Bilateral Hip Pain - Soccer Player

Abstract

HISTORY: A 16-year-old Asian male presented with 2 weeks of worsening groin pain. Pain began after a difficult soccer practice, without a specific inciting injury. Patient was evaluated by team’s athletic trainer and was referred to orthopedic surgery where x-rays were negative. One week later, patient presented to local pediatric emergency center with intermittent fevers, worsening pain and inability to ambulate. He denied any recent travel outside the US or new exposures. PHYSICAL EXAM: afebrile in no acute distress with tenderness to palpation over paraspinal muscles, costovertebral processes L3-L4 and quadriceps musculature. Patient walked with antalgic gait and found to have 2/5 strength hip flexion bilaterally with 5/5 strength in all other muscle groups. Cardiac, pulmonary and abdominal exam were unremarkable. There was no lymphadenopathy present on exam. DIFFERENTIAL DIAGNOSIS: 1. Ankylosing Spondylitis 2. Illiopsoas Abscess 3. Epidural abscess 4. Osteomyelitis 5. Malignancy TEST AND RESULTS: -ESR: elevated at 94 mm/hr, CRP: elevated at 4.57 mg/dL -CBC: mild normocytic anemia without leukocytosis or thrombocytopenia -CK, CMP, Uric Acid, LDH within normal limits -Blood culture: negative -Rheumatologic studies: ANA, adolase, ANCA were negative -Testicular US: negative -MRI of lumbar spine and pelvis: signal enhancement within the bones of pubis symphisis with significant surrounding soft tissue edema -Bone biopsy: focally degenerated bone, mixed chronic inflammation, fibrosis with reactive changes. No microorganisms present on special stains -Bone aerobic/anaerobic cultures: negative -Quantiferon gold: POSITIVE, mycobacterium sputum PCR: POSITIVE -Chest x-ray: negative FINAL/WORKING DIAGNOSIS: Tuberculosis osteomyelitis of the pelvis TREATMENT AND OUTCOMES: 1. Treatment with ethambutol, isoniazid, pyrazinamide, and rifampin daily until cleared by infectious disease 2. Close follow up with Infectious disease clinic with monitoring labs every 2 weeks 3. Indomethacin PRN for pain 4. Range of motion and strengthening exercises for bilateral hip flexors with physical therapy 5. Regular follow up with local department of health