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ECR 2013 / C-2543
Septic arthritis of the pubic symphysis: Report of 5 cases and review of literature
Congress: ECR 2013
Poster No.: C-2543
Type: Scientific Exhibit
Keywords: Infection, Arthritides, Acute, Laboratory tests, Diagnostic procedure, Comparative studies, MR, CT-High Resolution, Conventional radiography, Pelvis, Musculoskeletal system, Musculoskeletal joint
Authors: J. Quispe Bravo1, J. A. Narváez2, G. C. Rivera Sierra3, J. Hernández Gañán4, E. De Lama Salvador5, R. Mast2; 1L´Hospitalet de Llobregat (Barcelona) , ESP/ES, 2HOSPITALET DE LLOBREGAT/ES, 3L´Hospitalet de Llobregat (Barcelona) /ES, 4L' Hospitalet de Llobregat/ES, 5Barcelona/ES
DOI:10.1594/ecr2013/C-2543

Methods and Materials

Retrospective review of the cases of septic arthritis diagnosed in a tertiary care hospital, between July 2009 and June 2012.

 

CASE 1:
- 62-year-old male patient who presented at the emergency room with fever (38 ° C) for 3 hours of evolution, and perineal and sacroiliac joint pain of 14 days duration.
- Antecedents: retropubic prostatic adenomectomy in June 2009 for BPH.

- Laboratory data: leukocytosis and increased ESR and CRP levels.

- Positive urine culture of Pseudomonas aeruginosa, serial blood cultures were negative.

 

- CT  (Fig. 1 Fig. 2  Fig. 3 ) and Radiographs ( Fig. 4 ) were demonstrative of arthritis of the symphysis pubis.

 

 

Fig. 1: Fig 1 Case 1. Septic arthritis of the pubic symphysis. Image showing joint space widening of the pubic symphysis, with small cortical erosions in both facets. Axial CT.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 4: Fig 4 case 1.- Radiography of the pelvis, which shows pubic symphysis sclerosis regarding history of septic arthritis in resolution.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

- Treatment with broad-spectrum antibiotics, intravenously for 4 weeks and oral for two 2 weeks achieved clinical improvement. At the end of the treatment, the patient had no pain and remained afebrile
-No recurrence occurred during the monitoring period (2 years)

 

CASE 2:
- 64-year-old male was visited at the emergency room with fever (38° C), and pubic pain radiating to the perineum and buttocks that limits ambulation during the last two months.
- Antecedents: prostate acinar adenocarcinoma diagnosed in 2010, which underwent surgery with robotic-guided radical prostatectomy in May 2010.
- Laboratory data: leukocytosis and increased ESR and CRP leves.

 Urine cultures and serial blood culture were negative.

 

- CT (Fig. 5 Fig. 6 Fig. 7  ) and Radiographs (Fig. 8 ) were diagnostic of septic arthritis of the pubic symphisis.

 

Fig. 6: Case 2. Septic arthritis of the pubic symphysis in a 64-year-old man. Axial CT. Osseous destruction at the pubic symphysis.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 8: Case 2. Septic arthritis of the pubic symphysis in a 64-year-old. Plain A-P radiograph of the pelvis shows osseous destruction.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

A CT-guided Fine Needle Aspiration (FNA) was positive for Pseudomonas aeruginosa.

 

- Treatment includes broad spectrum antibiotics, intravenously for 4 weeks and oral for 2 weeks.
- Clinical course was good. At the end of the treatment, the patient had no pain and remained afebrile
No recurrence occurred during the monitoring period (2.5 years)

 

CASE 3:
- A 60-year-old female patient was derived to our hospital to study pubic and right groin inflammatory pain.
-Antecedents: right kidney and liver abscess by E. Coli in 2003; left nephrectomy for chronic pyelonephritis, as well as posterior right pyelonephritis with E. coli sepsis.
- Laboratory data: leukocytosis, and increased levels of ESR and PCR.

 Urine and serial blood cultures were negative.

- Fine-needle aspiration of periarticular fluid collection guided by CT obtained purulent material, with positive culture for S. aureus.

 

- CT (Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14  ), Radiographs (Fig. 15 ),  were diagnostic of septic arthritis of the symphysis pubis.

 

 

Fig. 12: Case 3. Erosions with joint space widening Contrast-enhanced coronal CT.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 15: Case 3. Septic arthritis of the pubic symphysis caused by Staphylococcus aureus in a 60-year-old female. A-P radiograph widened symphysis pubis as a sign of abscess formation in the symphysis.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 


- Treatment with broad spectrum antibiotics during 6 weeks (IV 4 weeks and  oral 2 weeks) achieved remission of symptoms.
- Two months later, patient presented relapse of infection in the pubic symphysis, with high fever and pubic pain. At this moment, fluid collections  were identified in the adductor and in the right iliopsoas muscles by ultrasound and CT.

- No recurrence occurred during the monitoring period (1 year)

 

 

CASE 4:

 


- 61- year-old female patient was derived to our hospital for fever (39ºC) of four days duration and pubic pain of 10 days duration, with functional limitation. This patient presented a previous S.aureus bacteremia, due tonative valve endocarditis.

-Antecedents: 10 days before the admission, a transvaginal ultrasound examination was performed. A colpoperineoplasty and vaginal hysterectomy for uterine prolapse was performed in 2009.
- Laboratory data: leukocytosis, neutrophilia and increased ESR and CRP; thrombocytopenia,

Blood cultures were positive for S. aureus.

-CT (Fig. 16 Fig. 17 Fig. 18  ), ultrasound ( Fig. 19 ), TC (Fig. 20 Fig. 21 Fig. 22 Fig. 23  Fig. 24 ),Radiographs ( Fig. 25 ), were diagnostic of septic arthritis of the symphysis pubis.

An ultrasound-guided FNA was positive for S.aureus.

 

 

Fig. 16: Case 4. - Septic arthritis of the symphysis pubis in a 61 year old woman. Distension of the joint capsule of the symphysis associated to abscesses at the left adductor muscle. Contrast-enhanced axial CT. Blood cultures were positive for S. aureus.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 21: Case 4. - Signs of septic arthritis of the pubic symphysis, with lower paraarticular and adductor muscles left abscess . Contrast-enhanced coronal CT.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

- Treatment with broad-spectrum antibiotics (IV for 4 weeks and oral for 2 weeks), and several percutaneous image-guided joint aspirations were performed, but persistence of periarticular abscesses required surgical debridement, and curettage of the pubic symphysis.

 

- Six months later, patient presented severe mitral valve disease, secondary to previous S. aureus bacterial endocarditis, and was scheduled for cardiac surgery

 

 

CASE 5:


A 45-years-old man presented at emergency department with fever (38° C), pubic pain radiating to the perineum and buttocks. He referred walking limitation for two months, as well as right inguinal mass in the last days.

-Antecedents: high-energy traumatism (motorcycle accident) in 1991 requiring nephrectomy, splenectomy and orchiectomy, as well as unstable pelvic fracture treated with external fixation. Posterior complications included pubic symphysis diastasis and urinary ureteroescrotal fistula, with pyuria and inguinal abscess, which required new surgical intervention in 1994.
- Laboratory data: leukocytosis and increased ESR and CRP levles.,

Urine and serial blood cultures were negative.


- Retrograde cysto-urethrograph  ( Fig. 26 ), ultrasound ( Fig. 27 ), radiographs (Fig. 28  ), CT ( Fig. 29 Fig. 30 Fig. 31 Fig. 32 Fig. 33 Fig. 34  ), CT (Fig. 36 ),   and Radiographs ( Fig. 37 ), demonstrated septic arthritis of the pubic symphysis, with periarticular, right inguinal abscess and fistula in the middle third of the prostatic urethra.

 

 

Fig. 26: Case 5. - 45 year old male patient. Retrograde cystourethrography reports urethral fistula.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 27: Case 5. - 45 year old male patient. Ultrasound soft tissue collection reports asbcesification at right inguinal level.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 28: Case 5. - 45 year old male patient. Radiography of pelvis with pubic diastasis with not sharply delimited oseus margins.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 32: Case 5. - 45 year old male patient. Septic arthritis pubic with distension of the joint capsule, extending into space prevesical. Bilateral external iliac lymph nodes.
References: Radiodiagnostico, Hospital Universitario Bellvitge, Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

An ultrasound-guided FNA was performed. Obtained material was sent to microbiological culture, which was positive for polymicrobial agents.

 

- Treatment with broad spectrum antibiotics (IV for 4 weeks and oral for 2 weeks) achieved initial clinical improvement, but 4 months latter, the patient presented again with high fever and inflammatory pain. At the this moment, a double surgery was performed by urologists and orhopedists, with resection of the urinary fistula and curettage of the bone cavity. Two fistulas were evident from the skin to joint cavity of the pubic symphysis and prostatic urethra.
- Clinical course was good, with no fever, and pain improvement.

 

- 2 months later, the patient was readmitted by the same symptoms. At this moment, it was performed a new pubic symphysis debridement + curettage of the bone cavity.

Two years later, a surgical intervention was performed to excise a new cutaneous fistula. Plastic reconstruction was performed with a vascularized myocutaneous flap.

Late-stage complications include bladder incontinence, and pelvic lymphocele.

 

 

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