BioMed Central Page 1 of 4 (page number not for citation purposes) Journal of Medical Case Reports Open Access Case report A novel observation of pubic osteomyelitis due to Streptococcus viridans after dental extraction: a case report Naseem Naqvi* 1 , Rizwana Naqvi 2 , Christopher Wong 3 and Sushmita Pearce 4 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. Journal of Medical Case Reports 2008, 2:255 http://www.jmedicalcasereports.com/content/2/1/255 Page 2 of 4 (page number not for citation purposes) had 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 × 10 9 /litre with a neutrophil count of 6.8 × 10 9 /litre and platelets of 412 × 10 9 /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 spiking 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 palpation 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]. Journal of Medical Case Reports 2008, 2:255 http://www.jmedicalcasereports.com/content/2/1/255 Page 3 of 4 (page number not for citation purposes) Osteomyelitis 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. References 1. Amichay Merovitz A Meirovitz, Gotsman Israel, Lilling Menachem, Bogot Naama R, Fridlender Zvi, Wolf Dana G: Osteomyelitis of Magnetic resonance imaging scan of the pelvis showing extensive marrow oedema of the left pubic ramusFigure 1 Magnetic resonance imaging scan of the pelvis show- ing extensive marrow oedema of the left pubic ramus. Publish with BioMed Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral Journal of Medical Case Reports 2008, 2:255 http://www.jmedicalcasereports.com/content/2/1/255 Page 4 of 4 (page number not for citation purposes) the pubis after strenuous exercise; a case report and review of literature. J Bone Joint Surg Am 2004, 86:1057-1060. 2. McHenry MC, Alfidi RJ, Wilde AH, Hawk WA: Hematogenous osteomyelitis; a changing disease. Cleve Clin Q 1975, 42:125-153. 3. del Busto R, Quinn EL, Fisher EJ, Madhavan T: Osteomyelitis of the pubis. Report of seven cases. JAMA 1982, 248:1498-1500. 4. Seve P, Pu , Sève P, Boibieux A, Pariset C, Clouet PL, Bouhour D, Tigaud S, Biron F, Chidiac C, Peyramond D: Pubic osteomyelitis in athletes. Rev Med Interne 2001, 22:576-581. 5. Diane V, Scott Kendall G: Presentation of osteitis and osteomy- elitis pubis as acute abdominal pain. The Permanente Journal 2007, 11(2):. 6. Rosenthal RE, Spickard WA, Markham RD, Rhamy RK: Osteomyeli- tis of the symphysis pubis: a separate disease from osteitis pubis. Report of three cases and review of the literature. J Bone Joint Surg Am 1982, 64(1):123-8. 7. Ukwu HN, Graham BS, Latham RH: Acute pubic osteomyelitis in athletes. Clin Infect Dis 1992, 15:636-638. 8. Karpos PA, Spindler KP, Pierce MA, Shull HJ Jr: Osteomyelitis of the pubic symphysis in athletes: a case report and literature review. Med Sci Sports Exerc 1995, 27:473-479. 9. Pauli S, Willemsen P, Declerck K, Chappel R, Vanderveken M: Osteo- myelitis pubis versus osteitis pubis: a case presentation and review of the literature. Br J Sports Med 2002, 36:71-73. 10. Buchman AL: Streptococcus viridans osteomyelitis with endo- carditis presenting as acute onset lower back pain. J Emerg Med 1990, 8:291-294. 11. Rose HD: Viridans streptococcal osteomyelitis of the spine. J Bone Joint Surg Am 1981, 63: 506. 12. Roberts DE: Femoral osteomyelitis after tooth extraction. Am J Orthop 1998, 27:624-626. 13. Ribner BS, Freimer EH: Femoral osteomyelitis caused by Strep- tococcus viridans. 1982, 142(9):1739. . Central Page 1 of 4 (page number not for citation purposes) Journal of Medical Case Reports Open Access Case report A novel observation of pubic osteomyelitis due to Streptococcus viridans after. after dental extraction: a case report Naseem Naqvi* 1 , Rizwana Naqvi 2 , Christopher Wong 3 and Sushmita Pearce 4 Address: 1 Department of Acute Medicine, Dumfries & Galloway Royal Infirmary,. 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 spiking to 39°C