Osteitis/osteomyelitis pubis simulating acute appendicitis
This case, published in the International Journal of Surgery Case Reports, illustrates two things:

•There is a continuum among diagnostic entities previously considered disparate: athletic hernia and osteitis pubis, and osteomyelitis pubis.
•These diagnostic entities may simulate an acute abdomen.

A 16 years old young man came to Emergency Department because of right lower quadrant abdominal pain that was acute in onset and had worsened over the prior two days; it was accompanied by fever, anorexia, nausea, and vomiting.

Two years ago he had fractured his right clavicle; and because of the poor alignment and delayed healing, operative reduction and fixation was performed.

He was remarkably tender in the right lower quadrant of his abdomen, with involuntary guarding and positive psoas and obturator signs. His WBC count and Urinalysis were normal. Ultrasound identified “mildly prominent, non-specific lymph nodes” but not the appendix. The MRI was also “somewhat equivocal” -free fluid in the pelvis with inflammation, but the appendix was not visualized; nevertheless, the radiologist opined that the findings were consistent with either appendicitis or inflammatory bowel disease.

Unfortunately, the MRI did not include the pubic symphysis and contiguous musculature.

The diagnostic impression was appendicitis; however, this was not corroborated by laparoscopy, which revealed a normal appendix. No other intra-abdominal pathology was identified. The presumptive diagnosis became gastroenteritis, and an uneventful recovery was anticipated.

This prediction initially appeared correct, and he was discharged only to return the evening of the second post-operative day, complaining once again of exquisite right lower quadrant abdominal pain, this time associated with fever, leukocytosis, and elevated inflammatory markers.

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