A Masked Sacroilitis - PDF Document

Presentation Transcript

  1. A Masked Sacroilitis Hira Ahmed DO, Alicia Kodsi MD, Santina Bruno DO, Christina GagliardoMD, Michelle KatzowMD Maimonides Infant and Children’s Hospital of Brooklyn Discussion • Septic sacroiliitis presents with nonspecific signs and symptoms, which can be difficult to differentiate from sciatica, septic arthritis, pelvic abscess or disc herniation4. • Differential diagnosis: sciatica, septic hip arthritis , acute abdomen • Exam findings: + FABER test, tenderness over the posterior sacroiliac joint, to deep palpation of the lower abdomen, and on rectal exam. • Laboratory studies: elevated WBC count and ESR/CRP, +/-positive blood cultures or SI joint aspirates 6. MRI is the most sensitive imaging test. • Causive organisms: Staphylococcus aureus most common • Treatment: Should be based on available cultures. Empiric treatment should include Staphylococcus aureus coverage with oxacillin IV or vancomycin IV in areas w/ high prevalence of MRSA. Alternatives: Linezolid or clindamycin in areas with low prevalence of clindamycin resistance. • Complications include abscess formation and sequestrum. Learning Objectives • Torecognize the clinical features of pyogenic sacroiliitis, including the ways it can mimic acute abdomen. • To learn the most common pathogens associated with pyogenic sacroiliitis. • To learn the treatment options that are available Case Presentation • 15 y/o boy with no PMH presents with 1 day of fever, RLQ pain, and one episode of non-bloody, non-bilious emesis. • Diagnosed clinically with acute appendicitis, underwent laparoscopic appendectomy and was discharged pain-free on POD 1. Pathology showed a normal appendix. • POD 3 developed right hip and thigh pain, which progressed over the next 4 days. Evaluation • Febrile to 40.3°C, RLQ tenderness without rebound or guarding, well- healing surgical scars, and pain with passive right hip flexion and extension. • Lab studies showed WBC 14 K/UL (80% neutrophils), ESR 36 mm/hr, and CRP 11.4 mg/dl. • Abdominal U/S was negative for fluid collections. CT abdomen/pelvis with contrast was unremarkable. Hip MRI with contrast showed enhancement of the right sacroiliac joint • Blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA) Clinical Course • 14 days of nafcillin IV • Transitioned to cephalexin PO, total course of 6 weeks of antibiotic therapy Asymmetric joint fluid at the right sacroiliac joint PEARLS • Septic (pyogenic) sacroiliitis is an unusual diagnosis found in otherwise healthy pediatric patients. • Can be difficult to diagnose as it can mimic more common causes of abdominal and lower back pain • Broadening the differential can lead to earlier diagnosis and treatment and minimize the risk of complications. References: Besbes L, Haddad S, Abid A, et al. Pyogenic Sacroiliitis in Children: Two Case Reports. Case Reports in Medicine 2012;Article ID 415323 Cohn SM, SchoetzDJ. Pyogenic sacroiliitis: another imitator of the acute abdomen. Surgery 1986; 100:95–98 Doita M, YoshiyaS, Nabeshima Y, et al. Acute pyogenic sacroiliitis without predis- posing conditions. Spine2003;28:E384-9. Gorissen J, Wojciechowski M, Somville J, HuygheI, Parizel PM, RametJ(2007). Pyogenic Sacroiliitis in a 14-year old girl. EurJ Pediatr 166:263,264 Molinos A, Gutie ́rrez B, Lovillo M, et al. Pyogenic sacroili- itis in children—a diagnostic challenge,Clinical Rheumatol- 
ogy, vol. 30, no. 1, pp. 107–113, 2011. 
 Srinivasan S, Miller C, Akhras N, et al. Pediatric Pyogenic Sacroiliitis and Osteomyelitis. Infectious Disease Reports 2012; 4:e18 Asymmetric enhancement of bone edema involving R sacrum and iliac