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Paper text:
a 64-year - old male with history of diabetes mellitus type 2 , hypertension and alcohol abuse presented with acute onset of severe , bilateral groin pain radiating to his back and exacerbated by moving .
specifically , the abdominal , groin , hip , genital , and skin exams were normal .
the basic laboratory tests were normal except for mildly elevated liver function tests and crp of 9.2 mg / l ( normal 8 mg / l ) .
u / l , bilirubin total 2.7 mg / dl and direct 1.2 mg / dl , and inr 1.3 . ) . on the third day after admission he developed fever and leukocytosis with left shift .
imaging studies including computed tomography ( ct ) angiogram of abdomen and pelvis showed cirrhotic liver , splenomegaly , and mild thickening of the right - sided colon . a magnetic resonance imaging ( mri ) of the lumbar spine revealed degenerative disc disease with signal abnormality in the l2l3 intervertebral disc and diffuse vertebral marrow signal change .
given the finding of right - sided colon thickening and no other abnormalities on the imaging studies , it was felt to be related to diverticulitis or colitis . with the prompt response to the antibiotic treatment
two weeks later , he returned with the same complaint : bilateral groin pain radiating to his back and exacerbated by moving .
however , an erythrocytes sedimentation rate was 108 and a crp level was 77.6 mg / dl .
the chief complaint of painful gait and persistent lack of abdominal findings on physical exam , made the initial diagnosis of diverticulitis or colitis questionable .
the recurrence of initial symptoms and elevated inflammatory markers despite the 10-day course of antibiotics pointed towards an infectious process such as discitis , osteomyelitis , occult abscess , deep venous thrombosis , or endocarditis .
multiple imaging studies were negative for deep venous thrombosis , intracardiac vegetations , discitis or osteomyelitis . an x - ray of pelvis showed a widened pubic symphysis with widening of the left sacroiliac joint , which could be due to prior pelvic trauma .
whole - body white blood cell scan with single - photon emission computed tomography images suggested infection of the symphysis pubis and adjacent muscles .
ct pelvis with iv contrast showed enhancing fluid collections in adductor muscles and a fluid density in the symphysis pubis suspicious for abscesses .
a 6-week course of iv ceftriaxone with subsequent oral amoxicillin treatment was continued until radiographic abscesses resolution .
septic arthritis of the pubic symphysis is a rare disease . according to ross and hu in their review of 100 cases ,
the most common complaint was pubic pain and the symptoms were present for more than three months before the diagnosis was made .
identified risk factors included female incontinence surgery , being an athlete , pelvic malignancy , and iv drug use .
due to high risk of osteomyelitis ( identified in 97% of cases ) , prolonged antibiotic treatment was recommended . in the review of 100 cases by ross and hu ,
the sensitivity of initial pelvic radiographs was only 68% ( bone destruction , marginal irregularities , symphyseal widening ) .
thirty - one patients had pelvic ct scans , 90% of which were abnormal ( bony erosions , abscesses , masses or symphyseal widening ) .
ten patients had pelvic mri , of which all showed abnormalities ( bony destruction , fluid within symphysis , symphyseal widening , mass and edema in muscles ) .
our diagnosis was greatly facilitated by use of single - photon emission computed tomography , however it was the unusually widened symphysis pubis on pelvic x - ray that alerted the radiologist about pathological process in this joint .
in retrospect , the mri revealed fluid within the pubic joint . in hospitals without this technology
, the diagnosis can be made with the above - described radiologic studies , especially if the initially normal studies are repeated .
streptococcus anginosus belongs to the normal human flora and is not commonly involved in clinically significant infections .
abscesses , skin , soft tissue and intra - abdominal and other infections were reported .
it remains unclear why the patient developed the disease without any of the described risk factors , although , diabetes or alcohol abuse and liver cirrhosis might have contributed .
the simultaneous occurrence of muscle abscesses and the isolation of the microorganism , which is , only rarely associated with septic arthritis of the pubic symphysis are also unusual about this case .
septic arthritis of the pubic symphysis is a rare disease . 
 typical clinical features include fever , pubic or groin pain , pain with hip motion , and painful or waddling gait . identified predisposing factors to develop an infection in pubic joint include female incontinence surgery or postpartum period ; sports , especially soccer ; pelvic malignancy ; and intravenous drug abuse . 
 the most often identified microorganisms were staphylococcus aureus and pseudomonas aeruginosa . 
 osteomyelitis complicates the majority of cases , and about half of the patients require surgical debridement along with a prolonged antibiotic treatment . 
 we report a case of streptococcus anginosus septic arthritis of the pubic symphysis . 
 the patient did not have any of the above risk factors .