A 16 years old young man came to Geisinger Emergency Department because of right lower quadrant abdominal pain that was acute in onset and had worsened over the prior two days; it was accompanied by fever, anorexia, nausea, and vomiting.
PMH: He was an accomplished athlete; and his father's over-riding concern was that his son be evaluated thoroughly and treated expeditiously, so as to resume football practice as soon as possible!
Two years ago he had fractured his right clavicle; and because of the poor alignment and delayed healing, operative reduction and fixation was performed (Figure 1).
He was remarkably tender in the right lower quadrant of his abdomen, with involuntary guarding and positive psoas and obturator signs. His WBC count and Urinalysis were normal. Ultrasound identified "mildly prominent, non-specific lymph nodes" but not the appendix. The MRI was also "somewhat equivocal" -free fluid in the pelvis with inflammation, but the appendix was not visualized; nevertheless, the radiologist opined that the findings were consistent with either appendicitis or inflammatory bowel disease. Unfortunately, the MRI did not include the pubic symphysis and contiguous musculature.
The diagnostic impression was appendicitis; however, this was not corroborated by laparoscopy, which revealed a normal appendix. No other intra-abdominal pathology was identified. The presumptive diagnosis became gastroenteritis, and an uneventful recovery was anticipated. This prediction initially appeared correct, and he was discharged only to return the evening of the second post-operative day, complaining once again of exquisite right lower quadrant abdominal pain, this time associated with fever, leukocytosis, and elevated inflammatory markers (Table 1).
Fluid in the retro-pubic space of Retzius
Two rim enhancing collections within the pectineus and rectus abdominal muscle denoting either myositis or a periosteal abscess
Blurring of the cortex (growth plate) of the right superior pubic ramus
The second admission's CT and MRI demonstrate (Fig. 2, Fig. 3):
Blood cultures were obtained, and he was treated empirically with NSAID's and antibiotics to cover presumed osteitis pubis or osteomyelitis. Clindamycin was switched to Cefazolin, because the blood culture grew MSSA, resistant to Clindamycin. Clinical improvement was followed by discomfort in his right shoulder, and radiographs disclosed septic arthritis in the sternoclavicular joint (Fig. 4).
The consultant orthopedist explored the sternoclavicular joint and drained approximately 10 ml of purulent material. The joint was irrigated; infected bone and cartilage were curetted; and adjacent soft tissues were debrided. The hardware was not removed, but ultimately this might be necessary.