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Official websites use. Share sensitive information only on official, secure websites. 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 author and source are credited. We discuss a case of methicillin-resistant Staphylococcus aureus MRSA osteomyelitis pubis in a year-old female patient with an active history of intravenous IV drug injection. While IV drug users are typically infected with Pseudomonas aeruginosa in cases of osteomyelitis of the pubic symphysis, our patient presented with a rare case of MRSA infection of the pubis symphysis. In this case, an investigation using magnetic resonance imaging MRI , elevated levels of erythrocyte sedimentation rate ESR , C-reactive protein CRP , and culture was consistent with the diagnosis of osteomyelitis. Osteomyelitis pubis is an infection that causes necrosis and destruction of the pubic bone. The goal of this case report is to promote awareness of this phenomenon to hasten diagnosis and early treatment. Keywords: methicillin-resistant staphylococcus aureus mrsa , cocaine, pubic symphysis, intravenous drug use ivdu , pubic osteomyelitis. It often presents as a severe subacute pubic pain that is exacerbated by weight bearing and active movements such as walking. Such localized musculoskeletal pain in addition to an elevated ESR makes this diagnosis likely \[ 1 , 2 \]. We describe the case of a year-old female with an active history of IV drug use with injection into her mons pubis region, leading to the development of pubic symphysis osteomyelitis. The patient has undergone incision and drainage, started on intravenous IV antibiotics to cover for methicillin-resistant Staphylococcus aureus MRSA , and failed to complete a full course of treatment as she left against medical advice. While IV drug users are typically infected with Pseudomonas aeruginosa in cases of osteomyelitis of the pubic symphysis \[ 1 \], athletes are mostly infected with Staphylococcus aureus. Patients who have a history of IV abuse are susceptible to antibiotic-resistant infections, such as MRSA, and a resultant complicated treatment course. Providers should have a high suspicion of osteomyelitis of the pubic symphysis if patients present with pubic pain, difficulty in ambulating, and an elevated ESR. We present a case of a year-old female with a medical history significant for polysubstance abuse consisting of opioids, cocaine, alcohol, and benzodiazepines, a hepatitis C infection, and an active chronic history of IV use who presented to the Emergency Department ED complaining of pain, swelling, and drainage in her mons pubis. The symptoms had been occurring for a two-week period prior to admission, with the pain progressively worsening causing her to have difficulty with ambulation, hence prompting her to seek medical assistance. The patient endorsed ongoing severe polysubstance abuse and injecting cocaine and heroin into her groin. The patient denied fever, chills, shortness of breath, nausea, vomiting, dysuria, diarrhea, or vaginal discharge. She denied recent trauma or sexual activity. Physical examination was notable for hemodynamic stability as the patient was afebrile with a temperature Her pudendal area appeared swollen, with mild tenderness on palpation. There was no identifiable fluid collection, no erythema, and no bloody discharge. Laboratory results were remarkable for a white blood cell count of Of note, the patient was prescribed 10 mg oxycodone every four to six hours, as needed, for pain. In the ED, the patient was started on vancomycin and piperacillin-tazobactam. The patient was stabilized and admitted to the medicine floor for further diagnostic imaging and management. On the medicine floor, to assess the progression of the pelvic infection, computed tomography CT without contrast was planned due to the patient's setting of acute kidney injury. CT showed persistent fluid collection of the mons pubis with possible draining sinus tract extending into the pubic symphysis. Increasing osseous destruction of the pubic bone was noted along with reactive dystrophic soft tissue calcifications Figure 1. The evidence was concerning an active infection with chronic osteomyelitis and septic arthritis. Initially, general surgery was consulted and recommended management via pack wounds with iodoform gauze, continuation of the broad-spectrum antibiotics, and consultation with orthopedic surgery and infectious disease. Red arrow indicates large overlying phlegmonous changes and anterior multi-loculated abscess, and orange arrow indicates destruction of the pubic symphysis with cortical erosions. Soft tissue swelling anterior and posterior to the pubic symphysis consistent with septic arthritis was also noted. The patient underwent surgical incision and drainage, intraoperative wound cultures returned positive for MRSA, and the patient was transitioned to a renal dosage of piperacillin-tazobactam 2. Prior to discharge, a peripherally inserted central catheter line was placed for continuation of IV antibiotics for another four to six weeks. However, the patient was lost to follow-up. Nineteen days later, the patient returned to the ED complaining of pelvic pain. Given the patient's history, diagnostic imaging of MRI was conducted, which revealed pubic symphysis osteomyelitis with an abscess straddling with destroyed joint spaces. Myositis and fasciitis of the surrounding structures was evident. Figure 2. The patient was once again lost to follow-up as she left against medical advice. Red arrow indicates destructive changes of the symphysis pubis with osteomyelitis of the pubic bodies. We present a case of MRSA osteomyelitis of the pubic symphysis in a patient with IV injection of heroin and cocaine into the pubic region. While the pathogenesis remains unclear \[ 1 \], we speculate that the infectious process occurred from hematogenous spread or direct inoculation from the needle. IV drug use can predispose a patient to infectious complications presumably from a combination of altered immune competence and injection of contaminated material \[ 2 \]. The clinical presentation of an infectious cause compared to an inflammatory cause of the suprapubic pain overlap. It is important to distinguish between the two, as the course of treatment is different. Providers often confuse osteitis pubis, a self-limited inflammatory condition, with osteomyelitis pubis, an infectious process that can cause necrosis and destruction of the bone. Osteitis is often secondary to overuse injuries often seen in athletes. Osteomyelitis is often due to postoperative inoculation or after gynecological, urological operation, or endoscopic inguinal hernia repair \[ 1 \]. There should be high clinical suspicion for osteomyelitis if a patient presents with severe subacute pubic pain that is exacerbated by weight bearing and active movements such as walking. This localized musculoskeletal pain in addition to an elevated ESR, makes this diagnosis likely \[ 1 , 2 \]. Of the 13 reported cases of infectious pubis in IV drug user patients, temperature and leukocyte count were normal or slightly elevated \[ 2 \]. Thus, involvement of the hip adductor accounts for pain experienced with ambulation \[ 4 \], as exhibited in this patient. IV drug users of a younger age are more predisposed to septic arthritis of symphysis pubis due to the laxity of the ligament, as it is bound by flexible fibrocartilage with thin layers of hyaline cartilage \[ 1 , 4 \]. In comparison, older patients have sclerosed and ossified joints, which reduce the risk of bacteremia \[ 4 \]. While IV drug users are typically infected with Pseudomonas aeruginosa in cases of osteomyelitis of the pubic symphysis, \[ 4 \], athletes are mostly infected with Staphylococcus aureus. While our patient was lost to follow-up, in case reports reviewed by Magarian and Reuler, it has been shown that patients who followed up after discharge and completed a prolonged four-to six-week course of antibiotics did not exhibit recurrence or require debridement \[ 2 \]. Often, chronic cases of osteomyelitis necessitate surgical debridement \[ 5 , 6 \], as increasing prevalence of antibiotic-resistance organisms such as MRSA complicates antimicrobial therapy options \[ 6 \]. To ensure targeted treatment, direct sampling of the bone for culture and sensitivity is essential. However, since vancomycin has been associated with nephrotoxicity in some patients, linezolid mg IV every 12 hours is indicated in patients presenting with abnormal kidney function \[ 5 , 7 , 8 \]. Providers should have a clinical suspicion of osteomyelitis of the pubic symphysis if a patient presents with pubic pain, difficulty in ambulating, and an elevated ESR on laboratory studies. Scientific investigations report that this condition often occurs postoperatively; however, it is of upmost importance to recognize that this infectious process can occur in patients who partake in IV drug use. This patient population is susceptible to infection with Pseudomonas aeruginosa ; however, our patient highlights the possibility of MRSA infection. Suprapubic osteomyelitis in IV drug users is a rarity; thus, awareness of this phenomenon can aid in diagnosis and early targeted treatment to prevent a complicated treatment course. We would like to give a special thanks to Dr. Kent Reichel for his contribution with interpretation of the radiological images. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus. As a library, NLM provides access to scientific literature. Find articles by Karimah Best. Find articles by Siham Hussien. Find articles by Atika Malik. Find articles by Salauni Patel. Find articles by Miriam B Michael. Accepted Jan 17; Collection date Jan. Open in a new tab. The authors have declared that no competing interests exist. Consent was obtained or waived by all participants in this study. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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