A 28-Year-Old Soccer Player With Odd Abdominal Pain, Fatigue

Thomas D. Pinkney, MB ChB; Simon F. Hobbs, MB ChB; Timothy D. Stone, MB ChB; Tim C.F. Sykes, MD, BSc, MB BCh, FRCS


August 09, 2021


The MRI (Figure) revealed abnormal marrow signal in the pubis, with periosteal elevation and marked soft-tissue reaction. These features demonstrated a significant inflammatory condition of the pubic symphysis. These MRI findings, along with the proven bacteremia and elevated inflammatory markers, were consistent with a final diagnosis of osteomyelitis pubis.

Inflammation of the fibrocartilaginous pubic symphysis joint is rare and occurs in two forms: infective and noninfective. The noninfective variant, osteitis pubis, was first described by Beer[1] in 1924; it is a self-limited inflammatory condition of the joint and its surroundings. In contrast, osteomyelitis pubis involves infective inflammation of bone, and it accounts for 2% of all reported cases of hematogenous osteomyelitis.[2] Both conditions share a very similar clinical presentation, and distinguishing between them can be difficult.

The etiology of both osteitis pubis and osteomyelitis pubis is not fully understood; similar causative factors have been cited for both conditions. These factors include athletic overexertion, pregnancy and childbirth, urologic or gynecologic manipulation, intravenous drug abuse, and surgery.[3,4] Although the mechanisms by which surgery, childbirth, or intravenous injection result in osteomyelitis pubis can be readily explained by hematogenous dissemination or extension of local infection, athletic exertion as an cause is less straightforward. Certain sports are known to predispose athletes to injury of the groin and pubic symphysis, particularly those that involve repetitive twisting or turning motions at the pelvis, such as soccer, hockey, rugby, and tennis.[4]

One theory is that some form of low-grade localized trauma occurs in the region (which may go unnoticed by the patient), followed by a transient bacteremia opportunistically seeding the damaged area.[5] This transient bacteremia may arise from any number of innocuous causes, ranging from minor skin trauma to dental extraction.[6,7]

The most common pathogen found in patients with osteomyelitis pubis is S aureus, although in intravenous drug users it is more commonly Pseudomonas aeruginosa. In postsurgical cases, mixed gram-negative bacteria are often the causative agents.[7,8,9] Individual cases have also been reported with a wide range of other organisms, such as Streptococcus viridans, Staphylococcus epidermidis, and Salmonella species.[6,7,8]


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