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Journal of Medical Case Reports
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Case report
A novel observation of pubic osteomyelitis due to Streptococcus
viridans after dental extraction: a case report
Naseem Naqvi*
1
, Rizwana Naqvi
2
, Christopher Wong
3
and Sushmita Pearce
4
Address:
1
Department of Acute Medicine, Dumfries & Galloway Royal Infirmary, UK,
2
Department of Medicine, Macclesfield District General
Hospital, East Cheshire NHS Trust, UK,
3
Department of Renal Medicine, Aintree University Hospitals NHS Trust, Liverpool, UK and
4
Department
of Medicine, Royal Albert Edward Infirmary, Wigan, UK
Email: Naseem Naqvi* - ; Rizwana Naqvi - ;
Christopher Wong - ; Sushmita Pearce -
* Corresponding author
Abstract

Introduction: Pubic osteomyelitis should be suspected in athletic individuals with sudden groin
pain, painful restriction of hip movements and fever. It is an infrequent and confusing disorder,
which is often heralded by atypical gait disturbance and diffuse pain in the pelvic girdle. The most
common pathogen is Staphylococcus aureus but, on occasions, efforts to identify infectious agents
sometimes prove negative. Pubic osteomyelitis due to Streptococcus viridans has not been reported
previously in the literature.
Case presentation: We describe the case of a fit 24-year-old athlete, who had a wisdom tooth
extracted 2 weeks prior to the presentation, which could have served as a port of entry and
predisposed the patient to transient bacteraemia.
Conclusion: S. viridans is well known for causing infective endocarditis of native damaged heart
valves, but to the best of the authors' knowledge it has not been reported previously as a cause of
pubic osteomyelitis. We believe that this case should alert physicians to the association between
dental procedures and osteomyelitis of the pubis secondary to S. viridans.
Introduction
Pubic osteomyelitis is an uncommon osseous infection. It
accounts for 2% of all osteomyelitis of bone [1,2]. Groups
at risk include intravenous drug users [3], people with dia-
betes and patients who have undergone urological and/or
obstetrical procedures [4]. Another, less well-known pre-
disposing factor is strenuous physical activity in athletes
[1]. The most common pathogen causing pubic osteomy-
elitis is Staphylococcus aureus. We describe the case of a
patient with pubic osteomyelitis due to Streptococcus viri-
dans, which developed after dental extraction.
Case presentation
A 24-year-old, previously fit and well, male fitness instruc-
tor and football player presented to the emergency depart-
ment complaining of pain in his groin and buttocks.
Symptoms started 3 days before he presented to the hos-
pital, and he had engaged in strenuous exercise and jog-

ging for 7 hours the day before admission to the hospital.
He thought initially that he had sprained his groin mus-
cles while exercising and decided to defer coming to the
hospital. There was no other significant past medical his-
tory of any illnesses, although the patient reported having
Published: 31 July 2008
Journal of Medical Case Reports 2008, 2:255 doi:10.1186/1752-1947-2-255
Received: 23 August 2007
Accepted: 31 July 2008
This article is available from: />© 2008 Naqvi et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( />),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Medical Case Reports 2008, 2:255 />Page 2 of 4
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had an extraction of a wisdom tooth 2 weeks prior to this
presentation.
On examination in the emergency department, he was a
fit-looking man who appeared very anxious. He was
brought into the emergency department in a wheelchair.
On initial assessment in the emergency department, he
was pyrexial with a temperature of 38.6°C, blood pressure
127/77 mmHg, and a regular pulse of 73 beats per
minute. On examination of his musculoskeletal system,
he was unable to stand and required the support of two
people. Examination of the lower limbs revealed painful
restriction of hip flexion and extension, with a power of 5/
5 in both hips and knees. There was no overlying ery-
thema or tenderness over the hip joints. On neurological
examination, sensations were intact to all modalities
(intact light touch, pinprick, joint position and vibration

sense) with a flexor plantar response. There were no cra-
nial nerve palsies and the cerebellar examination did not
reveal any ataxias or nystagmus. No abnormalities were
detected on cardiovascular, respiratory and abdominal
examination, apart from mild tenderness in the lower
abdomen without guarding or rebound. Bowel sounds
were present and genital examination was unremarkable
with good anal tone. No tenderness was elicited on exam-
ination of the spine.
Initial investigations revealed a normal full blood count
(haemoglobin 15.2 g/litre, white blood cell count 8.7 ×
10
9
/litre with a neutrophil count of 6.8 × 10
9
/litre and
platelets of 412 × 10
9
/litre), normal urea, creatinine and
electrolytes with the exception of raised C-reactive protein
(CRP) at 142 mg/litre. He was admitted to the acute
assessment ward with the possible differential diagnosis
of acute myositis or pelvic and/or psoas abscess, and
blood cultures were performed. An urgent computed tom-
ography (CT) scan of his abdomen and pelvis did not
reveal any evidence of psoas or pelvic abscess and serum
creatinine kinase levels were 40 U/litre. Other enzymes
including lactate dehydrogenase, aldolase, aspartate
transaminase and alanine transaminase were all within
normal limits.

On the second day of admission, he started having swing-
ing pyrexia (body temperature spiking to 39°C and touch-
ing the baseline of 36.6°C every 6 hours) with rigors. At
that time, his weakness and pain were severe enough to
limit even turning and sitting up in bed. Repeat examina-
tion revealed severe tenderness to palpation over the sym-
physis pubis, more marked on the left. Initial sets of blood
cultures revealed heavy growth of S. viridans. He was com-
menced on high doses of ceftriaxone (2 g three times a
day) and gentamicin (80 mg once a day). A magnetic res-
onance imaging (MRI) scan of the pelvis suggested mar-
row oedema of the left pubic bone extending all the way
up to the left sacro-iliac joint and soft tissue swelling of
the pubic symphysis, changes highly suggestive of osteo-
myelitis of the left pubic ramus (Figure 1).
A bone scan showed increased uptake of contrast over the
left pubic ramus and subsequent needle aspiration of the
left pubic bone grew S. viridans on cultures. Further inves-
tigations to exclude any potential cause of immunodefi-
ciency, including human immunodeficiency virus testing,
were negative.
The patient gradually improved on intravenous antibiot-
ics, started ambulating and became apyrexial after a
week's course of antibiotics. The level of CRP came down
to 50 mg/litre from an initial value of 142 mg/litre. He
was later discharged from the hospital on 4 weeks of oral
clindamycin. He was reviewed in the clinic 4 weeks after
his discharge and showed complete clinical recovery. The
CRP level had returned to normal (less than 5 mg/litre)
and subsequent blood cultures were sterile.

Discussion
Pubic osteomyelitis should be suspected in athletic indi-
viduals with sudden abdominal, pelvic or groin pain,
painful restriction of hip movements and fever. The
pathogenesis of this disease in athletes is thought to
involve pre-existing trauma or sports injury and subse-
quent seeding of this area during transient bacteraemia
following surgical procedures, for example, dental extrac-
tion [4]. The main differential diagnosis of pubic osteo-
myelitis is osteitis pubis.
Osteitis pubis is a painful, noninfectious, self-limited
inflammatory condition of the pubic bone associated
mainly with genitourinary surgery, but it also occurs fol-
lowing minor trauma or as a manifestation of overuse in
athletes [5]. Whereas the initial clinical symptoms of the
two conditions may be similar, the presence of fever and
progressive clinical deterioration favours an infectious
process and emphasises the need for repeated cultures. It
is still unclear why athletes are at risk of developing this
rare condition. This condition commonly occurs in spe-
cific athletic endeavours, such as football or running, that
involve strenuous physical exercise and may produce
excessive stress to the pelvis. In addition, it has been sug-
gested that the immune system in athletes may be com-
promised during strenuous exercise, which might increase
their susceptibility to transient bacteraemia caused by
minor skin or mucous membrane trauma; however, this
issue is debatable. Finally, a pre-existing subclinical ostei-
tis pubis may make athletes locally susceptible to osteo-
myelitis [5]. It is important to recognise that both

conditions may occur simultaneously in one patient [6].
Journal of Medical Case Reports 2008, 2:255 />Page 3 of 4
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Osteomyelitis of the pubic bone is an infrequent and con-
fusing disorder, which is often heralded by atypical gait
disturbance and diffuse pain in the pelvic girdle [7]. Diag-
nosis of pubic osteomyelitis is often delayed in young
patients as it occasionally mimics pelvic pathology result-
ing in unnecessary invasive procedures in the search for
the cause of an acute onset of lower abdominal pain.
Symptoms of fever, nausea, vomiting, anorexia and lower
abdominal pain and tenderness in a young patient can
easily be mistaken for those of acute appendicitis. The
classic symptoms of pubic osteomyelitis include pain in
the groin or adjacent areas with radiation to the thigh and
limitation of motion. The classic signs include local ten-
derness and swelling, a high temperature, occasionally an
elevated erythrocyte sedimentation rate and leucocytosis.
The port of entry of infection is often unclear and any his-
tory of preceding injuries, infections or dental procedures
should be specifically looked for when eliciting history.
Any history of painful restriction of hip movements
should be specifically explored as it is often wrongly diag-
nosed as true muscular weakness of the pelvic girdle mus-
cles or septic arthritis of the hip joint.
We found 19 reported cases of pubic osteomyelitis in ath-
letes, including our patient, in a review of the literature
[8]. All patients were active athletes who participated in
strenuous physical activity. In most of the 18 other
patients, diagnosis was delayed. The average time from

the start of symptoms to diagnosis was 13 days (range 1 to
30 days). Changes in plain radiographs of the pubic bone
usually appear only several weeks after the clinical presen-
tation of osteomyelitis and, therefore, are not reliable in
making the diagnosis. Typical changes include pubic rare-
faction and osteolysis. Sclerosis may appear later. A tech-
netium bone scan shows increased uptake and may
facilitate an earlier diagnosis. In three patients, diagnosis
was made only after aspiration and culture. In most of the
cases reviewed, the infectious agent was identified. The
most common pathogen was Staphylococcus aureus, which
was identified in cultures of blood or local aspirate [9]
To the authors' knowledge, S. viridans has not been previ-
ously reported as a cause of pubic osteomyelitis, although
there are case reports of vertebral osteomyelitis caused by
S. viridans in people with diabetes [10,11] and two cases
of femoral osteomyelitis due to S. viridans [12,13]. S. viri-
dans are aerobic, Gram-positive cocci most abundant in
oral flora as commensals and are well known for causing
infective endocarditis of native damaged heart valves
although, in our patient, there was no clinical evidence of
endocarditis as evidenced by a normal transoesophageal
echocardiogram. Dental extraction in our patient could
have served as a port of entry and predisposed the patient
to transient bacteraemia.
Conclusion
Pubic osteomyelitis is a challenging diagnostic dilemma.
We believe that this novel observation should alert physi-
cians to the association between dental procedures and
pubic osteomyelitis due to S. viridans. It is important to

take a history of dental extraction in all patients who
present with fever and pelvic pain. It is also important to
investigate patients with MRI scans as X-rays are neither
sensitive nor specific enough for detecting osteomyelitis.
Changes in plain radiographs of the pubic bone usually
appear only several weeks after the clinical presentation of
osteomyelitis and therefore are not reliable in making the
diagnosis. Early diagnosis and treatment can prevent sub-
sequent deformities of the pelvic bones and morbidity
due to chronic osteomyelitis and joint deformities.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NN Chief author, RN Assisted in the preparation of man-
uscript, SP Consultant in-charge for the patient's manage-
ment, as well as ideas for the writing of the case report,
CW Proof-read the manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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Magnetic resonance imaging scan of the pelvis showing extensive marrow oedema of the left pubic ramusFigure 1
Magnetic resonance imaging scan of the pelvis show-
ing extensive marrow oedema of the left pubic
ramus.
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