Proximal femoral osteomyelitis following a ruptured sigmoid diverticulitis—a case report and review of literature

Abstract

Introduction Adult long-bone osteomyelitis is relatively uncommon in the developed countries. Ruptured sigmoid diverticulitis can seldom present as an extraperitoneal manifestations in the gluteal area, around the hips, or in the proximal thigh. These extraperitoneal manifestations can present a diagnostic challenge and need a high index of suspicion. Case report We present a case of a 67-year-old male with osteomyelitis of the proximal femur following a ruptured diverticular disease of the sigmoid colon. Discussion The diagnosis was delayed resulting in advanced destruction of the hip necessitating a two-stage hip replacement. We hereby discuss the unusual extraperitoneal presentations of sigmoid diverticulitis and the need to identify them early. Keywords Femoral osteomyelitis . Sigmoid diverticulitis Case reportA 67-year-old male was admitted into the hospital with a history of lower back pain with radiation to the back of the left thigh. Clinical diagnosis of acute discitis/disc prolapse was made. An urgent MRI was performed which revealed no evidence of discitis or significant disc prolapse. As he continued to have intermittent temperature spikes and persistently high CRP, an abdominal and pelvic CAT scan was performed. The scan revealed a severe sigmoid diverticular disease and a small psoas collection. The psoas collection was aspirated under ultrasound guidance followed by a 3-week course of oral antibiotics. Repeat CAT scan after 6 weeks showed improved diverticular disease and no new collection. The areas of the hips and the proximal thigh/ femur were not specifically examined or commented upon in both the CAT scans.He was discharged from the clinic with a plan for followup by his general practitioner. He presented around 6 months later with progressively worsening left-groin pain of few months duration. He had been treated by his practitioner with strong analgesics including morphine patch. Repeat blood tests at this stage revealed a high CRP and ESR. X-rays of the pelvis revealed destruction of the proximal femur with loss of joint space (Fig. 1). An urgent MRI scan of the pelvis revealed proximal femoral osteomyelitis with advanced destruction of the femoral head (Fig. 2). Fig. 1 X-ray showing destruction of left femoral head