CME CASE STUDY Presentation of Osteitis and Osteomyelitis Pubis as Acute Abdominal Pain By Diane V Pham, MD Kendall G Scott, MD Abstract Case Presentation Osteitis pubis is the most common inflammatory condi- A previously healthy male, age 17 years, presented tion of the pubic symphysis and may present as acute ab- with a three-day history of severe right lower quadrant dominal, pelvic, or groin pain. Osteomyelitis pubis can abdominal pain. Initial workup findings, including those occur concurrently and spontaneously with osteitis pu- for a computed tomography scan of the abdomen and bis. Primary care physicians should consider these con- pelvis, were normal, and he was treated with nonste- ditions in patients presenting with abdominal and pelvic roidal anti-inflammatory drugs (NSAIDs). He returned pain. A thorough history, including type of physical ac- two days later with a fever of 38.3 ° C and worsening tivity, and a focused physical examination will be useful, sharp, constant abdominal pain, radiating to the supra- and imaging modalities may be helpful. A biopsy and pubic area and exacerbated by movement. He was nau- culture of the pubic symphysis will usually confirm the seated and anorectic and vomited nonbilious, diagnosis. Treatment for osteitis pubis generally involves nonbloody material once. His past medical history and rest and anti-inflammatory medications. Failure with this a review of systems provided no new insights. conservative treatment should alert the physician to the His abdomen was soft and nondistended, but he ex- Osteitis pubis is possibility of osteomyelitis, which needs treatment with hibited right lower quadrant tenderness with involun- a common antibiotics. Prognosis for recovery is excellent with de- tary guarding and rebound tenderness. The psoas, ob- but often finitive diagnosis and treatment. turator, and Rovsing’s signs were positive; rectal undiagnosed examination findings were normal. The leukocyte count condition causing Introduction was 12,400 cells/mL, with a polymorphonuclear leu- pain in the pubic Abdominal pain may be the presenting symptom in kocytosis. Diagnostic laparoscopy showed no defini- area, groin, and a wide range of diseases. This proposes a difficult chal- tive intra-abdominal pathology, although a long, mildly lower rectus lenge for the primary care physician. Acute pain often engorged retroperitoneal appendix was removed; the abdominal requires emergency surgical intervention, but unnec- pathologist found no inflammation. muscle. essary invasive procedures can be avoided when a good Fever and worsening abdominal and suprapubic pain Osteomyelitis history is taken and thorough physical examination is persisted, with pain radiating to both groins and pre- pubis is an conducted. Osteitis pubis is a common but often undi- venting ambulation. Additional detailed history uncov- infectious disease agnosed condition causing pain in the pubic area, groin, ered the information that the patient was an avid col- with clinical and lower rectus abdominal muscle. Osteomyelitis pubis lege soccer and tennis player and had participated in a manifestations is an infectious disease with clinical manifestations simi- soccer tournament the previous week. Examination now similar to those lar to those of osteitis pubis. These conditions are of- showed tenderness in the right lower quadrant and of osteitis pubis. ten overlooked as or masked by abdominal pain, which suprapubic and bilateral groin areas, tenderness of the may lead to unnecessary tests and procedures. This pubic symphysis, and worsening pain with abduction case report discusses the onset of acute abdominal pain of either hip. He developed bilateral inguinal lymphad- in an athlete with both osteomyelitis and osteitis pu- enopathy, with no evident skin lesion. He had nega- bis. It is important to recognize that both conditions tive findings on blood tests including total protein, al- may occur simultaneously in one patient. Failure to bumin, liver tests, complement components 3 and 4, identify both disease processes could lead to inaccu- creatine kinase, aldolase, beta 2 -microglobulin, anti-DNA, rate treatment and lifelong complications. and antinuclear antibody panel. His erythrocyte sedi- Diane V Pham, MD, (left) is a third-year family medicine resident at the Fontana Medical Center, CA. E-mail: diane.v.pham@kp.org. Kendall G Scott, MD, (right) is the Program Director for the Southern California Kaiser Permanente Residency Program in Fontana and an Adjunct Assistant Professor in the Department of Physician Assistant Education at Loma Linda University, CA. E-mail: kendall.g.scott@kp.org. 65 The Permanente Journal/ Spring 2007/ Volume 11 No. 2
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