Open AccessCase report A novel observation of pubic osteomyelitis due to Streptococcus viridans after dental extraction: a case report Naseem Naqvi*1, Rizwana Naqvi2, Christopher Wong3
Trang 1Open Access
Case report
A novel observation of pubic osteomyelitis due to Streptococcus
viridans after dental extraction: a case report
Naseem Naqvi*1, Rizwana Naqvi2, Christopher Wong3 and Sushmita Pearce4
Address: 1 Department of Acute Medicine, Dumfries & Galloway Royal Infirmary, UK, 2 Department of Medicine, Macclesfield District General
Hospital, East Cheshire NHS Trust, UK, 3 Department of Renal Medicine, Aintree University Hospitals NHS Trust, Liverpool, UK and 4 Department
of Medicine, Royal Albert Edward Infirmary, Wigan, UK
Email: Naseem Naqvi* - naseemnaqvi@doctors.org.uk; Rizwana Naqvi - drriz00@yahoo.com;
Christopher Wong - Christopher.Wong@aintree.nhs.uk; Sushmita Pearce - Sushmita.Pearce@wwl.nhs.uk
* Corresponding author
Abstract
Introduction: Pubic osteomyelitis should be suspected in athletic individuals with sudden groin
pain, painful restriction of hip movements and fever It is an infrequent and confusing disorder,
which is often heralded by atypical gait disturbance and diffuse pain in the pelvic girdle The most
common pathogen is Staphylococcus aureus but, on occasions, efforts to identify infectious agents
sometimes prove negative Pubic osteomyelitis due to Streptococcus viridans has not been reported
previously in the literature
Case presentation: We describe the case of a fit 24-year-old athlete, who had a wisdom tooth
extracted 2 weeks prior to the presentation, which could have served as a port of entry and
predisposed the patient to transient bacteraemia
Conclusion: S viridans is well known for causing infective endocarditis of native damaged heart
valves, but to the best of the authors' knowledge it has not been reported previously as a cause of
pubic osteomyelitis We believe that this case should alert physicians to the association between
dental procedures and osteomyelitis of the pubis secondary to S viridans.
Introduction
Pubic osteomyelitis is an uncommon osseous infection It
accounts for 2% of all osteomyelitis of bone [1,2] Groups
at risk include intravenous drug users [3], people with
dia-betes and patients who have undergone urological and/or
obstetrical procedures [4] Another, less well-known
pre-disposing factor is strenuous physical activity in athletes
[1] The most common pathogen causing pubic
osteomy-elitis is Staphylococcus aureus We describe the case of a
patient with pubic osteomyelitis due to Streptococcus
viri-dans, which developed after dental extraction.
Case presentation
A 24-year-old, previously fit and well, male fitness instruc-tor and football player presented to the emergency depart-ment complaining of pain in his groin and buttocks Symptoms started 3 days before he presented to the hos-pital, and he had engaged in strenuous exercise and jog-ging for 7 hours the day before admission to the hospital
He thought initially that he had sprained his groin mus-cles while exercising and decided to defer coming to the hospital There was no other significant past medical his-tory of any illnesses, although the patient reported having
Published: 31 July 2008
Journal of Medical Case Reports 2008, 2:255 doi:10.1186/1752-1947-2-255
Received: 23 August 2007 Accepted: 31 July 2008 This article is available from: http://www.jmedicalcasereports.com/content/2/1/255
© 2008 Naqvi et al; licensee BioMed Central Ltd
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Trang 2had an extraction of a wisdom tooth 2 weeks prior to this
presentation
On examination in the emergency department, he was a
fit-looking man who appeared very anxious He was
brought into the emergency department in a wheelchair
On initial assessment in the emergency department, he
was pyrexial with a temperature of 38.6°C, blood pressure
127/77 mmHg, and a regular pulse of 73 beats per
minute On examination of his musculoskeletal system,
he was unable to stand and required the support of two
people Examination of the lower limbs revealed painful
restriction of hip flexion and extension, with a power of 5/
5 in both hips and knees There was no overlying
ery-thema or tenderness over the hip joints On neurological
examination, sensations were intact to all modalities
(intact light touch, pinprick, joint position and vibration
sense) with a flexor plantar response There were no
cra-nial nerve palsies and the cerebellar examination did not
reveal any ataxias or nystagmus No abnormalities were
detected on cardiovascular, respiratory and abdominal
examination, apart from mild tenderness in the lower
abdomen without guarding or rebound Bowel sounds
were present and genital examination was unremarkable
with good anal tone No tenderness was elicited on
exam-ination of the spine
Initial investigations revealed a normal full blood count
(haemoglobin 15.2 g/litre, white blood cell count 8.7 ×
109/litre with a neutrophil count of 6.8 × 109/litre and
platelets of 412 × 109/litre), normal urea, creatinine and
electrolytes with the exception of raised C-reactive protein
(CRP) at 142 mg/litre He was admitted to the acute
assessment ward with the possible differential diagnosis
of acute myositis or pelvic and/or psoas abscess, and
blood cultures were performed An urgent computed
tom-ography (CT) scan of his abdomen and pelvis did not
reveal any evidence of psoas or pelvic abscess and serum
creatinine kinase levels were 40 U/litre Other enzymes
including lactate dehydrogenase, aldolase, aspartate
transaminase and alanine transaminase were all within
normal limits
On the second day of admission, he started having
swing-ing pyrexia (body temperature spikswing-ing to 39°C and
touch-ing the baseline of 36.6°C every 6 hours) with rigors At
that time, his weakness and pain were severe enough to
limit even turning and sitting up in bed Repeat
examina-tion revealed severe tenderness to palpaexamina-tion over the
sym-physis pubis, more marked on the left Initial sets of blood
cultures revealed heavy growth of S viridans He was
com-menced on high doses of ceftriaxone (2 g three times a
day) and gentamicin (80 mg once a day) A magnetic
res-onance imaging (MRI) scan of the pelvis suggested
mar-row oedema of the left pubic bone extending all the way
up to the left sacro-iliac joint and soft tissue swelling of the pubic symphysis, changes highly suggestive of osteo-myelitis of the left pubic ramus (Figure 1)
A bone scan showed increased uptake of contrast over the left pubic ramus and subsequent needle aspiration of the
left pubic bone grew S viridans on cultures Further
inves-tigations to exclude any potential cause of immunodefi-ciency, including human immunodeficiency virus testing, were negative
The patient gradually improved on intravenous antibiot-ics, started ambulating and became apyrexial after a week's course of antibiotics The level of CRP came down
to 50 mg/litre from an initial value of 142 mg/litre He was later discharged from the hospital on 4 weeks of oral clindamycin He was reviewed in the clinic 4 weeks after his discharge and showed complete clinical recovery The CRP level had returned to normal (less than 5 mg/litre) and subsequent blood cultures were sterile
Discussion
Pubic osteomyelitis should be suspected in athletic indi-viduals with sudden abdominal, pelvic or groin pain, painful restriction of hip movements and fever The pathogenesis of this disease in athletes is thought to involve pre-existing trauma or sports injury and subse-quent seeding of this area during transient bacteraemia following surgical procedures, for example, dental extrac-tion [4] The main differential diagnosis of pubic osteo-myelitis is osteitis pubis
Osteitis pubis is a painful, noninfectious, self-limited inflammatory condition of the pubic bone associated mainly with genitourinary surgery, but it also occurs fol-lowing minor trauma or as a manifestation of overuse in athletes [5] Whereas the initial clinical symptoms of the two conditions may be similar, the presence of fever and progressive clinical deterioration favours an infectious process and emphasises the need for repeated cultures It
is still unclear why athletes are at risk of developing this rare condition This condition commonly occurs in spe-cific athletic endeavours, such as football or running, that involve strenuous physical exercise and may produce excessive stress to the pelvis In addition, it has been sug-gested that the immune system in athletes may be com-promised during strenuous exercise, which might increase their susceptibility to transient bacteraemia caused by minor skin or mucous membrane trauma; however, this issue is debatable Finally, a pre-existing subclinical ostei-tis pubis may make athletes locally susceptible to osteo-myelitis [5] It is important to recognise that both conditions may occur simultaneously in one patient [6]
Trang 3Osteomyelitis of the pubic bone is an infrequent and
con-fusing disorder, which is often heralded by atypical gait
disturbance and diffuse pain in the pelvic girdle [7]
Diag-nosis of pubic osteomyelitis is often delayed in young
patients as it occasionally mimics pelvic pathology
result-ing in unnecessary invasive procedures in the search for
the cause of an acute onset of lower abdominal pain
Symptoms of fever, nausea, vomiting, anorexia and lower
abdominal pain and tenderness in a young patient can
easily be mistaken for those of acute appendicitis The
classic symptoms of pubic osteomyelitis include pain in
the groin or adjacent areas with radiation to the thigh and
limitation of motion The classic signs include local
ten-derness and swelling, a high temperature, occasionally an
elevated erythrocyte sedimentation rate and leucocytosis
The port of entry of infection is often unclear and any
his-tory of preceding injuries, infections or dental procedures
should be specifically looked for when eliciting history
Any history of painful restriction of hip movements
should be specifically explored as it is often wrongly
diag-nosed as true muscular weakness of the pelvic girdle
mus-cles or septic arthritis of the hip joint
We found 19 reported cases of pubic osteomyelitis in
ath-letes, including our patient, in a review of the literature
[8] All patients were active athletes who participated in
strenuous physical activity In most of the 18 other
patients, diagnosis was delayed The average time from
the start of symptoms to diagnosis was 13 days (range 1 to
30 days) Changes in plain radiographs of the pubic bone
usually appear only several weeks after the clinical
presen-tation of osteomyelitis and, therefore, are not reliable in
making the diagnosis Typical changes include pubic
rare-faction and osteolysis Sclerosis may appear later A tech-netium bone scan shows increased uptake and may facilitate an earlier diagnosis In three patients, diagnosis was made only after aspiration and culture In most of the cases reviewed, the infectious agent was identified The
most common pathogen was Staphylococcus aureus, which
was identified in cultures of blood or local aspirate [9]
To the authors' knowledge, S viridans has not been
previ-ously reported as a cause of pubic osteomyelitis, although there are case reports of vertebral osteomyelitis caused by
S viridans in people with diabetes [10,11] and two cases
of femoral osteomyelitis due to S viridans [12,13] S
viri-dans are aerobic, Gram-positive cocci most abundant in
oral flora as commensals and are well known for causing infective endocarditis of native damaged heart valves although, in our patient, there was no clinical evidence of endocarditis as evidenced by a normal transoesophageal echocardiogram Dental extraction in our patient could have served as a port of entry and predisposed the patient
to transient bacteraemia
Conclusion
Pubic osteomyelitis is a challenging diagnostic dilemma
We believe that this novel observation should alert physi-cians to the association between dental procedures and
pubic osteomyelitis due to S viridans It is important to
take a history of dental extraction in all patients who present with fever and pelvic pain It is also important to investigate patients with MRI scans as X-rays are neither sensitive nor specific enough for detecting osteomyelitis Changes in plain radiographs of the pubic bone usually appear only several weeks after the clinical presentation of osteomyelitis and therefore are not reliable in making the diagnosis Early diagnosis and treatment can prevent sub-sequent deformities of the pelvic bones and morbidity due to chronic osteomyelitis and joint deformities
Competing interests
The authors declare that they have no competing interests
Authors' contributions
NN Chief author, RN Assisted in the preparation of man-uscript, SP Consultant in-charge for the patient's manage-ment, as well as ideas for the writing of the case report,
CW Proof-read the manuscript
Consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images A copy of the written consent is available for review by the Editor-in-Chief of this journal
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Magnetic resonance imaging scan of the pelvis showing
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Figure 1
Magnetic resonance imaging scan of the pelvis
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ramus.
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