A 56‐year‐old woman with a history of atrial fibrillation, diabetes, and rheumatoid arthritis on chronic narcotics presented after being found unresponsive at home. She was hypopneic and intubated for airway protection. Pressors were started after developing hypotension following intubation. Intravenous antibiotics were given for possible sepsis. Urine cultures grew E. coli and 1 of 2 blood cultures grew coagulase‐negative staphylococcus. Repeat blood cultures were negative. Cardiac echo revealed no vegetations. Head CT scan and chest x‐ray were unremarkable. Abdominal/pelvic CT scan revealed erosions of both pubic rami at the pubic symphysis with adjacent soft‐tissue attenuation thought to represent a phlegmonous collection and possibly resultant osteomyelitis. She was rapidly extubated and weaned off pressors. Subsequent history revealed inadvertent ingestion of excess narcotic pain medication and prior episodes of gout. Physical exam revealed tophi of the elbow. Fluoroscopic‐guided bone biopsy of the symphysis pubis revealed purulent whitish‐appearing material. Pathology revealed necrosis and acute inflammation. Biopsy cultures were negative, but uric acid crystals were present. Serum uric acid level was 10.1 mg/dL. She was treated with colchicine and indomethacin. Indomethacin was subsequently changed to prednisone. Her pain markedly improved.
Gout most commonly affects articular spaces of the extremities. Gout of the symphysis pubis is a very rare occurrence with only five cases reported in the literature. It can be mistaken for other causes of pelvic or groin pain. Other disease processes affecting the symphysis pubis include infection, metastasis, amyloidosis, plasmacytoma, and chrondrosarcoma. CT imaging may aid in the diagnosis of gouty arthropathy with findings that include symphysis pubis erosions with overhanging edges, “punched‐out” lesions, and associated hyperdense calcified tophus. Tissue sampling revealing negative birefringent monosodium urate monohydrate crystals on polarized microscopy confirms the diagnosis of gout.
Gouty arthropathy can mimic other conditions that cause pelvic pain and lead to unnecessary treatment or complications from overmedication. The purpose of this case is to increase clinician awareness of a common disease in an unusual location.