Abstract

Osteomyelitis of the pubic symphysis is a rare diagnosis, representing less than one percent of all cases of osteomyelitis reported. The risk factors from the literature review have been identified to be young athletes and females undergoing gynaecological or urological surgery. Diagnosis is usually difficult and is based on multitude investigations such as blood tests and radiological imaging like a computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan. The aetiological organisms include Staphylococcus aureus, Gram negative and polymicrobial agents. The management is multidisciplinary and consists of antibiotic regime with symptomatic control. A 64-year-old female presented to the Emergency department with a 6-week history of worsening right lower abdominal, groin and buttock pain. There was no obvious trauma but the patient felt she had sustained a groin injury whilst moving boxes at home. When the pain failed to resolve with analgesia, she decided to try acupuncture to this area. The acupuncture initially settled the abdominal and groin pain, but the pain soon recurred along with right buttock pain. On presentation to the hospital, she was afebrile with moderately elevated inflammatory markers. Clinical examination revealed tenderness on palpation over the right lower quadrant and towards the suprapubic region with no evidence of herniae or masses. Her mobility was significantly reduced at the right hip due to severe pain. Neurological examination confirmed tenderness over the L2-3 dermatomal distribution and reduced hip flexion due to pain. Computed Tomography (CT) of chest, abdomen and pelvis highlighted changes of pubic symphysis osteomyelitis; she was promptly started on empirical antibiotic treatment after blood cultures were taken. She went on to have MRI of the pelvis which confirmed the diagnosis of pubic symphysis osteomyelitis as well as pyomyositis extending in both adductor muscle compartments. On advice of the Microbiology team the patient had intravenous cefuroxime and metronidazole.