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Acute sacroiliitis

Article  in  Clinical Rheumatology · February 2016

DOI: 10.1007/s10067-016-3200-6

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Clin Rheumatol
DOI 10.1007/s10067-016-3200-6
REVIEW ARTICLE
Acute sacroiliitis
Gleb Slobodin 1,3 & Doron Rimar 2,3 & Nina Boulman 2,3 & Lisa Kaly 2,3 &
Michael Rozenbaum 2,3 & Itzhak Rosner 2,3 & Majed Odeh 1,3
Received: 6 January 2016 / Revised: 9 January 2016 / Accepted: 28 January 2016
# International League of Associations for Rheumatology (ILAR) 2016
Abstract The purpose of this study was to review the data on
the etiology, risk factors, clinical presentations, and diagnosis
of acute sacroiliitis. A Pubmed search utilizing the indexing
term Bacute sacroiliitis^ was conducted and the data pertinent
to the aim of the review was extracted and organized in accor-
dance with the preplanned structure of the manuscript. The
diagnosis of acute sacroiliitis is often challenging because of
both the relative rarity of this presentation and diverse charac-
ter of acute sacroiliac pain, frequently mimicking other, more
prevalent disorders. Technetium bone scintigraphy can local-
ize the disease process to the sacroiliac joint, while computed
tomography or magnetic resonance imaging can be used for
the detailed characterization and the extent of the disease as
well as the diagnosis of complications. Pyogenic sacroiliitis is
by far the most common cause of acute sacroiliitis.
Brucellosis, acute sacroiliitis in the course of reactive arthritis,
and crystalline-induced sacroiliitis frequently imitate pyogen-
ic sacroiliitis. Acute sacroiliitis can rarely be also related to
hematological malignancies or treatment with isotretinoin.
Awareness to the possibility of acute sacroiliitis and a thor-
ough physical examination are the necessary prerequisites to
its timely diagnosis, while the appropriate laboratory and im-
aging studies should confirm the precise diagnosis and direct
the appropriate treatment strategy.
* Gleb Slobodin
gslobodin@yahoo.com
1
Internal Medicine A, Bnai Zion Medical Center, Haifa, Israel
2
Rheumatology, Bnai Zion Medical Center, Haifa, Israel
3
Ruth and Bruce Rappaport Faculty of Medicine, Technion,
47 Golomb St, Haifa, Israel
Keywords Acute sacroiliitis . Pyogenic sacroiliitis .
Sacroiliitis
Introduction
Sacroiliitis, an inflammation of the sacroiliac joint (SIJ), is a
hallmark of ankylosing spondylitis and may also be seen in
the course of other rheumatic and non-rheumatic disorders,
such as psoriatic arthropathy, familial Mediterranean fever,
Bechet’s disease, hyperparathyroidism, and others.
Prolonged low back pain, particularly inflammatory low back
pain, main features of which are insidious in onset, night
worsening, morning stiffness, improvement after exercise,
and/or radiation to the buttocks has been recognized as a ma-
jor clinical manifestation of chronic rheumatic sacroiliitis long
ago [1].
Acute sacroiliitis has been described in medical literature
relatively uncommonly, mainly in a form of patient case re-
ports or case series, and typically featuring the underlying
infectious, rheumatic, neoplastic, or even drug-related causal-
ity. The diagnosis of acute sacroiliitis is often challenging
because of the relative rarity of this condition and the diverse
clinical presentation of acute sacroiliac pain, frequently mim-
icking other, more prevalent disorders originating in the
neighboring structures. The published data on acute
sacroiliitis to date is somewhat disjointed, and the aim of this
review is to consolidate the accumulated knowledge on this
topic.
Methods
A Pubmed search utilizing the indexing term Bacute
sacroiliitis^ was conducted. One hundred ninety-two English

language articles were retrieved. Sixty-eight relevant articles
were reviewed, references noted in these articles were also
assessed. The data pertinent to the aim of the review was
extracted and organized in accordance with the preplanned
structure of the manuscript.
Results
Anatomical considerations
The SIJ is composed of a superior/dorsal syndesmosis (the
fibrous part of the joint in which the bony surfaces are united
by interosseous ligaments) and distal/ventral articulation,
lined with fibrocartilage in the peripheral zones and predom-
inantly hyaline cartilage in its inner portions [2]. The ventral
part of the SIJ is covered with the joint capsule, which is
associated with strong core ligaments, stabilizing the joint,
but on the other hand, is relatively thin and frequently has
defects that allow fluid substances, such as joint effusion or
pus, to leak out onto the surrounding structures. Thus, the
anatomical architecture enables the extension of sacroiliac
disease, such as pyogenous sacroiliitis, from the SIJ anteriorly,
onto the psoas major muscle. Sometimes, other muscles adja-
cent to the SIJ, such as pyriformis, biceps femoris, gluteus
maximus, quadratus lumborum muscles may be involved,
contributing to the dispersion of sacroiliac pain to different
referral zones. Major nerve structures, such as the lumbosacral
plexus (fibers from L4–L5) or even the dorsal sacral plexus
can be irritated by the acute sacroiliac process and, along with
dorsal lumbosacral rami which innervate the SIJ itself, con-
tribute to severe, sometimes, excruciating sacroiliac pain in
the course of acute sacroiliitis [3, 4].
Sacroiliac joint pain
New-onset intense pain is a major clinical manifestation of
acute sacroiliitis, pointing to the diagnosis. However, the char-
acter of acute SIJ pain may be variable in different individuals
without a specific diagnostic pattern. Thus, the diagnosis of
acute sacroiliitis is frequently overlooked at presentation.
While the classic distribution of SIJ pain involves the ipsilat-
eral buttock and paramidline lower lumbar area (in 94 and
72 %, respectively), its radiation to the groin (14 %), lower
abdomen (2 %), upper lumbar area (6 %), and/or lower ex-
tremity (up to 50 %)—including thigh and trochanteric pain,
lower leg pain, and even foot pain—may lead to confusion,
suggesting alternative diagnoses, such as intervertebral disk
disruption, hip joint disease, or even an abdominal event [4,
5]. This variability in the character of the sacroiliac pain may
arise from the diverse innervation of the SIJ, involvement of
the adjacent ligaments, muscles or nerves, or may depend on
the specific location of injury within the SIJ itself [4].
Clin Rheumatol
The pain of acute sacroiliitis is usually intense and may be
disabling in some patients, preventing treading, sitting, or
even movement in the bed. In others, SIJ pain characteristi-
cally exacerbates during walking, weight bearing, or climbing
steps.
Physical examination is usually remarkable for the signif-
icant tenderness of the involved SIJ on palpation and positive
sacroiliac pain provocation tests, such as FABER (for flexion,
abduction, and external rotation) or Gaenslen’s maneuvers.
However, the specificity of provocative SIJ maneuvers is rel-
atively low, and their positive predictive value for sacroiliac
origin of the pain was calculated as about 60 % in a study
using sacroiliac joint block as the diagnostic gold standard [6].
Pyogenic sacroiliitis
Pyogenic sacroiliitis is by far the most frequently reported
cause of the acute sacroiliitis syndrome [7–15]. Vyskocil
et al. summarized 166 cases of bacterial pyogenic sacroiliitis
published between 1878 and 1990 [7]. Since then, dozens of
additional cases have been reported in the medical literature,
examining the occurrence and features of pyogenic sacroiliitis
in specific patient groups.
Pyogenic sacroiliitis is mostly a disease of young adults
20–30 years of age. The disease can develop in any age, how-
ever, with a reported range from 1 to 72 years [7, 8]. Pyogenic
sacroiliitis is typically unilateral. The explosive onset of the
disease is seen in 2/3 of patients and typically includes high-
or low-grade fever and severe continuous pain, originating
from the affected SIJ and felt most often in the buttock, low
back, and/or hip area. Sometimes pain can radiate down to the
lower leg. Acute abdominal pain, localized in the lower quad-
rants as well as tenderness on rectal examination have been
reported in about 10 % of patients with pyogenic sacroiliitis,
but usually in conjunction with pain in other areas [7, 9, 10]. In
severe cases, the patient can present motionless in his bed,
with the leg extended and externally rotated or flexed at the
hip and abducted, partially because of the spasm of the prox-
imally located pyriformis muscle [9]. Other patients usually
limp, refusing to bear weight on the ipsilateral leg. Sacroiliac
tenderness is invariably found on physical examination, while
stressing the SIJ by Gaenslen’s maneuver or FABER test may
trigger excruciating pain. Passive hip motion is usually unlim-
ited, ruling out the acute hip joint disease. Laboratory studies
show almost uniformly elevated erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP), but leukocytosis is
less typical and is seen in only about half of the patients [7, 9].
Various imaging modalities can contribute to the early diag-
nosis of pyogenic sacroiliitis. Technetium bone scintigraphy, a
highly sensitive tool for the diagnosis of septic arthritis in gen-
eral, can be particularly useful in patients with pyogenic
sacroiliitis, restricting the poorly localized process to the affect-
ed joint. The radionuclide uptake is usually substantial and
Clin Rheumatol
becomes positive within a 48-h disease onset. Exceptionally,
cases of pyogenic sacroiliitis and negative bone scan have also
been reported [7]. Magnetic resonance imaging provides a de-
tailed evaluation of the joint and surrounding soft tissues, dem-
onstrating prominent bone marrow edema adjacent to the SIJ
surfaces, synovitis of SIJ itself, and edema in the neighborhood
soft tissues, which may help to distinguish infectious from non-
infectious sacroiliitis [11]. Computed tomography (CT) is prob-
ably a less sensitive imaging for acute pyogenic sacroiliitis, but
still can show early widening of the affected SIJ, capsule bulg-
ing or abscess formation anteriorly to the SIJ, as well as adja-
cent reactive bony sclerosis and erosions at later phase. On the
other hand, X-ray films of SIJ usually do not have diagnostic
value in the early stages of pyogenic sacroiliitis. It should be
stressed, however, that probably not a wrong imaging method
was chosen, but an erroneous diagnostic direction, leading to
avoidable spine, hip, or abdominal evaluations, or even unnec-
essary surgical procedures, represent the major diagnostic prob-
lem of pyogenic sacroiliitis [7, 8].
Suggested risk factors for pyogenic sacroiliitis include in-
travenous drug use [7, 9, 12], infections, particularly skin in-
fections and infective endocarditis [7, 13], and pregnancy.
Clostridium sacroiliitis with gas gangrene following SIJ injec-
tion has also been reported [14]. However, the primary site of
infection cannot be identified in over 40 % of patients with
pyogenic sacroiliitis [7, 8].
It has been hypothesized that hormonal effects of pregnan-
cy permit relaxation of the ligaments supporting the sacrum
and pelvic bones, which, along with increased mechanical
load on the SIJ, may lead to microscopic areas of injury within
the SIJ and predispose pregnant women to more frequent sa-
croiliac disease [15]. Almoujahed et al. reviewed 15 cases of
pregnancy-associated pyogenic sacroiliitis [16]. Three of
those patients were intravenous drug users, three patients
had urinary tract infection, two patients suffered from infec-
tive endocarditis, and two patients had endometritis. The dis-
ease started acutely in ten of the patients, only six of whom
had fever on presentation. All patients complained of buttock,
low back, and/or hip pain. Bilateral SIJ involvement was seen
in two patients. If not treated properly, the infection had a
propensity to extend to the structures periarticular to SIJ, ne-
cessitating surgical drainage or debridgement. Preterm labor,
related to pyogenic sacroiliitis, was reported in one case.
Septic shock due to pyogenic sacroiliitis during pregnancy
was also reported [15].
Pediatric pyogenic sacroiliitis has been further characterized
recently [17–19]. Traumatic events, insect bites, atopic derma-
titis, furunculosis, and folliculitis were recognized as risk fac-
tors for pyogenic sacroiliitis in children [7, 17, 19]. Similarly to
adults, a misdiagnosis is common at presentation and may be
due to the wide variety of clinical presentations including hip,
back, knee, and abdominal pain, due to low level of suspicion
for the disease, and by negative radiographic findings [18].
Sonographic examination of hips may be useful for exclusion
of hip joint effusion, while MRI has been suggested as a most
useful imaging for both diagnosis and follow up of pediatric SIJ
infection [18, 19].
Blood cultures can be negative in up to 50 % of the pa-
tients, particularly in a pediatric population [20]. Imaging-
guided diagnostic SIJ aspiration should be performed in pa-
tients with high clinical suspicion for pyogenic sacroiliitis and
negative blood cultures, particularly in those who do not re-
spond well to empiric antibiotic therapy.
The most common pathogen reported in the cases of pyo-
genic sacroiliitis has been Staphylococcus aureus. In intrave-
nous drug users, S. aureus and Pseudomonas aureginosa have
been equally common [7]. Other reported pathogens, isolated
from patients with pyogenic sacroiliitis, include various
Staphylococci, Streptococci, Salmonella, Klebsiella species,
and others [7, 21, 22]. Therefore, the initial empiric antibiotic
therapy should always be directed against S. aureus and cover
Gram-negative organisms as well, including P. aureginosa, in
intravenous drug users. The antimicrobial therapy for pyogen-
ic sacroiliitis should be continued for at least 4–8 weeks, de-
pending on the patient’s status, pathogen isolated, and the
presence of complications. Delay in the diagnosis and/or in-
appropriate treatment of pyogenic sacroiliitis can lead to grave
consequences, such as bacteremia with septic shock, osteomy-
elitis, or abscess formation [7, 13, 20].
Acute brucellar sacroiliitis
Sacroiliitis is the most frequently reported osteoarticular location
of brucellosis, seen in more than 10 % of patients [23, 24].
Brucella can cause both septic and reactive sacroiliitis.
Usually, Brucella sacroiliitis has been reported as a relatively
mild indolent disease with a good prognosis [23, 25]. Rarely,
brucellosis may manifest with acute sacroiliitis, clinically similar
to pyogenic sacroiliitis [26]. Bilateral involvement of SIJ can be
seen in up to 25 % of the patients and concomitant spondylitis
and peripheral arthritis are not uncommon in patients with
Brucella sacroiliitis [24]. A history relating to the use of unpas-
teurized dairy products should always be looked for in these
patients, while concomitant additional clinical signs suggestive
of brucellosis, such as fever, sweats, malaise, and/or
hepatosplenomegaly should not be missed. A Rose-Bengal test
for brucellosis should be performed in suspicious cases, includ-
ing those with clinical picture of septic sacroiliitis and negative
blood cultures. While the differentiation between septic and re-
active Brucella sacroiliitis is complicated, all patients usually
respond well to treatment with doxycycline and rifampicin [26].
Acute inflammatory sacroiliitis
Indolent sacroiliitis, demonstrable by X-rays or bone scan, is a
common manifestation of reactive arthritis [27, 28]. However,

acute sacroiliitis in the course of reactive arthritis has been
only rarely reported [27, 29]. The pain syndrome of acute
inflammatory sacroiliitis can be undistinguishable from that
of pyogenic sacroiliitis, though accompanying fever is less
typical, CRP/ESR are only moderately elevated and the in-
flammation does not involve the adjacent soft tissue struc-
tures. Bone scintigraphy is useful in demonstrating the distri-
bution of the inflammatory process to the SIJ and throughout
the skeleton; CT can outline the SIJ irregularities/erosions and
joint capsule bulging; while MRI-seen bone marrow edema
parallels the extent of inflammation, with SIJ synovitis,
capsulitis, and/or enthesitis demonstrated as well (Fig. 1).
Both SIJs can be affected, and other joints and entheses are
frequently involved. The history of recent gastrointestinal or
genitourinary infection and/or characteristic extra-articular
manifestations of reactive arthritis, such as conjunctivitis or
keratoderma may be key to the diagnosis. Acute postpartum
inflammatory sacroiliitis, which occurs a few days after deliv-
ery and is associated with fever, leukocytosis, high ESR and
responds to the treatment with non-steroidal anti-inflammato-
ry drugs (NSAIDs), has been reported [30]. We have observed
recently a case of acute non-septic erosive sacroiliitis, which
developed in a patient with para-rectal abscess (unpublished
data). Of interest, it has been suggested, that sacroilitis may be
more frequently seen in the course of chlamydial, compared to
non-chlamydial reactive arthritis [31].
Crystalline-induced acute sacroiliitis
Both gout and calcium pyrophosphate dihydrate (CPPD) de-
position disease can involve the SIJ. Gout, favoring unambig-
uously the appendicular skeleton, can occasionally affect the
Fig. 1 MRI of a patient with an acute unilateral inflammatory sacroiliitis.
Synovitis (arrow), bulging of the joint capsule (asterisk), and intense
bone marrow edema of the iliac bone (arrowheads) and sacrum are seen
Clin Rheumatol
axial joints too [32]. While the SIJ involvement by gout is
typically asymptomatic and manifests primarily by character-
istic punched out lesions, surrounded by sclerosis, and best
seen on CT, a few cases of acute gouty sacroiliitis are available
in the medical literature [33–35]. Most of these reported pa-
tients have been postmenopausal women with a previous his-
tory of appendicular gout and acute onset of sacroiliac pain. In
these reports, fever may be observed and ESR/CRP are typi-
cally elevated in acute gouty sacroiliitis. The finding of tophi
on physical examination and elevated serum levels of uric acid
should always raise the suspicion for acute gouty sacroiliitis in
the appropriate clinical setting. Still, pyogenic sacroiliitis in a
patient with known gout should not be missed, and the diag-
nostic aspiration of the involved SIJ has to be done in equiv-
ocal cases. On the other hand, the examination of SIJ aspirate
of patient with suspected pyogenic sacroiliitis should also in-
clude polarized microscopy, as gouty involvement of the SIJ
has been also reported without any evidence of advanced
gouty peripheral arthritis or visible tophi [34].
Asymptomatic chondrocalcinosis of the SIJ can be seen in
up to 40 % of patients with CPPD deposition disease [36].
Acute sacroiliitis secondary to CPPD deposition has been re-
ported rarely [5, 37]. The diagnosis was usually made based
on the clinical picture of acute non-septic sacroiliitis, linear
calcific deposits within the affected SIJ (Fig. 2) and evidence
of polyarticular chondrocalcinosis. CT imaging has probably
the best sensitivity for the diagnosis of CPPD deposits within
the SIJ.
Crystalline-induced acute sacroiliitis can respond to treat-
ment with NSAIDs, colchicine and/or corticosteroids, admin-
istered systemically or by intra-SIJ injection [34–37].
Fig. 2 CT of a patient with known CPPD, presenting with acute right
sacroiliac pain. Characteristic calcium pyrophosphate dehydrate
deposition is seen inside the widened right sacroiliac joint (arrow)
Clin Rheumatol
Acute sacroiliitis related to isotretinoin treatment
Isotretinoin, a retinoid indicated for the treatment of severe
acne, has been associated with various musculoskeletal side
effects, including arthralgia with or without arthritis, myalgia,
and soft tissue calcification. Bilateral or unilateral sacroiliitis
has also been reported as another complication of isotretinoin
therapy [38–44]. Sacroiliitis usually develops acutely, within
days or weeks after initiation of isotretinoin treatment. It man-
ifests with sacroiliac pain, mildly or moderately elevated CRP/
ESR, and bone marrow edema adjacent to the SIJ and seen by
MRI. Peripheral arthritis, paradoxical deterioration of acne
with transformation to acne fulminans or development of
poorly understood debilitating muscle weakness or neuropa-
thy have sometimes been reported as accompanying the
sacroiliitis symptoms triggered by isotretinoin treatment.
Full convalescence of isotretinoin may require several months
after cessation of the drug, while glucocorticosteroids and
NSAIDs can alleviate the clinical symptoms of acute disease.
The mechanisms of isotretinoin-induced sacroiliitis have not
been elucidated as yet.
Acute sacroiliitis related to malignant disorders
Sacroiliitis has been cited as one of the cancer-associated rheu-
matic syndromes [45]. The acute onset of paraneoplastic
sacroiliitis has been reported primarily in hematological malig-
nancies. Acute unilateral or bilateral sacroiliitis with fever, ele-
vated ESR/CRP, and positive technetium bone scintigraphy may
be a presentation of acute myelogenous or lymphoblastic leuke-
mia, as well as of Hodgkin’s lymphoma [46–48]. The diagnostic
changes in the peripheral blood count or lymphadenopathy can
appear with a delay of weeks or even months, potentially leading
to an initial misdiagnosis of pyogenic or inflammatory
sacroiliitis. The fluctuating behavior of paraneoplastic
sacroiliitis, with temporary improvement, may mislead the phy-
sician away of the diagnosis of underlying malignancy.
Discussion
Acute sacroiliitis is an uncommonly seen clinical syndrome,
which can mimic other, more prevalent disorders, such as
Table 1 Causes of acute sacroiliitis
Commonly reported Infrequently reported Rarely reported
Pyogenic sacroiliitis Brucellar sacroiliitis Malignancy-related
sacroiliitis
Inflammatory sacroiliitis Isotretinoin-related
Gouty sacroiliitis sacroiliitis
CPPD-related sacroiliitis
acute back pain with or without radicular syndrome, acute
hip arthritis or trochanteric bursitis, and acute abdomen.
Awareness to this clinical entity, its clinical manifestations,
and evidence-based diagnostic approach are the necessary
prerequisites to its timely diagnosis. Physical examination
with palpation of the SIJ and performance of maneuvers
stressing the SIJ should be performed in all patients with pos-
sible acute sacroiliitis, while positive findings should drive the
appropriate imaging studies [49]. Technetium bone scintigra-
phy, which can localize the disease process to the SIJ, may be
indicated in patients with equivocal clinical presentation,
while more directed CT and, particularly, MR imaging of the
affected SIJ should be used for the detailed characterization of
the disease process, diagnosis of the extent of the disease,
elucidation of the presence of complications and exclusion
of alternative diagnoses, such as sacral stress fractures. Fever
in the course of acute sacroiliitis should always lead to suspi-
cion for pyogenic sacroiliitis, with blood cultures obtained and
immediate appropriate systemic antibacterial treatment
started. Primary source of infection should be uncovered, if
possible. When necessary, SIJ diagnostic aspiration should be
performed. The absence of fever does not exclude septic
sacroiliitis, particularly in the presence of significantly elevat-
ed ESR/CRP. While pyogenic sacroiliitis is by far the most
frequently reported cause of acute sacroiliac disease, rare con-
ditions causing acute sacroiliitis should not be missed
(Table 1). A thorough history of the disease, past medical
history, full physical examination, as well as awareness to
the possible etiologic factors for acute sacroiliitis are requisite
for the precise diagnosis.
Compliance with ethical standards
Disclosures None.
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