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

Disclosures

August 09, 2021

In both osteomyelitis pubis and osteitis pubis, patients usually present with vague unilateral or bilateral pelvic, groin, or lower abdominal pain. The pain generally worsens with exercise, and patients may report difficulty ambulating. When standing or walking, patients tend to lean forward secondary to adductor or rectus muscle spasm. Upon examination, abduction of the hip results in significant pain, and the patient's range of movement may be diminished as well.

The insidious onset and nonspecific nature of these symptoms, coupled with the unfamiliarity of clinicians with these conditions, leads to a high rate of delayed diagnosis. These entities are often misdiagnosed as subclinical inguinal hernias, coxarthrosis, and adductor muscle spasms.[3] One review of 18 cases of osteomyelitis pubis reported an average delay of 13 days from the onset of symptoms to diagnosis (range, 1-30 days).[7]

In osteomyelitis pubis, symptoms tend to progressively worsen, whereas osteitis pubis is largely self-limited. The key differentiating factor between these conditions is the establishment of (or absence of) infection, which is implicated by signs of systemic infection (such as fever, tachycardia, vomiting, and elevated inflammatory markers) but is only confirmed by verification of the presence of organisms either in blood cultures (in severe cases) or by aspiration or biopsy of the pubic symphysis region.

Plain radiographs are of limited value in the initial stages of both conditions because radiographic changes occur weeks later. In the early stages of disease, MRI is much more sensitive; both conditions will produce some edema of the bone marrow, but the presence of fluid and extensive soft-tissue reaction raises suspicion for osteomyelitis.[4] Three-phase bone scintigraphy normally shows increased uptake in all three phases in osteomyelitis pubis, but uptake is increased only in the mineralization (or delayed) phase in the case of osteitis pubis.[3]

The symptoms and signs of established osteomyelitis pubis (lower abdominal pain, fever, vomiting, tachycardia, and elevated inflammatory markers) closely mimic those of more common lower abdominal pathologies, such as appendicitis or diverticulitis; as such, the rates of negative laparotomy and laparoscopy in these patients are fairly high.[4,6,8]

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