Osteomyelitis of the Ischium in a Hemodialysis Dependent Adult – A Rare Case Report

Abstract

Introduction: Osteomyelitis of the pelvis is rare, and the correct diagnosis may be missed during the early stage when the correct treatment would be most beneficial. Osteomyelitis requires multidisciplinary treatment to cure or control symptoms. Case Presentation: A 71-year-old woman, with end stage renal disease on hemodialysis, presented in emergency department for purulent drainage of a right buttock swelling. A pelvic computer tomography (CT) revealed a collection of the gluteal musculature and an activated chronic osteomyelitis with one osteolytic lesion on right ischiopubic branch. The patient underwent surgical treatment, with need of two interventions. First, she was only submitted to surgical drainage of the abscess. She completed a cycle of antibiotic therapy, with good response. Two months later, she returns with fever and drainage of the surgical wound. A pelvic CT showed an area of bone destruction at right ischium, with an increase in bone sequestration. She underwent a partial orchiectomy and surgical debridement of necrotic tissues. A Klebsiella oxytoca, Proteus mirabilis and multidrug-resistant Staphylococcus epidermidis was isolated. She was on antibiotic therapy for 4 months. Three years later, she remains without new symptoms or signs of active osteomyelitis. Conclusion: Pelvic osteomyelitis represents a diagnostic challenge, because the symptoms and signs vary, depending on the initial site of infection, its duration and the direction of its spread. Osteomyelitis of the ischium is generally diagnosed in the late stage with complications. Treatment of pelvic osteomyelitis is challenging due to the anatomic constraints of the pelvis and the high degree of comorbidity in affected patients. A multidisciplinary approach is often required. This case of a chronic abscess with osteomyelitis of the ischium is rare and was neglected for months because of the absence of constitutional symptoms in a hemodialysis dependent woman.