Not Your Typical Pelvic Pain

HISTORY: A 52 year old man presented to the office with 2 weeks of severe bilateral atraumatic groin pain. His past medical history was unremarkable aside from prostate cancer status post prostatectomy 4 weeks ago. He denied any prior hip problems. He was evaluated by his urologist shortly after pain onset, and was told his pain was likely musculoskeletal and unrelated to his surgery. He was taking Ibuprofen 600 mg 3 times daily for pain. Ibuprofen allowed him to ambulate with moderate, opposed to significant pain, however he still noted a limp when walking. PHYSICAL EXAMINATION: Bilateral hip: No gross deformities. Antalgic gait. Tenderness to the abductor origins bilaterally and pubic symphysis; no tenderness of the groin, ASIS, AIIS, or greater trochanter.Decreased painful hip flexion to 110 degrees, external rotation to 60 degrees and internal rotation to 10 degrees bilaterally.There is groin pain with FADIR and FABER bilaterally.Resisted strength testing with hip flexion limited by pain; 4+/5 adduction and abduction. Positive log roll bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Iliopsoas Bursitis 2. Adductor Strain 3. Osteitis Pubis 4. Osteomyelitis of the pubic symphysis TEST AND RESULTS: Blood Work: 1.WBC of 7.5 × 10^9/L2.ESR elevated at 105 mm/hr3.CRP elevated at 57.9 mg/L MRI Pelvis without contrast:1. Postsurgical changes from prostatectomy. 2. Findings suspicious for osteomyelitis of the pubic symphysis.3. Intramuscular edema of the bilateral adductor muscles that could be secondary to inflammatory changes of the pubic symphysis or infectious myositis. CT-guided bone marrow biopsy of pubic bone grew Pseudomonas Aeruginosa FINAL/WORKING DIAGNOSIS: Osteomyelitis of the pubic symphysis TREATMENT AND OUTCOMES: 1.Admitted to the hospital for treatment of osteomyelitis of the pubic symphysis2.Patient’s pain level gradually improved during his treatment course. He was discharged after 10 days on 2 antibiotics with no complications.3.Continued on a 6-week course of IV and PO antibiotics: Cefepime 2 g IV every 8 hours and Linezolid 600 mg p.o. every 12 hours. 4. The patient had close follow up with infectious disease specialists outpatient after his discharge and had to get weekly blood work including CBC, CMP, ESR, CRP.