Introduction: Groin pain is a common symptom in athletes that can be challenging to treat. Sports related injury rates in the groin are estimated to be 8-25% of all injuries.[1] Pubic osteitis can be the cause of groin pain in athletes and has a general prevalence ranging from 0.5-6.2%. The repetitive trauma alone or in conjunction with opposing shearing forces across the pubic symphysis is likely the main contributing factor in many athletes especially those in soccer, football, and ice hockey.[2] Not all cases of groin pain are straight forward and when athletes present with systemic symptoms further detailed evaluation is warranted.

History: A 16-year-old male presents to the ER with hip and groin pain for the past 1 month. He reports sharp shooting pain associated with exercise, walking, and standing for a prolonged time and a constant dull ache while at rest. The pain radiates to his lower back, hips, groin, and legs. He reports feeling weak and now is having difficulty with ambulation. Throughout the course of gradual worsening musculoskeletal pain, the patient develops intermittent fevers, chills, sweats, and recalls weight loss.

Physical Exam: Vital signs are normal. The exam is significant for tenderness to palpation over his paraspinal muscles in the lumbar spinal region(L>R), mild tenderness over vertebral processes of L4-L5. Tenderness to palpation of bilateral thighs, ASIS, and pubic symphysis. 2/5 strength with hip flexion bilaterally due to pain. He can flex hips to 110 degrees but has significant pain beyond that point. He has pain with abduction, adduction, internal and external rotation of the legs. Sensation intact. 3+ patellar reflex bilaterally. Patient with antalgic gait and prefers walking with straight legs.

Diagnostic Evaluation: Patient underwent extensive evaluation in the emergency department and inpatient. Evaluation included normal CMP, CK, UA, and urine culture. CBC significant for normocytic anemia. Elevated inflammatory markers with an ESR at 94 and elevated CRP at 4.57. Blood cultures x2 are negative. Urine gonorrhea and chlamydia negative. TSH and free T4 normal. Extensive rheumatologic workup unremarkable. LDH and uric acid normal. Imaging included normal testicular US, CT brain without contrast, pelvic x-rays with frog leg, and CXR. MRI spine showed non-specific decreased bone marrow signal. MRI pelvis significant for symphyseal injury, extensive edema within the soft tissue pelvis with a small amount of hemorrhage, strains of adductors, sacral edema, and injury to the R adductor. QuantiFERON gold assay was positive. Bone biopsy showed inflammatory cells and inflammatory changes, however additional stains including acid fast and specific TB stains were negative.

Final/ Working Diagnosis: TB pubic osteomyelitis vs pubic osteitis

Discussion/ Outcome: Pubis osteitis is diagnosed with an MRI of the pelvis which will have evidence of subchondral bone edema. MRI may additionally demonstrate fluid in the pubic symphysis joint and small tears of the adductor muscles. Xrays can be helpful especially in the acute phase to rule out fracture, however, is not diagnostic for pubic osteitis.[3] TB pubic osteomyelitis is a rare condition but has been reported in a small series of case reports.[4] After a detailed review of patient’s symptoms, he had developed intermittent fevers, cough, episodes of sweating, and weight loss and had also traveled to the Philippines throughout his childhood. With the combination of historical findings, it prompted a QuantiFERON test which was positive. The patient underwent a bone biopsy which was positive for signs of inflammation but no evidence of bacterial or tubercular specific process. The patient was started on IV antibiotics initially, but once the QuantiFERON test was positive he was transitioned to TB treatment therapy. The conundrum of the case is whether the patient had pubic osteitis with incidental positive QuantiFERON test suggesting latent TB, or if the presentation was a true TB pubic osteomyelitis. The combination of close follow up, physical therapy, NSAIDS, and TB treatment resulted in symptomatic improvement.

Figure 1