Pyogenic Sacroiliitis due to Group AStreptococcusfollowing Uncomplicated Pregnancy and Vaginal Delivery

Abstract

Background. Although the incidence of pregnancy-associated pyogenic sacroiliitis is low, it is associated with significant morbidity and mortality. Timely diagnosis of the condition is challenging due to its nonspecific clinical features. Case. A 31-year-old primigravida had an uncomplicated pregnancy and labour. Postpartum, she developed persistent fever and debilitating hip pain on ambulation. White cell count was normal (7.3 × 109/L) and C-reactive protein was elevated (468.4 mg/L). Streptococcus pyogenes was identified on vaginal swabs and blood cultures, and a pelvic magnetic resonance imaging scan revealed bilateral sacroiliitis. Conclusion. Pyogenic sacroiliitis is a potentially lethal cause of postpartum pain. It should be considered as a differential diagnosis even in low-risk women who present with debilitating pelvic pain in or around pregnancy, particularly when initial therapy appears unsuccessful.

Infectious Postpartum Sacroiliitis: The Importance and Difficulty of Early Diagnosis

“…7,11 By analysis of published postpartum sacroiliitis cases (Table 1), the most common form of clinical presentation is fever, associated with pain in the buttock, with possible limping gait, and acute onset (up to one week after delivery). [1][2][3][4][5][6][7][8][9][10][11] In the present case report, the clinical subacute onset (two weeks) might be related to treatment with corticosteroids in the suspected post-anesthetic epidural hematoma.…”

“…[1][2][3][4][5][6][7][8][9][10][11] The pathogenesis of infectious sacroiliitis results from either direct extension from a local infection or via hematogenous spread of bacterial infections (endocarditis, sinusitis, urinary tract infections or postpartum endometritis). 1,2,9-11 The concomitant diagnosis of post-epidural anesthesia hematoma in this patient also raises the possibility that this post-anesthetic complication may compete for the differential diagnosis of low back pain and for the infectious source of sacroiliitis.…”

“…[1][2][3][4][5][6][7] A review published in 2013 by Bart et al presents 20 cases of infectious postpartum sacroiliitis 1 (including a review published by Almoujahed et al in 2003, of 15 cases). 2 After that, Nair et al (2013), 3 Park et al (2013), 4 Shaikh et al (2014), 5 Imagama et al (2015) 6 and Millwala et al (2015), 7 published another five cases.…”

“…[1][2][3][4][5][6][7] A review published in 2013 by Bart et al presents 20 cases of infectious postpartum sacroiliitis 1 (including a review published by Almoujahed et al in 2003, of 15 cases). 2 After that, Nair et al (2013), 3 Park et al (2013), 4 Shaikh et al (2014), 5 Imagama et al (2015) 6 and Millwala et al (2015), 7 published another five cases. Nair et al reported a rare case of postpartum tuberculous sacroiliitis, which has not been reported in the literature earlier (the patient completely recovered with antituberculous treatment) 3 and Millwala et al described a woman who received several sessions of acupuncture treatment during her gestation at the site of her sacroiliac joint for sciatica, which developed biopsy-confirmed sacroiliitis with methicillin-sensitive Staphylococcus aureus during the immediate postpartum period.…”

“…7 Table 1 shows the characteristics of cases of infectious postpartum sacroiliitis published in the literature since 1966 (search on PubMed/Medline with 'Postpartum period', 'Infectious sacroiliitis', 'Septic arthritis' and 'Septic sacroiliitis' -Medical Subject Headings [MeSH] terms). [1][2][3][4][5][6][7] Considering its rather unspecific symptoms during pregnancy and puerperium, the establishment of an early diagnosis is difficult, making the delay of treatment a serious risk of irreversible damage to the joint and development of post-infectious complications. 1,2,5,6 …”