Open Journal of Pediatrics, 2013, 3, 291-293 OJPed Published Online December 2013 (
Osteomyelitis of the pubis in a young athlete revealed by
severe abdominal pain
Lamiae Chater*, Karima Atarraf, Moulay Abderrahmane Afifi
Department of Pediatric Surgery, CHU Hassan II, Fez, Morocco
Email: *
Received 31 July 2013; revised 29 August 2013; accepted 7 September 2013
Copyright © 2013 Lamiae Chater et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Acute osteomyelitis is a co mmon condition in children.
Only early diagnosis prevents complications. The lo-
cation at the pubic bones is very rare, even excep-
tional at the pubis symphis. We report a case of os-
teomyelitis of the pubis in a young athlete of 14 years
old whose symptoms were discussing an acute abdo-
men, to illustrate the unusual clinical presenta tion, so
as not to miss the diagnosis and avoid unnecessary
Keywords: Osteomyelitis; Pubis; Childhood; A thlete;
Acute Abdominal Pain
Acute hematogenous osteomyelitis is a bone disease
caused by a germ usually the staphyloccocus aureus. Its
headquarters is fertile metaphysis of long bones near the
knee and far from the elbow. Diagnosis is clinical and
must be as early as possible to initiate treatment quickly,
otherwise the risk of fatal sepsis and especially the evo-
lution to the chronicity is significant [1].
Osteomyelitis of pubis represents less than 1% of lo-
cations. The pathogenesis of this entity is explained by
the location of a secondary bacteremia on undisturbed
We report a case of pubic osteomyelitis in a young
boy practicing a sporting activity revealed by acute ab-
dominal pain to illustrate the somewhat unusual pre-
A young judoka aged 14 years was admitted to our hos-
pital for severe abdominal pain. The symptoms started it
a week ago, when a history of severe right lower quad-
rant abdominal pain with a fever was developed. There
was a history of local trauma in the pelvic area 20 days
before. The boy reported worsening abdominal and su-
prapubic pain radiating to both groins and preventing
ambulation. He was vomited nonbilious. Physical ex-
amination has obj ectified a fever to 39 ˚C, and abdominal
examination showed right lower quadrant tenderness, but
remains soft. The leukocyte count was 11,400 cells/ml.
The erythrocyte sedimentation rate was 97 mm/h and the
C-reactive protein (CRP) level was 25 mg/l.
A pelvic radiography (Figure 1) showed osteolysis of
the upper inne r angl e of the right pubis wi t hout periost ea l
reaction. Ultrasonography showed a hypoechoic collec-
tion of 10 mm behind the rectus abdominis muscle. A
computed tomography scan of the abdomen and pelvis
revealed a hypodensity collection around the pubic
symphysis (Figure 2) with an osteolytic appearance of
the pubis (Figures 3 and 4). These findings were consis-
tent with osteomyelitis of the pubis with suppuration.
Figure 1. Pelvic radiography showed slight deformity with
irregularity of the right side of the pubic symphis.
*Corresponding author.
L. Chater et al. / Open Journal of Pediatrics 3 (2013) 291-293
Figure 2. Computed tomography scan of the abdomen and
pelvis revealed a hypodense collection arround the pubic
Figure 3. Computed tomography scan of the pelvis: an
osteolytic appearance of pubic symphis.
Figure 4. Computed tomography scan of the pelvis in 3D
showed an osteolytic appearance of pubic.
The symphis pubis was explored through a Pfannen-
stiel-type incision. 3 cc of the pus was encountered and
the bone appeared soft and distinctly abnormal. Bacterio-
logical study showed gram positive cocci, and culture
yielded a light growth of Staphylococcus aureus. The
staphylococcus was sensitive to flucloxacillin, so this
drug was given intravenously for 10 days, then orally.
Histopathological study of fragments of bone tissue from
the lesion was consistent with the diagnosis of the os-
teomyelitis of the pubis.
The boy remained without fever and the local pain
disappeared. His gait gradually returned to normal. His
white blood cell count normalized and his CRP level was
Osteomyelitis of the pelvic bones accounts for between
3% and 8% of cases of osteomyelitis in childhood [2].
Localization in the bones around the pubic symphysis is
very rare. And the invo lvemen t of th e pub ic sy mphysis is
exceptional and often undiagnosed condition causing
abdominal pain.
Osteomyelitis of the pubis in athlete is exceptional
with only nineteen cases reported in the literature. The
age of onset varies between ten and 28 years [3,4].
The pathophysiology remains unclear. In athletes,
some authors have discussed the role of pre-existing
damage of the pubis by the microtrauma which would
promote bacterial infection during a transitional bac-
teremia [3-5].
A detailed medical history is necessary to help the
doctor to make the diagnosis. Indeed, osteomyelitis of
the athlete usually occurs in the aftermath of a sport.
Usually there is a history of fever at the onset of the ill-
ness [6]. Thorough examination of the groin, abdomen,
hips, spine and lower limbs is essential [7].
Sometimes, clinical examination can objectify sensi-
tivity or defense of the right iliac fossa or next to the
pubic symphysis. These symptoms can be easily con-
fused with acute appendicitis [1] especially if they are
associated with vomiting and febrile syndrome as is the
case of our patient, hence the importance of a good in-
terview and a thorough clinical examination to avoid
abusive laparotomy.
The diagnosis of osteomyelitis is essentially clinical.
Laboratory data are not required for the diagnosis. There
may be an increased leukocyte cells count and an ele-
vated sedimentation rate, similar to data fo und with acu te
abdominal pain.
The radiograph of the pelvis centered on the pubis of-
ten shows irregular cortical and osteolysis. Later appears
bone sclerosis [5,8,9]. These radiographic signs appear a
few weeks after the onset of clinical symptoms [4,5,8].
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L. Chater et al. / Open Journal of Pediatrics 3 (2013) 291-293
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Ultrasound can explore early and quite different facets of
the pelvic bone in search of a subperiosteal abscess.
Bone scintigraphy can also provide early signs showing a
hypersignal in pubic symphysis [4].
MRI appears the most effective for the diagnosis of
osteomyelitis of the pubis [8]. It shows signs of edema
and inflammation resulting in abnormal signal of the
bone and the symphysis, or muscles. This is a crucial
consideration in assessing the presence and extent of
pubic infection. The typical appearance is localized with
decreased signal on T1-weighted images and signal en-
hancement in T2-weighted image area.
Staphylococcus aureus is the organism most com-
monly involved. Its isolation is made by blood cultures
and puncture-aspiration, if not by open surgery [3,8,10].
The main differential diagnosis is with osteitis pubis in
athletes. Originally described by Beer in 1924, osteitis
pubis is an inflammatory process and non-infectious
[8,9,11-13]. The sports activity is a predisposing factor
[4,6-9,12,14]. It usually occurs after surgery of the uro-
genital tract. Osteitis of the athlete could increase the risk
of osteomyelitis [12].
The treatment of pubic osteomyelitis requires appro-
priate antibiotic. Initially antibiotics are given intrave-
nously for two weeks, followed by oral antibiotics for at
least six weeks. In rare cases, surgery is necessary to
drain a retropubic abscess, curettage of the lesion or re-
moval of bone sequestration [3,10].
A good knowledge of the disease should allow a diagno-
sis before the stage of subperiosteal abscesses and early
treatment, which makes the exceptional surgical indica-
These conditions are often overlooked or masked by
abdominal pain, which may lead to unnecessary tests and
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