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Psoas Abscess Associated with Pubic Symphysis Osteomyelitis

(A) Simple pelvic radiology showed a pubic diastasis visualizing ill-defined bone margins without fracture lines. (B) The tomography showed the presence of bone destruction, a consequence of the pubic symphysis osteomyelitis. Also, a retroperitoneal abscess was found, approximately 30 cm long, with muscle involvement of the psoas and ipsilateral ileopsoas.

Infectious osteitis pubis is often diagnosed as sterile osteitis pubis, so this diagnosis requires a high level of suspicion.

The following case is about a 56-year-old woman with a personal history of diabetes mellitus and secondary complications related to her illness, due to poor glycemic control. The patient went to the Emergency Department as a result of a 3-month history of coxalgia. The pain did not respond to major opioids and even increased, precluding the woman from walking. In the physical examination, the patient presented great pain with passive and active mobilization of the entire joint range on the right hip. Analytical testing was performed, with a leukocyte count of 27.93 × 103/dL and a erythrocyte sedimentation rate of 125 mm/h. The results found in the simple pelvic radiology and tomography are shown in the Figure.

Initially, percutaneous drainage was performed with culture of abscess aspiration. A Staphylococcus aureusmethicillin-sensitive was isolated and treated with cloxacilin. In the absence of clinical improvement, surgical debridement was performed and, after 5 weeks with antibiotic treatment, the patient was discharged, with great decrease in her symptoms as well as the size of the abdominal collections. The patient was followed up, and 3 months later a favorable evolution was verified.

Frequently, pubic osteomyelitis is an underdiagnosed disorder.1 Most of the cases are initially classified as osteitis pubis,2 especially for patients who have undergone urological surgery (24%). According to the latest literature review, surgery or recent genitourinary manipulation is the most important predisposing factor, followed by sports practice, pelvic neoplasic process, and injection drug use. In the case presented, the patient did not present any of the risk factors mentioned. However, it can be assumed that it was her diabetes that could have caused an immunosuppression situation, prediposing her to certain infectious diseases.

The most prevalent clinical characteristics within this pathology include increased pubic sensitivity (88%), followed by fever >38°C (74%) and pain at rest, as well as pain present during limb mobilization. In the described case, all symptoms occurred except for fever, which was not evident, probably due to the fact that the abscess was encapsulated and did not have an effect at a systemic level.

The main pathogen described within the literature is S. aureus (34%), followed in prevalence by Pseudomonas aeuruginosa (24%), both accounting for more than half of the cases. Knowing the infectious etiology that causes the disorder is essential to establish a targeted antibiotic treatment and to optimize the prognosis of the underlying infectious disease. In addition, the presence of a psoas abscess was associated (as it can occur in cases of vertebral osteomyelitis3), whose antigravity distribution could be attributed to the fact that the patient remained at bedrest for a long period of time due to the pain suffered.

Imaging diagnosis involves a computed tomography scan or magnetic resonance imaging for those patients in whom an infectious pubic osteitis is suspected, because a simple pelvic radiograph might be normal during the first disease manifestations.

The treatment is based on antibiotic therapy according to antibiogram for at least 4-6 weeks. In refractory cases, drainage guided by either computed tomography scan or surgical debridement is indicated.

In conclusion, it can be confirmed that the osteomyelitis is a rare entity that requires a high diagnostic suspicion. It is important to establish a clinical-radiological correlation and to determine the microbiological origin in order to design an individualized antibiotic therapeutic plan, assessing the possibility of draining purulent collections when necessary to achieve a favorable evolution.

Acknowledgments

We thank G. Díaz-Ibero, MD, Division of Radiology, Hospital Universitario de Getafe, Madrid.

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-Fernando Garcia-Prieto, MD, A. Casillas-Villamor, MD

This article originally appeared in the September issue of The American Journal of Medicine.

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