Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 303e305
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Postpartum pyogenic sacroiliitis with methicillin-resistant Staphylococcus aureus in a healthy adult: A case report and review of the literature Takashi Imagama*, Atsunori Tokushige, Akihito Sakka, Kazushige Seki, Toshihiko Taguchi Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 October 2013
Objective: Back and buttock pain during pregnancy and the postpartum period generally improves spontaneously and rarely causes problems. However, such pain is infrequently induced by pyogenic sacroiliitis. Case report: We herein present a 37-year-old female patient with no previous medical history who developed pyogenic sacroiliitis with severe right buttock pain 7 days after cesarean delivery. Arthrocentesis was performed, and a culture revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA). After 6 weeks of treatment with intravenous antibiotics, her infection became quiescent. Eight cases of pyogenic sacroiliitis during the postpartum period and seven cases during pregnancy have been reported, but most of the causative pathogens were methicillin-sensitive Staphylococcus or Streptococcus species. Conclusion: This report describes the first case of postpartum pyogenic sacroiliitis caused by MRSA. The frequency of infection with MRSA has recently increased, and community-acquired MRSA, which affects even healthy young people, has also become a problem. Antibiotics for empirical therapy after a diagnosis of pyogenic sacroiliitis, including anti-MRSA antibiotics, should be carefully selected. Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: conservative treatment healthy adult methicillin-resistant Staphylococcus aureus postpartum pyogenic sacroillitis
Introduction
Case report
Back and buttock pain during pregnancy and the postpartum period is frequently observed and generally resolves spontaneously. However, it is sometimes associated with gynecological diseases (e.g., abnormal pregnancy), urological diseases (e.g., urinary calculi and pyelonephritis), and orthopedic diseases (e.g., lumbar disc herniation). It has been reported that back and buttock pain is infrequently induced by pyogenic sacroiliitis. Rapid diagnosis of pyogenic sacroiliitis is important because a delay in the diagnosis and treatment may result in irreversible joint destruction. In this report, we present an extremely rare case of severe buttock pain due to pyogenic sacroiliitis caused by methicillinresistant Staphylococcus aureus (MRSA) during the postpartum period.
A 37-year-old female patient with no medical or family history had no particular problems during pregnancy. However, at 36 weeks of pregnancy, a nonreassuring fetal status was found, and her first child was born by cesarean delivery. She had no postoperative abnormalities, and the surgical wound site healed well. However, 7 days after surgery, right buttock pain developed with no trigger. She visited the hospital because of the gradually worsening buttock pain, gait disturbance, and fever. Her body temperature was 38.4 C, and severe tenderness was present in the right buttock. A pelvic compression test was positive for the right buttock. Blood testing showed a white blood cell level of 13.96 109/L, a left shift on the differential white blood count, and a remarkably elevated C-reactive protein level of 220 mg/L. A pelvic radiograph showed no remarkably abnormal findings such as osteolysis or osteosclerosis (Fig. 1), but contrast-enhanced computed tomography revealed enlargement of the right iliac muscle and an abscess accompanied by ring-enhancing lesions anteroposterior to the right sacroiliac joint (Fig. 2).
* Corresponding author. Department of Orthopaedic Surgery Graduate School of Medicine, Yamaguchi University, 1-1-1, Minamikogushi, Ube, 755-8505, Japan. E-mail address: [email protected] (T. Imagama).
http://dx.doi.org/10.1016/j.tjog.2013.10.044 1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
304
T. Imagama et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 303e305
Fig. 1. Plain pelvic radiograph. There are no obvious abnormal findings.
Fig. 3. Plain magnetic resonance imaging. In the right sacroiliac joint, (A) T1-weighted image shows low intensity, and (B) T2-weighted image shows high intensity indicating inflammation.
Fig. 2. Contrast-enhanced computed tomography images. An abscess accompanied by the ring enhancing lesion anteroposterior to the right sacroiliac joint is observed (arrow). The right iliac muscle is enlarged.
Magnetic resonance imaging centered on the right sacroiliac joint was performed. The T1-weighted image showed low intensity, and the T2-weighted image revealed abnormal high intensity of the bone marrow and a lesion believed to be an abscess 1.5 cm in diameter in the region anteroposterior to the joint (Fig. 3). Based on these results, the patient was diagnosed with pyogenic sacroiliitis. X-ray-guided puncture of the sacroiliac joint and abscess was performed, and approximately 2 mL of milketea-like puncture fluid was collected. Culture of the puncture fluid revealed the presence of MRSA. Blood and urine cultures were negative. After a 3-week combined administration of vancomycin and rifampicin, a 3-week administration of arbekacin was performed. Her symptoms subsequently disappeared, her blood test results became normal, and she was discharged from the hospital. One year after discharge, no recurrence was observed, and she has a favorable prognosis. Discussion It is generally reported that pyogenic sacroiliitis accounts for 1.5e10% of all cases of septic arthritis and is a rare disease. It is highly associated with gynecological infection, pelvic trauma, and
drug abuse [1]. Therefore, when the major complaints comprise relatively frequently observed symptoms such as back pain, it is difficult to achieve a diagnosis, and treatment delay becomes a problem. In particular, pyogenic sacroiliitis occurring during the postpartum period and pregnancy is very rare, and only seven cases during pregnancy and eight cases during the postpartum period have been reported (Table 1) [1e14]. With respect to the pathogenesis of pyogenic sacroiliitis, increased joint laxity of the pelvis influenced by hormones and hematogenous infection evoked by damage to the sacroiliac joint caused by enlargement of the uterus and childbearing have been reported [15]. In our case, pyogenic sacroiliitis occurred 7 days after childbearing, and in all previously reported cases, it developed within 3 weeks after childbearing and after a midterm pregnancy. These time frames might correspond to the period of uterus enlargement and the duration until stabilization of the postpartum pelvis. In terms of the clinical symptoms of pyogenic sacroiliitis, most patients, including the present patient, have buttock pain that is often severe and is sometimes accompanied by gait disturbance. In previous reports, pathogenic bacteria were identified in 12 of 15 cases of pyogenic sacroiliitis during pregnancy and the postpartum period. These 12 cases included seven of 13 cases in which blood culture was performed and five of eight cases in which culture of pus via joint aspiration was performed. In our case, blood and urine cultures were negative, but a joint aspirate culture identified MRSA. Because effective antibiotics could be used from the early phase, our case had a favorable prognosis. In all cases, pyogenic sacroiliitis occurs after the organogenesis period of the fetus. Therefore, we conclude that when pyogenic sacroiliitis is suspected, joint puncture with fluoroscopic guidance and culture of both the puncture fluid and blood should be performed. It was previously reported that Staphylococcus species (6 cases, 50%) and Streptococcus species (5 cases, 41.7%) account for the majority of bacterial species causing pyogenic sacroiliitis. Delbarre et al [16] reported that approximately 50% of pathogenic bacteria of pyogenic sacroiliitis are S. aureus. Therefore, penicillin or cephem antibiotics might be the most appropriate first-line drugs for empirical antibiotic therapy. Pyogenic sacroiliitis caused by MRSA has not been previously reported, and our case is very rare. However, the fatality rate of MRSA infection is reportedly higher than that of methicillin-sensitive
T. Imagama et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 303e305
305
Table 1 Characteristics of the 15 reported cases of pyogenic sacroiliitis in pregnancy and postpartum. Study
Age (y)
Pregnancy week or interval from delivery
Risk factors
Symptoms
Cultures
Species
Treatment (duration of drug use)
In pregnancy [1] 33 [2] 31
25 wk 23 wk
IDU, UTI None
Buttock & thigh pain Back and buttock pain
Blood/joint Blood/joint
NA/Staphylococcus epidermidis Staphylococcus aureus/NA
[3] [4]
26 17
24 wk 24 wk
Buttock & leg pain Back & buttock pain
Joint Blood/joint
Staphylococcus aureus Staphylococcus aureus/NA
[5]
18
28 wk
None IDU, UTI Endocarditis UTI
Nafcillin (42 d) Cloxacillin (56 d) RFP þ ofloxacin (4 mo) Cefazolin (42 d) Antibiotics (49 d)
Hip pain
Joint
Staphylococcus sp.
[6]
24
26 wk
Endocarditis
Back & hip pain
Blood
a Streptococcus
[7]
28
32 wk
Sinusitis
Buttock pain
Blood/joint
NA: Streptococcus pneumoniae
Postpartum [8] 30
2d
None
Buttock pain
Blood
NA
[9]
37
6d
None
Hip pain
Blood
Group A Streptococcus pyogenes
[10]
26
21 d
None
Buttock pain
Blood/urine
NA/Escherichia coli
[10] [11] [12] [13] [14]
26 26 32 23 23
21 d 9d 2d 14 d 1d
None None None None IDU
Buttock & thigh pain Buttock & thigh pain Buttock pain Buttock pain Back & buttock pain
Blood Blood Blood/joint Blood Blood/joint
Group B Streptococcus, Escherichia coli Group B Streptococcus NA/NA NA Staphylococcus aureus/NA
Flucloxacillin (30 d) open drainage Antibiotics (42 d) open drainage Antibiotics (? d) resection Clindamycin (8 wk) Hysterectomy, oophorectomy Benzylpenicillin (3 mo) Clindamycin (3 mo) Ceftriaxone þ ofloxacin (1 mo) oral ofloxacin (2 mo) Pristinamycin þ RFP (3 mo) Penicillin G (42 d) Ceftriaxone (56 d) Antibiotics (56 d) Nafcillin (42 d)
IDU ¼ injection drug use; NA ¼ not available; RFP ¼ rifampin; UTI ¼ urinary tract infection.
S. aureus, and more than 64% of S. aureus species identified in intensive care units are MRSA [17]. In addition, the incidence of community-acquired MRSA infection, which even occurs in young people with no risk factors, has increased, and MRSA is one of the most alarming pathogenic bacteria [18e20]. In the present case, the onset was immediately after the patient's discharge from the hospital, and she had no contact with any animal that could have been the source of the infection. Furthermore, based on its resistance to multiple antimicrobial agents including b-lactams, hospital-acquired MRSA infection was strongly suspected in our case; however, we did not perform genetic screening for MRSA. Among the reported patients with pyogenic sacroiliitis during the postpartum period and pregnancy, only six patients had risk factors such as urinary tract infection, and more than half were healthy young people as in our case. Generally, MRSA infection is hardly suspected in healthy individuals and especially young people. However, the number of patients with MRSA infection, as in the present case, might increase. In previous cases of pyogenic sacroiliitis, when the pathogenic bacteria could not be identified and the effect of antibiotics was insufficient, the use of anti-MRSA drugs probably led to the favorable prognosis. Conflicts of interest The authors have no conflicts of interest relevant to this article. References [1] Vyskocil JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint. Case reports and review of the literature. Medicine 1991;70: 188e97. [2] Moros ML, Rodrigo C, Villacampa A, Ruiz J, Lapresta C. Septic shock in pregnancy due to pyogenic sacroiliitis: a case report. J Med Case Rep 2009;3:6505. [3] Almoujahed MO, Khatib R, Baran J. Pregnancy-associated pyogenic sacroiliitis: case report and review. Infect Dis Obstet Gynecol 2003;11:53e7.
[4] Egerman RS, Mabie WC, Eifrid M, Whitnack E, Sibai BM. Sacroiliitis associated with pyelonephritis in pregnancy. Obstet Gynecol 1995;85:834e5. [5] Sandrasegaran K, Saifuddin A, Coral A, Butt WP. Magnetic resonance imaging of septic sacroiliitis. Skeletal Radiol 1994;23:289e92. [6] Wilbur AC, Langer BG, Spigos DG. Diagnosis of sacroiliac joint infection in pregnancy by magnetic resonance imaging. Magn Reson Imaging 1988;6: 341e3. [7] Chandler FA. Pneumococcic infection of the sacro-iliac joint complicating pregnancy. JAMA 1933;101:114e67. [8] Liu XQ, Li FC, Wang JW, Wang S. Postpartum septic sacroiliitis misdiagnosed as sciatic neuropathy. The Am J Med Sci 2010;339:292e5. [9] Haq I, Morris V. Post-partum septic sacroiliitis. Rheumatology (Oxford) 2001;40:1191e2. re P, Gaucher A, Pourel J, Blum A. Septic sacroiliitis [10] Tisserant R, Loeuille D, Pe during the postpartal period. Diagnostic contribution of magnetic resonance imaging. Rev Rhum Engl Ed 1999;66:512e5. [11] Jedwab M, Ovadia S, Dan M. Pyogenic sacroiliitis in pregnancy. Int J Gynaecol Obstet 1999;65:303e4. [12] Linnet KM, Gammelgaard L, Johansen M, Krarup N, Rasmussen KL. Bilateral pyogenic sacroiliitis following uncomplicated pregnancy and labor. Acta Obstet Gynecol Scand 1996;75:950e1. [13] Siam AR, Hammoudeh M, Uwaydah AK. Pyogenic sacroiliitis in Qatar. Br J Rheumatol 1993;32:699e701. [14] Gordon G, Kabins SA. Pyogenic sacroiliitis. Am J Med 1980;69:50e6. [15] Engelsbel S, Swartjes JM, Schutte MF. Pyogenic sacro-iliitis, a rare cause of peripartum pelvic pain. Eur J Obstet Gynecol Reprod Biol 1995;62:125e6. [16] Delbarre F, Rondier J, Delrieu F, Evrard J, Cayla J, Menkes CJ, et al. Pyogenic infection of the sacro-iliac joint. Report of thirteen cases. J Bone Joint Surg Am 1975;57:819e25. [17] Klevens RM, Edwards JR, Tenover FC, McDonald LC, Horan T, Gaynes R, et al. Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in US hospitals, 1992e2003. Clin Infect Dis 2006;42: 389e91. [18] Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436e44. [19] Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, et al. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 2003;290:2976e84. [20] Gorak EJ, Yamada SM, Brown JD. Community-acquired methicillin-resistant Staphylococcus aureus in hospitalized adults and children without known risk factors. Clin Infect Dis 1999;29:797e800.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Postpartum pyogenic sacroiliitis with methicillin-resistant Staphylococcus aureus in a healthy adult: A case report and review of the literature Takashi Imagama*, Atsunori Tokushige, Akihito Sakka, Kazushige Seki, Toshihiko Taguchi Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 October 2013
Objective: Back and buttock pain during pregnancy and the postpartum period generally improves spontaneously and rarely causes problems. However, such pain is infrequently induced by pyogenic sacroiliitis. Case report: We herein present a 37-year-old female patient with no previous medical history who developed pyogenic sacroiliitis with severe right buttock pain 7 days after cesarean delivery. Arthrocentesis was performed, and a culture revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA). After 6 weeks of treatment with intravenous antibiotics, her infection became quiescent. Eight cases of pyogenic sacroiliitis during the postpartum period and seven cases during pregnancy have been reported, but most of the causative pathogens were methicillin-sensitive Staphylococcus or Streptococcus species. Conclusion: This report describes the first case of postpartum pyogenic sacroiliitis caused by MRSA. The frequency of infection with MRSA has recently increased, and community-acquired MRSA, which affects even healthy young people, has also become a problem. Antibiotics for empirical therapy after a diagnosis of pyogenic sacroiliitis, including anti-MRSA antibiotics, should be carefully selected. Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: conservative treatment healthy adult methicillin-resistant Staphylococcus aureus postpartum pyogenic sacroillitis
Introduction
Case report
Back and buttock pain during pregnancy and the postpartum period is frequently observed and generally resolves spontaneously. However, it is sometimes associated with gynecological diseases (e.g., abnormal pregnancy), urological diseases (e.g., urinary calculi and pyelonephritis), and orthopedic diseases (e.g., lumbar disc herniation). It has been reported that back and buttock pain is infrequently induced by pyogenic sacroiliitis. Rapid diagnosis of pyogenic sacroiliitis is important because a delay in the diagnosis and treatment may result in irreversible joint destruction. In this report, we present an extremely rare case of severe buttock pain due to pyogenic sacroiliitis caused by methicillinresistant Staphylococcus aureus (MRSA) during the postpartum period.
A 37-year-old female patient with no medical or family history had no particular problems during pregnancy. However, at 36 weeks of pregnancy, a nonreassuring fetal status was found, and her first child was born by cesarean delivery. She had no postoperative abnormalities, and the surgical wound site healed well. However, 7 days after surgery, right buttock pain developed with no trigger. She visited the hospital because of the gradually worsening buttock pain, gait disturbance, and fever. Her body temperature was 38.4 C, and severe tenderness was present in the right buttock. A pelvic compression test was positive for the right buttock. Blood testing showed a white blood cell level of 13.96 109/L, a left shift on the differential white blood count, and a remarkably elevated C-reactive protein level of 220 mg/L. A pelvic radiograph showed no remarkably abnormal findings such as osteolysis or osteosclerosis (Fig. 1), but contrast-enhanced computed tomography revealed enlargement of the right iliac muscle and an abscess accompanied by ring-enhancing lesions anteroposterior to the right sacroiliac joint (Fig. 2).
* Corresponding author. Department of Orthopaedic Surgery Graduate School of Medicine, Yamaguchi University, 1-1-1, Minamikogushi, Ube, 755-8505, Japan. E-mail address: [email protected] (T. Imagama).
http://dx.doi.org/10.1016/j.tjog.2013.10.044 1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
304
T. Imagama et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 303e305
Fig. 1. Plain pelvic radiograph. There are no obvious abnormal findings.
Fig. 3. Plain magnetic resonance imaging. In the right sacroiliac joint, (A) T1-weighted image shows low intensity, and (B) T2-weighted image shows high intensity indicating inflammation.
Fig. 2. Contrast-enhanced computed tomography images. An abscess accompanied by the ring enhancing lesion anteroposterior to the right sacroiliac joint is observed (arrow). The right iliac muscle is enlarged.
Magnetic resonance imaging centered on the right sacroiliac joint was performed. The T1-weighted image showed low intensity, and the T2-weighted image revealed abnormal high intensity of the bone marrow and a lesion believed to be an abscess 1.5 cm in diameter in the region anteroposterior to the joint (Fig. 3). Based on these results, the patient was diagnosed with pyogenic sacroiliitis. X-ray-guided puncture of the sacroiliac joint and abscess was performed, and approximately 2 mL of milketea-like puncture fluid was collected. Culture of the puncture fluid revealed the presence of MRSA. Blood and urine cultures were negative. After a 3-week combined administration of vancomycin and rifampicin, a 3-week administration of arbekacin was performed. Her symptoms subsequently disappeared, her blood test results became normal, and she was discharged from the hospital. One year after discharge, no recurrence was observed, and she has a favorable prognosis. Discussion It is generally reported that pyogenic sacroiliitis accounts for 1.5e10% of all cases of septic arthritis and is a rare disease. It is highly associated with gynecological infection, pelvic trauma, and
drug abuse [1]. Therefore, when the major complaints comprise relatively frequently observed symptoms such as back pain, it is difficult to achieve a diagnosis, and treatment delay becomes a problem. In particular, pyogenic sacroiliitis occurring during the postpartum period and pregnancy is very rare, and only seven cases during pregnancy and eight cases during the postpartum period have been reported (Table 1) [1e14]. With respect to the pathogenesis of pyogenic sacroiliitis, increased joint laxity of the pelvis influenced by hormones and hematogenous infection evoked by damage to the sacroiliac joint caused by enlargement of the uterus and childbearing have been reported [15]. In our case, pyogenic sacroiliitis occurred 7 days after childbearing, and in all previously reported cases, it developed within 3 weeks after childbearing and after a midterm pregnancy. These time frames might correspond to the period of uterus enlargement and the duration until stabilization of the postpartum pelvis. In terms of the clinical symptoms of pyogenic sacroiliitis, most patients, including the present patient, have buttock pain that is often severe and is sometimes accompanied by gait disturbance. In previous reports, pathogenic bacteria were identified in 12 of 15 cases of pyogenic sacroiliitis during pregnancy and the postpartum period. These 12 cases included seven of 13 cases in which blood culture was performed and five of eight cases in which culture of pus via joint aspiration was performed. In our case, blood and urine cultures were negative, but a joint aspirate culture identified MRSA. Because effective antibiotics could be used from the early phase, our case had a favorable prognosis. In all cases, pyogenic sacroiliitis occurs after the organogenesis period of the fetus. Therefore, we conclude that when pyogenic sacroiliitis is suspected, joint puncture with fluoroscopic guidance and culture of both the puncture fluid and blood should be performed. It was previously reported that Staphylococcus species (6 cases, 50%) and Streptococcus species (5 cases, 41.7%) account for the majority of bacterial species causing pyogenic sacroiliitis. Delbarre et al [16] reported that approximately 50% of pathogenic bacteria of pyogenic sacroiliitis are S. aureus. Therefore, penicillin or cephem antibiotics might be the most appropriate first-line drugs for empirical antibiotic therapy. Pyogenic sacroiliitis caused by MRSA has not been previously reported, and our case is very rare. However, the fatality rate of MRSA infection is reportedly higher than that of methicillin-sensitive
T. Imagama et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 303e305
305
Table 1 Characteristics of the 15 reported cases of pyogenic sacroiliitis in pregnancy and postpartum. Study
Age (y)
Pregnancy week or interval from delivery
Risk factors
Symptoms
Cultures
Species
Treatment (duration of drug use)
In pregnancy [1] 33 [2] 31
25 wk 23 wk
IDU, UTI None
Buttock & thigh pain Back and buttock pain
Blood/joint Blood/joint
NA/Staphylococcus epidermidis Staphylococcus aureus/NA
[3] [4]
26 17
24 wk 24 wk
Buttock & leg pain Back & buttock pain
Joint Blood/joint
Staphylococcus aureus Staphylococcus aureus/NA
[5]
18
28 wk
None IDU, UTI Endocarditis UTI
Nafcillin (42 d) Cloxacillin (56 d) RFP þ ofloxacin (4 mo) Cefazolin (42 d) Antibiotics (49 d)
Hip pain
Joint
Staphylococcus sp.
[6]
24
26 wk
Endocarditis
Back & hip pain
Blood
a Streptococcus
[7]
28
32 wk
Sinusitis
Buttock pain
Blood/joint
NA: Streptococcus pneumoniae
Postpartum [8] 30
2d
None
Buttock pain
Blood
NA
[9]
37
6d
None
Hip pain
Blood
Group A Streptococcus pyogenes
[10]
26
21 d
None
Buttock pain
Blood/urine
NA/Escherichia coli
[10] [11] [12] [13] [14]
26 26 32 23 23
21 d 9d 2d 14 d 1d
None None None None IDU
Buttock & thigh pain Buttock & thigh pain Buttock pain Buttock pain Back & buttock pain
Blood Blood Blood/joint Blood Blood/joint
Group B Streptococcus, Escherichia coli Group B Streptococcus NA/NA NA Staphylococcus aureus/NA
Flucloxacillin (30 d) open drainage Antibiotics (42 d) open drainage Antibiotics (? d) resection Clindamycin (8 wk) Hysterectomy, oophorectomy Benzylpenicillin (3 mo) Clindamycin (3 mo) Ceftriaxone þ ofloxacin (1 mo) oral ofloxacin (2 mo) Pristinamycin þ RFP (3 mo) Penicillin G (42 d) Ceftriaxone (56 d) Antibiotics (56 d) Nafcillin (42 d)
IDU ¼ injection drug use; NA ¼ not available; RFP ¼ rifampin; UTI ¼ urinary tract infection.
S. aureus, and more than 64% of S. aureus species identified in intensive care units are MRSA [17]. In addition, the incidence of community-acquired MRSA infection, which even occurs in young people with no risk factors, has increased, and MRSA is one of the most alarming pathogenic bacteria [18e20]. In the present case, the onset was immediately after the patient's discharge from the hospital, and she had no contact with any animal that could have been the source of the infection. Furthermore, based on its resistance to multiple antimicrobial agents including b-lactams, hospital-acquired MRSA infection was strongly suspected in our case; however, we did not perform genetic screening for MRSA. Among the reported patients with pyogenic sacroiliitis during the postpartum period and pregnancy, only six patients had risk factors such as urinary tract infection, and more than half were healthy young people as in our case. Generally, MRSA infection is hardly suspected in healthy individuals and especially young people. However, the number of patients with MRSA infection, as in the present case, might increase. In previous cases of pyogenic sacroiliitis, when the pathogenic bacteria could not be identified and the effect of antibiotics was insufficient, the use of anti-MRSA drugs probably led to the favorable prognosis. Conflicts of interest The authors have no conflicts of interest relevant to this article. References [1] Vyskocil JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint. Case reports and review of the literature. Medicine 1991;70: 188e97. [2] Moros ML, Rodrigo C, Villacampa A, Ruiz J, Lapresta C. Septic shock in pregnancy due to pyogenic sacroiliitis: a case report. J Med Case Rep 2009;3:6505. [3] Almoujahed MO, Khatib R, Baran J. Pregnancy-associated pyogenic sacroiliitis: case report and review. Infect Dis Obstet Gynecol 2003;11:53e7.
[4] Egerman RS, Mabie WC, Eifrid M, Whitnack E, Sibai BM. Sacroiliitis associated with pyelonephritis in pregnancy. Obstet Gynecol 1995;85:834e5. [5] Sandrasegaran K, Saifuddin A, Coral A, Butt WP. Magnetic resonance imaging of septic sacroiliitis. Skeletal Radiol 1994;23:289e92. [6] Wilbur AC, Langer BG, Spigos DG. Diagnosis of sacroiliac joint infection in pregnancy by magnetic resonance imaging. Magn Reson Imaging 1988;6: 341e3. [7] Chandler FA. Pneumococcic infection of the sacro-iliac joint complicating pregnancy. JAMA 1933;101:114e67. [8] Liu XQ, Li FC, Wang JW, Wang S. Postpartum septic sacroiliitis misdiagnosed as sciatic neuropathy. The Am J Med Sci 2010;339:292e5. [9] Haq I, Morris V. Post-partum septic sacroiliitis. Rheumatology (Oxford) 2001;40:1191e2. re P, Gaucher A, Pourel J, Blum A. Septic sacroiliitis [10] Tisserant R, Loeuille D, Pe during the postpartal period. Diagnostic contribution of magnetic resonance imaging. Rev Rhum Engl Ed 1999;66:512e5. [11] Jedwab M, Ovadia S, Dan M. Pyogenic sacroiliitis in pregnancy. Int J Gynaecol Obstet 1999;65:303e4. [12] Linnet KM, Gammelgaard L, Johansen M, Krarup N, Rasmussen KL. Bilateral pyogenic sacroiliitis following uncomplicated pregnancy and labor. Acta Obstet Gynecol Scand 1996;75:950e1. [13] Siam AR, Hammoudeh M, Uwaydah AK. Pyogenic sacroiliitis in Qatar. Br J Rheumatol 1993;32:699e701. [14] Gordon G, Kabins SA. Pyogenic sacroiliitis. Am J Med 1980;69:50e6. [15] Engelsbel S, Swartjes JM, Schutte MF. Pyogenic sacro-iliitis, a rare cause of peripartum pelvic pain. Eur J Obstet Gynecol Reprod Biol 1995;62:125e6. [16] Delbarre F, Rondier J, Delrieu F, Evrard J, Cayla J, Menkes CJ, et al. Pyogenic infection of the sacro-iliac joint. Report of thirteen cases. J Bone Joint Surg Am 1975;57:819e25. [17] Klevens RM, Edwards JR, Tenover FC, McDonald LC, Horan T, Gaynes R, et al. Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in US hospitals, 1992e2003. Clin Infect Dis 2006;42: 389e91. [18] Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436e44. [19] Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, et al. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 2003;290:2976e84. [20] Gorak EJ, Yamada SM, Brown JD. Community-acquired methicillin-resistant Staphylococcus aureus in hospitalized adults and children without known risk factors. Clin Infect Dis 1999;29:797e800.
