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Bilateral groin pain from a rotten molar
Case Report
Bilateral groin pain from a rotten molar B J Keulers, R H M Roumen, M J Keulers, L Vandermeeren, J P H Bekke
Lancet 2005; 366: 94 Maxima Medical Centre, De Run 4600, PO Box 7777, 5500 MB Veldhoven, Netherlands (B J Keulers MD, R H M Roumen MD, L Vandermeeren MD, J P H Bekke MD); and Jeroen Bosch Ziekenhuis, Den Bosch, Netherlands (M J Keulers MD) Correspondence to: Dr B J Keulers [email protected]
94
A 58-year-old man was referred to the department of neurology in October, 2004, with progressive bilateral groin pain. He was unable to stand or lift his legs, and his hip flexors were weak. He was febrile, nauseous and constipated. We did not find any neurological abnormality on examination, but the patient had a tender lower abdomen, symphysis pubis, and groin. He had no signs of strangulated hernias. Blood tests showed a raised concentration of C-reactive protein (285 mg/L), with a white cell count of 14109/L. We did an abdominal CT, but found no retroperitoneal abscesses. We then did an exploratory laparotomy, but could find no cause for his high fever and severe pain. After the operation, he was still febrile, and his groin pain worsened. Ultrasound of the hip joints, pubic bones, groin muscles, and kidneys showed no abnormalities. We suspected that he might have sacroileitis or discitis, so we did a bone scan that showed a hot spot at the symphysis pubis. On the second postoperative day, blood cultures were positive for Staphylococcus aureus and we started intravenous flucloxacillin. We did cardiac ultrasound, looking for the source of the bacteraemia, but there were no signs of endocarditis. 4 days after admission, we still had not found the focus of the infection, so we did a pelvic MRI. The MRI showed bilateral abscesses in the adductor muscles with some infiltration of the symphysis (figure). We continued the search for the origin of the staphylococci, and found that our patient had a loose and decayed molar. An orthopantomogram of the jaw showed local mandibular necrosis. We extracted his decaying molar, then incised and drained the symmetrical adductor abscesses. His wounds were left open and cleaned daily. Cultures of the groin abscesses were positive for S aureus. Although pus from the tooth showed multiple bacteria, no S aureus was cultured, possibly because of the antibiotics he had already been given. We postulate that the dental infection was the most probable source of invading S aureus, which caused a septic symphysitis, leading to bilateral adductor pyomyositis. Unilateral groin pain and fever, can be caused by intra-abdominal infections or incarcerated hernias (inguinal, femoral, obturator), joint infection,
Figure: MRI showing bilateral abscesses in adductor muscles with some infiltration of symphysis
muscle abscesses after injections, sacroileitis, or discitis causing a psoas abscess. Bilateral abscesses of the adductor muscles have not been reported. Although bilateral abscesses of the psoas muscles have been described,1 these were secondary to spondylitis in an immunocompromised woman. Bilateral groin pain can occur after trauma or osteitis of the pubic bone, but these entities present without fever.2 Septic arthritis is frequently caused by haematogenous spread of S aureus,3 and pyomyositis can develop by local spread. Pelvic pyomyositis is notorious for mimicking an acute abdomen.4 In the early stages of myositis, CT will not show any abnormalities, but early MRI can be helpful in making this diagnosis.5 References 1 Dudler J, Balague F, Waldburger M. Bilateral primary brucellar psoas abscess. Br J Rheumatol 1994; 33: 988–90. 2 Andrews SK, Carek PJ. Osteitis pubis: a diagnosis for the family physician. J Am Board Fam Pract 1998; 11: 291–95. 3 Ross JJ, Hu LT. Septic arthritis of the pubic symphysis: review of 100 cases. Medicine (Baltimore) 2003; 82: 340–45. 4 Back SA, O’Neill T, Fishbein G, Gwinup G. A case of group B streptococcal pyomyositis. Rev Infect Dis 1990; 12: 784–87. 5 Soler R, Rodriguez E, Aguilera C, Fernandez R. Magnetic resonance imaging of pyomyositis in 43 cases. Eur J Radiol 2000; 35: 59–64.
www.thelancet.com Vol 365 July 2, 2005
Bilateral groin pain from a rotten molar B J Keulers, R H M Roumen, M J Keulers, L Vandermeeren, J P H Bekke
Lancet 2005; 366: 94 Maxima Medical Centre, De Run 4600, PO Box 7777, 5500 MB Veldhoven, Netherlands (B J Keulers MD, R H M Roumen MD, L Vandermeeren MD, J P H Bekke MD); and Jeroen Bosch Ziekenhuis, Den Bosch, Netherlands (M J Keulers MD) Correspondence to: Dr B J Keulers [email protected]
94
A 58-year-old man was referred to the department of neurology in October, 2004, with progressive bilateral groin pain. He was unable to stand or lift his legs, and his hip flexors were weak. He was febrile, nauseous and constipated. We did not find any neurological abnormality on examination, but the patient had a tender lower abdomen, symphysis pubis, and groin. He had no signs of strangulated hernias. Blood tests showed a raised concentration of C-reactive protein (285 mg/L), with a white cell count of 14109/L. We did an abdominal CT, but found no retroperitoneal abscesses. We then did an exploratory laparotomy, but could find no cause for his high fever and severe pain. After the operation, he was still febrile, and his groin pain worsened. Ultrasound of the hip joints, pubic bones, groin muscles, and kidneys showed no abnormalities. We suspected that he might have sacroileitis or discitis, so we did a bone scan that showed a hot spot at the symphysis pubis. On the second postoperative day, blood cultures were positive for Staphylococcus aureus and we started intravenous flucloxacillin. We did cardiac ultrasound, looking for the source of the bacteraemia, but there were no signs of endocarditis. 4 days after admission, we still had not found the focus of the infection, so we did a pelvic MRI. The MRI showed bilateral abscesses in the adductor muscles with some infiltration of the symphysis (figure). We continued the search for the origin of the staphylococci, and found that our patient had a loose and decayed molar. An orthopantomogram of the jaw showed local mandibular necrosis. We extracted his decaying molar, then incised and drained the symmetrical adductor abscesses. His wounds were left open and cleaned daily. Cultures of the groin abscesses were positive for S aureus. Although pus from the tooth showed multiple bacteria, no S aureus was cultured, possibly because of the antibiotics he had already been given. We postulate that the dental infection was the most probable source of invading S aureus, which caused a septic symphysitis, leading to bilateral adductor pyomyositis. Unilateral groin pain and fever, can be caused by intra-abdominal infections or incarcerated hernias (inguinal, femoral, obturator), joint infection,
Figure: MRI showing bilateral abscesses in adductor muscles with some infiltration of symphysis
muscle abscesses after injections, sacroileitis, or discitis causing a psoas abscess. Bilateral abscesses of the adductor muscles have not been reported. Although bilateral abscesses of the psoas muscles have been described,1 these were secondary to spondylitis in an immunocompromised woman. Bilateral groin pain can occur after trauma or osteitis of the pubic bone, but these entities present without fever.2 Septic arthritis is frequently caused by haematogenous spread of S aureus,3 and pyomyositis can develop by local spread. Pelvic pyomyositis is notorious for mimicking an acute abdomen.4 In the early stages of myositis, CT will not show any abnormalities, but early MRI can be helpful in making this diagnosis.5 References 1 Dudler J, Balague F, Waldburger M. Bilateral primary brucellar psoas abscess. Br J Rheumatol 1994; 33: 988–90. 2 Andrews SK, Carek PJ. Osteitis pubis: a diagnosis for the family physician. J Am Board Fam Pract 1998; 11: 291–95. 3 Ross JJ, Hu LT. Septic arthritis of the pubic symphysis: review of 100 cases. Medicine (Baltimore) 2003; 82: 340–45. 4 Back SA, O’Neill T, Fishbein G, Gwinup G. A case of group B streptococcal pyomyositis. Rev Infect Dis 1990; 12: 784–87. 5 Soler R, Rodriguez E, Aguilera C, Fernandez R. Magnetic resonance imaging of pyomyositis in 43 cases. Eur J Radiol 2000; 35: 59–64.
www.thelancet.com Vol 365 July 2, 2005