Case Presentation: 24 years old female presented in ER with persistent and progressive pain in the left lower back and left buttock for 1 week. Her pain was sharp, intermittent, severe pain, exacerbated with exertion and relieved with rest. No history of recent trauma or lifting heavy weights.Her past medical history was significant for obesity, and recent chemical abortion using methotrexate 1 month prior to the presentation. Two weeks before the presentation, she was evaluated in the ER for fever, chills, malaise and vaginal discharge. She was noted to have tachycardia and leukocytosis for which she was given intravenous fluids and her tachycardia improved. She was discharged with a prescription of 1 week of cephalexin for presumed endometritis due to recent abortion and an outpatient follow up was scheduled with gynecology. During her follow up, her pelvic exam and pelvic ultrasound were negative for any retained products of conception and she completed her antibiotic without symptom resolution.Physical exam revealed tenderness to palpation in left lower back and left buttock without any neurological compromise in lower extremities. Laboratory studies were significant for erythrocyte sedimentation rate (ESR) of 121 mm/hr and C-reactive protein (CRP) of 11.1 mg/L. Magnetic resonance imaging scan of pelvis was done due to notable elevation of acute phase reactants and it revealed left sacroiliitis with extension into left gluteus minimus.Patient was started on empiric vancomycin and ceftriaxone which was later transitioned to oral amoxicillin-clavulanate and levofloxacin for a total of 6 weeks of antibiotics. Patient had symptomatic improvement and her ESR and CRP trended down on outpatient follow up.
Discussion: We present a rare case of septic sacroiliitis as a complication of chemical abortion in 1st trimester of pregnancy. Sacroiliitis accounts for about 1.5% – 10% of all cases of septic arthritis and it is strongly associated with gynecological infections, pelvic trauma or drug abuse. It has been described well in post-partum period (3.4% – 12.8% of cases) after delivery, abortion or dilation and curettage. Early diagnosis is difficult because the symptoms are nonspecific in pregnancy and in the postpartum period, making the delay of treatment a serious risk of irreversible damage to the joint and development of post-infectious complications. On our literature review, there were no reported cases of sacroiliitis after chemical abortions.The pathogenesis of infectious sacroiliitis results from local contamination by contiguous infection or hematogenous spread of bacterial infections. Pregnancy itself can cause inflammation and associated pain in SI joints due to added pregnancy weight and release of hormone relaxin. The literature review describes that the use of methotrexate for abortion purpose with therapeutic-dose may presents with septic abortion ,cytotoxic effects – however there are no case reports that describe septic arthritis as a result of methotrexate use for chemical abortion.
Conclusions: On our literature review, there were no reported cases of sacroiliitis after chemical abortions. Aim of our presentation is to highlight this rare & treatable complication with potential serious complications including serious infections as bacteremia, infective endocarditis and long term disability especially if there is a delay in diagnosis and treatment.
