pregnancy-associated pyogenic sacroiliitis: case report...

Pregnancy-associated pyogenic sacroiliitis:case report and review

Mohammad O. Almoujahed, Riad Khatib and Joseph Baran

Division of Infectious Diseases, Department of Internal Medicine, St John Hospital and Medical Center,Detroit, MI

Background: Pyogenic sacroiliitis occurs infrequently during the peripartum period.Case: A case at our institution and a review of the literature were analyzed. A total of 15 cases were discovered.The onset of illness was during pregnancy (40% of cases), within 3 weeks postpartum (40%) or post-abortion(20%), and the presentation was usually acute (< 7 days in 67% of cases). Frequent manifestations includedlocalized pain in the hips or buttock, sacroiliac joint tenderness and fever. Computed tomography or magneticresonance imaging revealed joint involvement in all cases tested. Microbiology was confirmed by blood (40%) orjoint aspirate (75%), and most patients were treated with antibiotics. Surgical intervention took place in five cases.Preterm labor was reported in only one case. All patients responded well to therapy without locomotive disability,and persistent pain was uncommon.Conclusion: Septic sacroiliitis should be considered in peripartum patients who present with fever and severelocalized pain. Medical management is usually curative, and without an adverse effect on pregnancy.

Key words: SACROILIAC JOINT; SACROILIAC JOINT INFECTION; PERIPARTUM

INTRODUCTION

Sacroiliac joint disease usually presents with lowback pain that increases with ambulation.Although the majority of cases represent non-specific arthritis, this joint can be seeded afterbacteremia, resulting in a pyogenic process1. Thiscomplication is more common in injection drugusers, although it may develop after anybacteremia1,2. If it develops during pregnancy, itmay pose a diagnostic challenge, as pain in thelower back and buttocks is common and oftennonspecific during the pregnancy and postpartum

periods3,4. We encountered such a case whichprompted us to review all previously reported casesin the English literature and to present a compre-hensive review of this subject in order tocharacterize the clinical manifestations, diagnosticapproach, therapy and prognosis.

CASE REPORT

A 26-year-old woman, gravida-1 (24 weeks’gestation), para-0, presented with severe pain inthe right buttock region. This area was mildly

Infect Dis Obstet Gynecol 2003;11:53–57

Correspondence to: Dr Joseph Baran Jr, Medical Education, St John Hospital, 22101 Moross Road, Detroit, MI 48236, USA.E-mail: [email protected]

ã 2003 The Parthenon Publishing Group 53

The findings described in this article were presented in part as Poster #22, Clinical Research 2001, American Federation for MedicalResearch, Arlington, Virginia, on 8 March 2001.

irritable for a few weeks, but the pain then becameworse and began to radiate to the leg and toincrease with ambulation. The patient deniedexperiencing feverishness, chills or other systemicsymptoms. Her medical history was negative.She claimed that she did not smoke, drink alcoholor use injection drugs.

Physical examination was significant, revealinga temperature of 38.2ºC and localized tendernessover the right sacroiliac joint. Laboratory testsrevealed leukocytosis (14.7 ´ 106 white bloodcells/l with 87.7% neutrophils), an elevatederythrocyte sedimentation rate (70 mm/hour) andasymptomatic E. coli bacteriuria. Magnetic reso-nance imaging (MRI) of the lumbar spine wasunrevealing. The patient was suspected of havingeither sacroiliitis or piriformis syndrome, and wasstarted on oral prednisone, steroid injections inthe right sacroiliac joint and cephalexin for thebacteriuria. She noted some relief of her shootingpain initially, but the remaining symptoms con-tinued to worsen. MRI of the pelvis and sacroiliacjoint was performed on day 11 after admission. Itrevealed widening of the right sacroiliac joint, asoft tissue density anterior and posterior to thejoint space, and a fluid collection measuring3 ´ 3 ´ 6 cm within the iliacus muscle anterior tothe right sacroiliac joint, consistent with sacroiliitisand a probable abscess.

A computed tomography-guided aspiration ofthe sacroiliac joint fluid collection yielded 2.2 mlof thick, brownish, chocolate-like fluid, andthe Gram stain showed Gram-positive cocci inclusters. The patient was started on cefazolin IV6 grams/day, and steroids were gradually dis-continued. Culture grew methicillin-susceptibleStaphylococcus aureus. The patient showed clinicaland radiological improvement with follow-upMRI. Cefazolin was continued for a 6-weekcourse. She subsequently had an uneventfulnormal vaginal delivery. At a follow-up visit6 months after discharge, she was doing well withnormal ambulation, although she continued tohave mild discomfort in the right buttock.

SUBJECTS AND METHODS

A total of 14 cases published in English wereidentified through a MEDLINE search for articles

(1966–2001) and relevant bibliographies. Searchterms that were used included septic sacroiliitis,sacroiliitis, sacroiliac joint, septic arthritis andpregnancy. All cases identified in addition to ourswere included in the review1,3–12. Demographics,risk factors, clinical manifestations, microbiology,radiological studies, management and outcomewere noted.

RESULTS

The mean age of the patients was 25.4 years(range 17–35 years). The onset of illness wasduring pregnancy in six cases (40%)1,4,6,10,11

(including this case) within 3 weeks of deliveryin six instances (40%)3,5,7–9 and within 3 weeksof abortion in three cases (20%)7,11,12. Amongthe postpartum cases, forceps outlet delivery wasutilized in one case, 9 days prior to presentation9.In addition, delivery was complicated by anepisode of chills and bleeding within 24 hours ofvaginal delivery in one case5, and by high feverwith disseminated intravascular coagulopathy andfetal distress in another case5. Among the threepost-abortion cases, termination of pregnancywas spontaneous in one case12, induced but in-complete in one case11, and followed inductiondue to fetal death in the other case7.

Possible risk factors were identified in eightpatients (53.3%), including injection drug use(n = 3; 20%)1,3,10, infective endocarditis (n = 2;13%)4,10, urinary tract infection (n = 3; 20%)1,6,10,endometritis (n = 2; 13%)5,11 and extensive sinus-itis requiring multiple irrigations in thepre-antibiotic era11.

The clinical characteristics are listed in Table 1.Frequent manifestations included localized pain(100% of cases), sacroiliac joint tenderness (80%)and ambulatory impairment (47%). The intervalbetween the onset of symptoms and diagnosis was2–32 days, although the majority of cases (66.7%)had an acute onset (< 7 days). Of interest, feverwas absent in a substantial number of cases (n = 5;33.3% of patients with an adequate history)1,3,6,10,12.High fever and extension of infection to thesurrounding structure were common in patientsreported in the pre-antibiotic era, presumablybecause of a delay in recognition and lack oftherapy11,12. Leukocytosis was present in eight

Review of bacterial sacroiliac joint infections in pregnancy Almoujahed et al.

54 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY


INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 55

Age

Cultu

rec

Trea

tmen

t

Refe

renc

eYe

ars

(tim

e)a

Risk

fact

orsb

Ons

etSy

mpt

oms

Org

anism

BCJo

int

Antib

iotic

sdSu

rger

y

1 3 4 5 5 6 7 7 8 9 10 11 11 12 Cas

e

33(2

5w

eeks

)23

(1da

y)(p

ost-

P)

24(2

6w

eeks

)

26(3

wee

ks)

(pos

t-P)

26(3

wee

ks)

(pos

t-P)

18(2

8w

eeks

)35

(ata

bort

ion)

23(2

wee

ks)

(pos

t-P)

32(2

days

)(p

ost-

P)26

(9da

ys)

(pos

t-P)

17(2

4w

eeks

)

20(2

wee

ks)

(pos

t-A

)28

(32

wee

ks)

24(3

wee

ks)

(pos

t-A

)26

(24

wee

ks)

IDU

,UT

IID

U

Endo

card

itis

Endo

met

ritis

Non

e

UT

IN

one

Non

e

Non

e

Non

e

IDU

,UT

I,en

doca

rditi

sEn

dom

etrit

is

Sinu

sitis

Non

e

Non

e

Acu

te(3

days

)Su

bacu

te(2

1da

ys)

Acu

te(1

day)

Suba

cute

(21

days

)

Suba

cute

(21

days

)

Acu

te(6

days

)A

cute

Acu

te

Acu

te(1

day)

Acu

te(4

days

)

Acu

te(5

days

)

Acu

te(2

days

)

Suba

cute

Acu

te(7

days

)

Suba

cute

(14

days

)

Butt

ock

pain

Back

and

butt

ock

pain

Back

and

hip

pain

;fe

ver

Butt

ock

pain

;fev

er

Butt

ock

pain

;fev

er

Hip

pain

Butt

ock

pain

;fev

erBu

ttoc

kpa

in;f

ever

Butt

ock

pain

;fev

er

Butt

ock

pain

;fev

er

Back

and

butt

ock

pain

Leg

pain

;fev

er

Back

pain

;fev

erBa

ckpa

in

Butt

ock

pain

;fev

er

Stap

hylo

cocc

usep

ider

mid

isSt

aphy

loco

ccus

aure

us

Alp

haSt

rept

ococ

cus

Not

defin

ed

Not

defin

ed

Stap

hylo

cocc

ussp

ecie

sSt

aphy

loco

ccus

aure

usN

otde

fined

Not

defin

ed

Gro

upB

Stre

ptoc

occu

s

Stap

hylo

cocc

usau

reus

Stre

ptoc

occu

spn

eum

onia

e

Stre

ptoc

occu

spn

eum

onia

eN

otde

fined

Stap

hylo

cocc

usau

reus

- - + - ND

ND + - - + + ND - ND

ND

+ + ND

ND

ND + ND

ND - ND - + + ND +

Naf

cilli

n(4

2da

ys)

Naf

cilli

n(4

2da

ys)

Not

stat

ed(4

2da

ys)

Cef

tria

xone

(42

days

)

Pris/

Rif(

30da

ys)

Fluf

loxa

cin

Not

stat

edN

otst

ated

(56

days

)

Dic

loxa

cilli

n,ce

ftri-

axon

e(6

0da

ys)

Not

stat

ed(4

2da

ys)

Not

stat

ed(4

9da

ys)

Not

stat

ed

Not

stat

edN

otst

ated

Cef

azol

in(4

2da

ys)

Ope

ndr

aina

geN

one

Non

e

Non

e

Non

e

Ope

ndr

aina

geN

one

Non

e

Non

e

Non

e

Non

e

Rese

ctio

n

Rese

ctio

nD

ebrid

emen

t

Non

e

a Post

-P,p

ostp

artu

m;p

ost-

A,p

ost-

abor

tion;

b IDU

,inj

ectio

ndr

ugus

e;U

TI,

urin

ary

trac

tinf

ectio

n;c - ,

nega

tive;

+,p

ositi

ve;N

D,n

otdo

ne;d Pr

is,pr

istin

amyc

in;R

if,ri

fam

pin

Tab

le1

Clin

ical

char

acte

ristic

sof

pyog

enic

sacr

oilii

tisas

soci

ated

with

preg

nanc

yor

the

post

nata

lper

iod

of 13 cases (62%), and an elevated erythrocytesedimentation rate was observed in eight ofeight patients (100%).

Routine X-rays often yielded nonspecificfindings, whereas computed tomography (CT)and MRI, which were performed in seven and sixcases, respectively, showed evidence of boneerosion and joint involvement in all cases tested.A bone scan was obtained in five postpartum orpost-abortion cases, and it demonstrated increasedlocalized isotope uptake in the involved joint,consistent with sacroiliitis, in all cases. Bilateralinvolvement was uncommon (n = 2; 13.3%).

Microbiological etiology was determined in66.7% of cases. Bacteremia was documentedin four of ten cases and joint fluid culture waspositive in six of eight cases. In five cases, nomicroorganism was identified. The most commonorganism was Staphylococcus aureus.

The management was described in 14 cases.Three cases were reported in the pre-antibioticera11,12, all of which were treated with surgicaldebridement. The remaining cases received intra-venous antibiotics for 30–60 days; the medianperiod was 6 weeks. Surgical drainage wasrequired in only two cases1,6. All of the patientsrecovered, and only two patients had residualpain. Preterm labor was reported in one case3.

DISCUSSION

The diagnosis of pathologic conditions in thesacroiliac joints during pregnancy may pose adiagnostic challenge. Low back pain, which is theusual presentation of inflammatory processes inthis joint, is fairly common during pregnancy.Furthermore, the rare incidence of the disease,the nonspecific symptoms and the difficulty inlocalizing the pain without careful examinationall contribute to the problem of establishingthe diagnosis. Therefore when pregnant womendevelop septic sacroiliitis, the initial manifestationscan be attributed to pregnancy-associated arthro-pathy. The presenting manifestations are still

nonspecific and fever is absent in a substantialnumber of patients. Our case illustrates thischallenge. This patient presented with increasingbackache that was initially attributed to nervecompression. The sacroiliac source was not sus-pected for several days.

Our review illustrates the fact that this condi-tion is relatively rare. In a comprehensive reviewof all relevant publications from 1878 to 1990,Vyskocil et al.1 identified 163 cases of pyogenicsacroiliitis, only four of which were associated withpregnancy1. Since then, we have found ten addi-tional cases3–12. Our findings demonstrate thatwithout proper diagnosis and treatment, theinfection frequently extends to the periarticularstructures11,12. In addition, in cases that involvedpreterm labor or fetal death, it is uncertain whetherjoint infection preceded, coincided with orfollowed these obstetric events3,7,11.

The pathogenesis of the condition is suspectedto be hematogenous. In support of this conclusion,this condition was seen either in patients with ahistory of injection drug use or in those who hadrecently had an infection elsewhere, includingendocarditis, sinusitis and urinary tract infection.The most common organism was Staphylococcusaureus.

With regard to diagnosis, routine X-ray wasrarely helpful. Bone scan was helpful, but it shouldonly be done during the postpartum periodbecause of concerns about radiation exposure. CTand MRI are both very helpful. MRI is probablythe method of choice in pregnancy, as it providesa highly sensitive means of detailed evaluationof the joint and surrounding soft tissue withoutexposing the fetus to ionizing radiation4.

The treatment for pregnancy-related bacterialsacroiliitis is similar to that for nonpregnancy-related cases. Most authors recommend 4–6 weeksof parenteral antibiotic therapy. Only two patientsrequired surgical drainage after initiating anti-biotics, and in both cases the disease extendedto the surrounding structure1,6. The outcome oftreatment appears to be favorable.


56 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY

REFERENCES1. Vyskocil J, McIlroy M, Brennan T, et al. Pyogenic

infection of the sacroiliac joint: case report andreview of the literature. Medicine 1991;70:188–97

2. Zimmermann B III, Mikolich DJ, Lally EV. Septicsacroiliitis. Semin Arthritis Rheum 1996;26:592–604

3. Gordon G, Kabins SA. Pyogenic sacroiliitis. Am JMed 1980;69:50–6

4. Wilbur A, Langer B, Spigos D. Diagnosis ofsacroiliac joint infection in pregnancy by magneticresonance imaging. Magn Reson Imaging 1998;6:341–3

5. Tisserant R, Loeuille D, Pere P, et al. Septicsacroiliitis during the postpartal period: diagnosticcontribution of magnetic resonance imaging.Rev Rhum 1999;66:512–15

6. Sandrasegaran K, Saifudin A, Coral A, et al.Magnetic resonance imaging of septic sacroiliitis.Skeletal Radiol 1994;23:289–92

7. Siam A, Hammoudeh M, Uwaydah A. Pyogenicsacroiliitis in Qatar. Br J Rheumatol 1993;32:699–701

8. Linnet K, Kammelgaard L, Johansen M, et al.Bilateral pyogenic sacroiliitis following uncompli-cated pregnancy and labor. Acta Obstet GynecolScand 1996;75:950–1

9. Jedwab M, Ovadia S, Dan M. Pyogenic sacroiliitisin pregnancy. Int J Gynaecol Obstet 1999;65:303–4

10. Egerman RS, Mabie WC, Eifrid M, et al.Sacroiliitis associated with pyelonephritis inpregnancy. Obstet Gynecol 1995;85:834–5

11. Chandler F. Pneumococcic infection of thesacroiliac joint complicating pregnancy. JAMA1933;101:114–16

12. L’Episcopo JB. Suppurative arthritis of thesacroiliac joint. Ann Surg 1936;104:289–303

RECEIVED 07/16/02; ACCEPTED 10/08/02


INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 57

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