Images in Clinical Rheumatology
Sacroiliitis and Gluteal Abscess Secondary to Staphylococcus aureus Infection
Sacroilitis y absceso glúteo secundarios a infección por Staphylococcus aureus
Maria Llop Vilaltella
, Valentina Maldonado Romero, Carlos Guillén Astete, Carlos de la Puente Bujidos, Celia de Casanova Peña
Corresponding author
Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Three days before the onset of the symptoms, the patient had self-administered a dose of intraurethral alprostadil to treat erectile dysfunction secondary to prostatectomy for adenocarcinoma of the prostate. Physical examination revealed pain in response to pressure on left sacroiliac joint. The responses to the Lasègue test and to pressure applied on left piriformis muscle were positive. Laboratory tests revealed a C-reactive protein level of 251<span class="elsevierStyleHsp" style=""></span>mg/l (normal level, 0–5<span class="elsevierStyleHsp" style=""></span>mg/l) and a procalcitonin level of 1.18<span class="elsevierStyleHsp" style=""></span>ng/ml (<0.25), without leukocytosis or left shift. Abdominopelvic computed tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) detected the presence of cortical erosions, predominantly on the lower half of the iliac side of left sacroiliac joint, associated with subchondral sclerosis, all of which is compatible with the radiological diagnosis of left-sided sacroiliitis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Pelvic magnetic resonance imaging (MRI) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) revealed subchondral bone edema on both the sacral and iliac sides of left sacroiliac joint, as well as subtle signal hyperintensity in the articular interosseous space. In addition, myositis was observed in neighboring muscles, in left rotator muscles, as well as in the gluteus maximus, where the area of myositis was greater and was accompanied by a small central abscess. Thus, empirical antibiotic therapy with ceftriaxone and cloxacillin was begun.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">When methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> was isolated from the blood sample collected in the emergency department, ceftriaxone was discontinued, whereas cloxacillin administration was maintained.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Echocardiography revealed no evidence of endocarditis. One month later, follow-up MRI (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) showed that subchondral bone edema persisted on both the sacral and iliac sides of left sacroiliac joint, indicating the persistence of sacroiliitis; in contrast, the area of myositis and the abscess in gluteus maximus had disappeared, a foreseeable finding, given the short time elapsed since the first MRI. The patient continued to improve, both in clinical and analytical terms, with antibiotic therapy, which was maintained for 6 weeks.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Both infectious sacroiliitis and gluteal abscesses are uncommon conditions, representing less than 1% of all the cases of septic arthritis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> The clinical diagnosis is usually difficult, as the classical signs are fever and pain, with functional incapacity of the affected joint.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> In this case, as in the majority of the published series, the causative agent was <span class="elsevierStyleItalic">S. aureus</span>.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The risk factors most frequently identified in the cases of this type of joint infection reported in the literature are: intravenous drug use, pregnancy, trauma, endocarditis, hemoglobinopathies, immunosuppression, and skin, respiratory tract or genitourinary infections.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> According to different series, no predisposing agents or risk factors are identified in 40%–44% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,5,6</span></a> In our patient, intraurethral administration of alprostadil is a plausible candidate as the route of infection responsible for the bacteremia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Abscess management usually involves drainage by needle aspiration or surgery.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8–10</span></a> However, there have been reports of complete resolution with antibiotic therapy alone,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> as in the case we present here. To date, there are no established guidelines for the duration of antibiotic therapy, but most authors opt for a minimum of 6 weeks, which can be extended depending on the clinical status of the patient.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–5,7–10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Ethical Disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-08-01" "fechaAceptado" => "2015-01-22" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Llop Vilaltella M, Maldonado Romero V, Guillén Astete C, de la Puente Bujidos C, de Casanova Peña C. Sacroilitis y absceso glúteo secundarios a infección por <span class="elsevierStyleItalic">Staphylococcus aureus</span>. Reumatol Clin. 2015;11:398–400.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 705 "Ancho" => 995 "Tamanyo" => 112977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominopelvic computed tomography.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1365 "Ancho" => 995 "Tamanyo" => 149054 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of pelvis.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1341 "Ancho" => 984 "Tamanyo" => 155143 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Follow-up magnetic resonance image.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute pyogenic sacroiliitis without predisposing conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 5 | 14 |
| 2024 October | 165 | 43 | 208 |
| 2024 September | 145 | 23 | 168 |
| 2024 August | 143 | 46 | 189 |
| 2024 July | 130 | 33 | 163 |
| 2024 June | 163 | 43 | 206 |
| 2024 May | 182 | 56 | 238 |
| 2024 April | 177 | 33 | 210 |
| 2024 March | 156 | 36 | 192 |
| 2024 February | 101 | 36 | 137 |
| 2024 January | 104 | 29 | 133 |
| 2023 December | 81 | 31 | 112 |
| 2023 November | 95 | 26 | 121 |
| 2023 October | 102 | 33 | 135 |
| 2023 September | 149 | 42 | 191 |
| 2023 August | 126 | 42 | 168 |
| 2023 July | 78 | 32 | 110 |
| 2023 June | 103 | 33 | 136 |
| 2023 May | 111 | 39 | 150 |
| 2023 April | 81 | 19 | 100 |
| 2023 March | 127 | 30 | 157 |
| 2023 February | 97 | 39 | 136 |
| 2023 January | 112 | 23 | 135 |
| 2022 December | 107 | 38 | 145 |
| 2022 November | 115 | 45 | 160 |
| 2022 October | 106 | 44 | 150 |
| 2022 September | 117 | 40 | 157 |
| 2022 August | 100 | 59 | 159 |
| 2022 July | 100 | 52 | 152 |
| 2022 June | 88 | 39 | 127 |
| 2022 May | 116 | 52 | 168 |
| 2022 April | 112 | 48 | 160 |
| 2022 March | 128 | 50 | 178 |
| 2022 February | 122 | 43 | 165 |
| 2022 January | 133 | 49 | 182 |
| 2021 December | 92 | 45 | 137 |
| 2021 November | 95 | 41 | 136 |
| 2021 October | 101 | 55 | 156 |
| 2021 September | 76 | 47 | 123 |
| 2021 August | 59 | 34 | 93 |
| 2021 July | 98 | 43 | 141 |
| 2021 June | 75 | 33 | 108 |
| 2021 May | 106 | 39 | 145 |
| 2021 April | 184 | 111 | 295 |
| 2021 March | 119 | 30 | 149 |
| 2021 February | 61 | 37 | 98 |
| 2021 January | 50 | 22 | 72 |
| 2020 December | 46 | 20 | 66 |
| 2020 November | 89 | 31 | 120 |
| 2020 October | 63 | 15 | 78 |
| 2020 September | 62 | 24 | 86 |
| 2020 August | 57 | 16 | 73 |
| 2020 July | 29 | 19 | 48 |
| 2020 June | 47 | 18 | 65 |
| 2020 May | 51 | 18 | 69 |
| 2020 April | 38 | 25 | 63 |
| 2020 March | 23 | 10 | 33 |
| 2020 February | 2 | 0 | 2 |
| 2018 May | 8 | 0 | 8 |
| 2018 April | 51 | 8 | 59 |
| 2018 March | 60 | 11 | 71 |
| 2018 February | 37 | 3 | 40 |
| 2018 January | 30 | 2 | 32 |
| 2017 December | 46 | 5 | 51 |
| 2017 November | 28 | 3 | 31 |
| 2017 October | 34 | 11 | 45 |
| 2017 September | 36 | 7 | 43 |
| 2017 August | 34 | 8 | 42 |
| 2017 July | 38 | 11 | 49 |
| 2017 June | 51 | 14 | 65 |
| 2017 May | 76 | 13 | 89 |
| 2017 April | 37 | 7 | 44 |
| 2017 March | 47 | 5 | 52 |
| 2017 February | 29 | 5 | 34 |
| 2017 January | 34 | 11 | 45 |
| 2016 December | 66 | 12 | 78 |
| 2016 November | 64 | 12 | 76 |
| 2016 October | 83 | 15 | 98 |
| 2016 September | 76 | 11 | 87 |
| 2016 August | 54 | 4 | 58 |
| 2016 July | 37 | 8 | 45 |
| 2016 May | 2 | 0 | 2 |
| 2016 April | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2016 January | 1 | 50 | 51 |
| 2015 December | 4 | 29 | 33 |
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