A 76-year-old woman applied at the Department of Internal Medicine because of the persistent fever (38.8 C for approximately 4 weeks), constant feeling of tiredness, periodically occurring non-specific headache and severe pain in the right lumbosacral region radiating to the right lower extremity which occurred at rest and intensified when moving. In the medical history the patient reported that she suffers from diabetes type 2 (metformin 850 mg once daily), hypertension (ramipril 10 mg once daily, hydrochlorothiazide 12.5 mg once daily), hyperlipidemia (rosuvastatin 10 mg once daily) and hypothyroidism (levothyroxine 75 microg once daily).
In the laboratory tests were found following disorders: leukocytosis 17.7 x 109/l, anemia (hemoglobin 8.4 g/dl) and CRP 265 mg/l (n < 5 mg/l). Blood and urine cultures were sterile.
In lumbar spine magnetic resonance (MRI) degenerative changes with multilevel discopathy were noted. The patient was consulted by a neurologist and a specialist of infectious diseases. In the treatment empirical antibiotic (ciprofloxin 200 mg i.v. twice daily and amoxicillin 1000 mg p.o. twice daily) and non-steroidal anti-inflammatory drugs ware administered. As a result of this therapy the patient's general condition had improved (a decrease of fever and lumbosacral pain relief).
There was no basis for the diagnosis of inflammatory spondyloarthropathy or rheumatoid arthritis. The recurrence of the described symptoms occurred about two months later.
The patient applied at the Department of Rheumatology and Internal Diseases. Physical examination showed the following disorders: fever (39 C), limitation of motion of the hip joints, knee joints and lumbosacral spine, painfulness compression of the L4-S1 segment of the spine, which was more perceptible on the right side of the spine and on the right buttock. No pathological changes of the skin or muscles were noticed. Lymph nodes were not palpable.
The laboratory tests performed have shown a leukocytosis 13.98 x 109/l (nv 4-10) with neutrophils 10.72 x 109/l (nv 2.5-6.0), erythrocytes 3.13 x 1012/l (nv 4-5), hemoglobin 8.4 g/dl (nv 12-16), hematocrit 26.7% (nv 37-47), platelets 560 x 109/l (nv 140-440), hypoalbuminemia [albumin 3.2 g/dl (nv 4.3-5.1), 42.7% (nv 60-71)], hypergammaglobulinemia [gamma globulin 1.5 g/dl (nv 0.6-1.2), 20.3% (nv 8-16)], ESR 121 mm (nv 3-15), ultra-sensitive CRP 181.98 mg/l (nv 0-5), fibrinogenactivity > 9.10 g/l (nv 1.8-3.5), procalcitonin 0.06 ng/ml (nv 0-0.05). All other parameters like fasting glycaemia, transaminases, creatinine, eGFR, electrolytes, APTT, INR, TSH or tumor markers were normal. Occult blood fecal analysis (chromatography) for 3 consecutive days did not showed any abnormalities. In several times made urine analysis characterizing bacteriuria was found, but the urine culture was negative. X-ray of the chest was normal. USG of the abdominal cavity revealed widening of the renal pelvis in the left kidney.Based on the echocardiography mitral regurgitation without hemodynamic significance was found (EF: 67%). The myelogram showed hyperplasiaof the bone marrow granulocytic component (76.4%), mainly of the older form - of segmented kernel. The morphological characteristics of cells were without significant disorders.
The X-ray and the USG of the hip joints illustrated significant degenerative changes. In the X-ray of the sacroiliac joints a mixed but unspecific picture of the right sacroiliac joint was found (Fig. 1). Because of this further MRI was arranged. The MRI image of the sacroiliac joints has shown extensive, stalactite inflammation of the right sacroiliac joint with the infiltration of the muscles (Figs. 2, 3). There were also visible small abscesses in the right piriformis muscle and invasion of sacral canal spinal stenosis on the level of L4/L5. In addition, the twice made blood culture was positive and Staphylococcus aureus methicillin sensitive (MSSA) had been isolated. The patient was diagnosed with sacroiliac joint inflammation of infectious etiology (Staphylococcus aureus). It was the reason for starting antibiotic therapy according to the antibiogram: cefuroxime 3 x 750 mg i.v. (used for ten weeks in total) and ciprofloxacin i.v. 2 x 200 mg (for four weeks in total). Then, clindamycin 3 x 300 mg i.v. (for eight weeks in total) and after the patient has being discharged from the hospital clindamycin 3 x 300 mg p.o. (for other eight weeks).
Due to the spinal stenosis the patient was also consulted by a neurosurgeon and due to a slight widening of the renal pelvis of the left kidney the patient was consulted by a nephrologist and urologist in order to find a primary outbreak of the infection. But there had not been stated any association with urinary system. Two months after the start of antibiotic therapy the control CT of sacroiliac joints was performed. In this image the regression of all the pathological changes was observed (Fig. 4).
After five months of antibiotic therapy a relief of pain and fever had been achieved, the laboratory parameters had normalized (leukocytes 8 x 109/l, CRP 5 mg/l) and the patient had been discharged from the hospital. After six and after nine months after diagnosis the control MRI of the sacroiliac joints was performed. Their images showed further regression of the pathological changes. The patient is now being under the control of a rheumatologist and a neurosurgeon. Due to lasting back pain there are also plans for orthopedic surgery of the right sacroiliac joint.