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A case of suprapubic pain

Published:April 20, 2021DOI:https://doi.org/10.1016/j.ejim.2021.03.023

      Case Description

      A 71-year-old male with a past medical history of prostate cancer s/p radiation treatment seven years ago. He presented to the emergency department with acute onset pain in the suprapubic region. He denied associated symptoms of nausea, vomiting, urinary urgency, urinary frequency and dysuria. He was afebrile and hemodynamically stable on presentation. On abdominal examination he had suprapubic tenderness. Initial basic lab work including CBC, BMP and lactate levels were normal. Urinalysis was negative for any signs of infection. CT abdomen and pelvis with contrast was normal. MRI abdomen and pelvis is shown in Figure 1. What is the diagnosis?
      Fig. 1
      Fig. 1MRI abdomen revealeda T2 hyperintense signal within the pubic symphysis fibrocartilaginous joint space, which communicates with small T2 hyperintense fluid collections and intramuscular edema involving the left adductor musculature.

      Diagnosis

      Septic arthritis of the pubic symphysis

      Discussion

      MRI abdomen revealeda T2 hyperintense signal within the pubic symphysis fibrocartilaginous joint space, which communicates with small T2 hyperintense fluid collections and intramuscular edema involving the left adductor musculature. These findings were suggestive of pubic symphysis septic arthritis and infectious myositis changes. An ultrasound guided joint aspiration was performed by interventional radiology. The final cultures grew beta-hemolytic Streptococcus dysagalacticea sensitive to cephalosporins. He was treated with four weeks course of oral cephalosporins with complete resolution of his symptoms. Septic arthritis of the pubic symphysis is a rare condition. The major risk factors elucidated in the literature are incontinence surgery in females, overuse in athletes, history of pelvic malignancies and IV drug use. [
      • Ross JJ
      • Hu LT.
      Septic arthritis of the pubic symphysis: a review of 100 cases.
      ]. Most common causative organism is Staphylococcus. [
      • Ross JJ
      • Hu LT.
      Septic arthritis of the pubic symphysis: a review of 100 cases.
      ] CT and radiographs can be normal in the early phases. MRI is the most sensitive modality to confirm the diagnosis..It is often confused as osteitis pubis, a non-infectious inflammatory condition of the pubic symphysis caused by sheer force. [
      • Pauli S
      • Willemsen P
      • Declerck K
      • et al.
      Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature.
      ]. Culture of the infected joint is required to differentiate. Antibiotics are required for management of septic arthritis. However, osteitis pubis is self-limiting condition which improves with supportive management.

      Declaration of Competing Interest

      No authors have any financial or other conflicts of interest to declare.

      References

        • Ross JJ
        • Hu LT.
        Septic arthritis of the pubic symphysis: a review of 100 cases.
        Medicine. 2003; 82: s340-s344
        • Pauli S
        • Willemsen P
        • Declerck K
        • et al.
        Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature.
        Br J Sports Med. 2002; 36: 71-73