity collection around the pubic

symphysis (Figure 2) with an osteolytic appearance of

the pubis (Figures 3 and 4). These findings were consis-

tent with osteomyelitis of the pubis with suppuration.

Figure 1. Pelvic radiography showed slight deformity with

irregularity of the right side of the pubic symphis.

*Corresponding author.

OPEN ACCESS

L. Chater et al. / Open Journal of Pediatrics 3 (2013) 291-293

292

Figure 2. Computed tomography scan of the abdomen and

pelvis revealed a hypodense collection arround the pubic

symphis.

Figure 3. Computed tomography scan of the pelvis: an

osteolytic appearance of pubic symphis.

Figure 4. Computed tomography scan of the pelvis in 3D

showed an osteolytic appearance of pubic.

The symphis pubis was explored through a Pfannen-

stiel-type incision. 3 cc of the pus was encountered and

the bone appeared soft and distinctly abnormal. Bacterio-

logical study showed gram positive cocci, and culture

yielded a light growth of Staphylococcus aureus. The

staphylococcus was sensitive to flucloxacillin, so this

drug was given intravenously for 10 days, then orally.

Histopathological study of fragments of bone tissue from

the lesion was consistent with the diagnosis of the os-

teomyelitis of the pubis.

The boy remained without fever and the local pain

disappeared. His gait gradually returned to normal. His

white blood cell count normalized and his CRP level was

descending.

3. DISCUSSION

Osteomyelitis of the pelvic bones accounts for between

3% and 8% of cases of osteomyelitis in childhood [2].

Localization in the bones around the pubic symphysis is

very rare. And the invo lvemen t of th e pub ic sy mphysis is

exceptional and often undiagnosed condition causing

abdominal pain.

Osteomyelitis of the pubis in athlete is exceptional

with only nineteen cases reported in the literature. The

age of onset varies between ten and 28 years [3,4].

The pathophysiology remains unclear. In athletes,

some authors have discussed the role of pre-existing

damage of the pubis by the microtrauma which would

promote bacterial infection during a transitional bac-

teremia [3-5].

A detailed medical history is necessary to help the

doctor to make the diagnosis. Indeed, osteomyelitis of

the athlete usually occurs in the aftermath of a sport.

Usually there is a history of fever at the onset of the ill-

ness [6]. Thorough examination of the groin, abdomen,

hips, spine and lower limbs is essential [7].

Sometimes, clinical examination can objectify sensi-

tivity or defense of the right iliac fossa or next to the

pubic symphysis. These symptoms can be easily con-

fused with acute appendicitis [1] especially if they are

associated with vomiting and febrile syndrome as is the

case of our patient, hence the importance of a good in-

terview and a thorough clinical examination to avoid

abusive laparotomy.

The diagnosis of osteomyelitis is essentially clinical.

Laboratory data are not required for the diagnosis. There

may be an increased leukocyte cells count and an ele-

vated sedimentation rate, similar to data fo und with acu te

abdominal pain.

The radiograph of the pelvis centered on the pubis of-

ten shows irregular cortical and osteolysis. Later appears

bone sclerosis [5,8,9]. These radiographic signs appear a

few weeks after the onset of clinical symptoms [4,5,8].

L. Chater et al. / Open Journal of Pediatrics 3 (2013) 291-293

293

Ultrasound can explore early and quite different facets of

the pelvic bone in search of a subperiosteal abscess.

Bone scintigraphy can also provide early signs showing a

hypersignal in pubic symphysis [4].

OPEN ACCESS

MRI appears the most effective for the diagnosis of

osteomyelitis of the pubis [8]. It shows signs of edema

and inflammation resulting in abnormal signal of the

bone and the symphysis, or muscles. This is a crucial

consideration in assessing the presence and extent of

pubic infection. The typical appearance is localized with

decreased signal on T1-weighted images and signal en-

hancement in T2-weighted image area.

Staphylococcus aureus is the organism most com-

monly involved. Its isolation is made by blood cultures

and puncture-aspiration, if not by open surgery [3,8,10].

The main differential diagnosis is with osteitis pubis in

athletes. Originally described by Beer in 1924, osteitis

pubis is an inflammatory process and non-infectious

[8,9,11-13]. The sports activity is a predisposing factor

[4,6-9,12,14]. It usually occurs after surgery of the uro-

genital tract. Osteitis of the athlete could increase the risk

of osteomyelitis [12].

The treatment of pubic osteomyelitis requires appro-

priate antibiotic. Initially antibiotics are given intrave-

nously for two weeks, followed by oral antibiotics for at

least six weeks. In rare cases, surgery is necessary to

drain a retropubic abscess, curettage of the lesion or re-

moval of bone sequestration [3,10].

4. CONCLUSIONS

A good knowledge of the disease should allow a diagno-

sis before the stage of subperiosteal abscesses and early

treatment, which makes the exceptional surgical indica-

tions.

These conditions are often overlooked or masked by

abdominal pain, which may lead to unnecessary tests and

procedures.

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