1357
CLINICAL NOTE
Acute Bacterial Sacroiliitis in an Adult: A Case Report and
Review of the Literature
Meenakshi Bindal, MD, Brian Krabak, MD, MBA
ABSTRACT. Bindal M, Krabak B. Acute bacterial sacroi-
liitis in an adult: a case report and review of the literature. Arch
Phys Med Rehabil 2007;88:1357-9.
Bacterial septic sacroiliitis is an uncommon diagnosis that
occurs most frequently in children and young adults. Nonspe-
cific physical examination findings often make it difficult to
diagnose the condition, thus delaying appropriate treatment.
We review the case of middle-aged woman with sacroiliac joint
(SIJ) pain after a torsional injury. Radiographic films showed
the pelvis and left lower extremity to be normal. Despite
anti-inflammatory medications, analgesics, a corticosteroid in-
jection, and physical therapy, her pain persisted. Laboratory
data showed an elevated erythrocyte sedimentation rate and
C-reactive protein; otherwise, tests were normal, including
negative blood cultures. Magnetic resonance imaging (MRI)
revealed a left posteroinferior SIJ effusion and computed to-
mography (CT) showed an effusion and irregularity in the left
SIJ. An SIJ biopsy revealed inflammation suggestive of osteo-
myelitis. After a course of intravenous antibiotics, the symp-
toms completely resolved, thus supporting our diagnosis of
bacterial sacroiliitis. Repeat MRI and CT confirmed the com-
plete resolution of the sacroiliitis.
Key Words: Case report; Rehabilitation; Sacroiliac joint.
© 2007 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
YPICALLY, SACROILIAC joint (SIJ) pain is caused by
T trauma resulting from such activities as heavy lifting or
prolonged bending and lifting, or as the result of a rear– end
motor vehicle collision.1 Fortunately, most symptoms will re-
solve with appropriate treatment that includes activity modifi-
cation, medication, physical therapy, and/or injections. Pro-
longed SIJ pain, however, should prompt a physician to look
for other potential etiologies.
Although it represents less than 2% of all nontuberculous
septic arthritides,2-4 bacterial septic sacroiliitis is typically seen
in children and young adults. It is less common in middle-aged
and elderly people,5 unless there is a history of intravenous
drug use, skin and respiratory infections, or genitourinary tract
infections.5 Unfortunately, septic sacroiliitis has been difficult
to diagnose secondary to nonspecific physical examination
findings and poorly localized presenting symptoms.6,7 This
From the Department of Anesthesiology, University of Virginia, Charlottesville,
VA (Bindal); and Rehabilitation, Orthopaedics and Sports Medicine, University of
Washington, Seattle, WA (Krabak).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Brian J. Krabak MD, MBA, Rehabilitation Medicine, Univer-
sity of Washington, Box 356490, Seattle, WA 98195, e-mail: bkrabak@
u.washington.edu.
0003-9993/07/8810-11510$32.00/0
doi:10.1016/j.apmr.2007.07.004
often leads to an initial misdiagnosis that ultimately delays
effective treatment. We report the case of a middle-aged patient
who presented with signs, symptoms, and radiologic evidence
of unilateral bacterial sacroiliitis that resolved with antibiotic
treatment.
CASE DESCRIPTION
A 40-year-old woman without significant medical history
presented to our clinic with a 2-week history of pain in the left
gluteal region. She said her pain began after she lurched
forward while carrying her luggage at the airport. The pain was
sharp and progressed over the next several hours while she was
on the aircraft, prompting her to seek an evaluation in the
emergency department. Radiographs showed no abnormalities
in the pelvis and hip. The patient was treated for a muscle strain
and was given narcotic and anti-inflammatory medications on
her discharge from the emergency department. Several days
later she visited a local physician because of worsening gluteal
pain and associated lower back pain. Subsequent magnetic
resonance imaging (MRI) of the lumbar spine revealed a right-
sided disk protrusion at L2-3, a mild annular disk bulge at both
L4-5, and a posterior annular disk tear at L5-S1. She was
diagnosed with a piriformis muscle strain and treated with a
cortisone injection into the left gluteal region near the SIJ. In
addition, she was prescribed an oral steroid, a cyclo-oxygen-
ase-2 inhibitor, and physical therapy.
Two weeks later, she presented to our clinic with continued
sharp left gluteal pain that was extremely painful when she
engaged in any weight-bearing activity. The pain was aggra-
vated with sitting, standing, and lying down for prolonged
periods of time. She noted no exacerbation with coughing or
sneezing, or radiation of the pain down the leg, or paresthesias
in the leg, or back pain, bowel, and bladder changes. She
reported a mild low-grade fever, chills, and fatigue.
On physical examination, she was alert and oriented, with a
temperature of 37.9°C (100.1°F). There were no obvious rashes
of the skin or atrophy of muscles in the lower extremity. She
ambulated with an antalgic gait and was unable to place her full
weight on the left leg. Range of motion of the hip and spine
were limited because of the pain associated with movement of
the leg. She was tender to palpation at the left SIJ and gluteal
area. Strength testing was limited by pain, but was normal
distally in the left lower extremity. Sensation and reflexes were
within normative limits. The Patrick and Stinchfield tests were
both positive for pain in the SIJ and gluteal areas on the left
side. Radiographs of the left hip and pelvis did not reveal any
bony abnormalities.
We did a further diagnostic work-up because of the patient’s
continued extreme pain in the left gluteal region and new
constitutional symptoms (low-grade fever, chills, and fatigue).
Laboratory serologies revealed an elevated erythrocyte sedi-
mentation rate (ESR) of 69mm/h, an elevated C-reactive pro-
tein (CRP) of 7.5mg/dL, negative Lyme immunoglobulin G
and M antibodies, negative antinuclear antibody screen, and
negative human leukocyte antibody B-27. She had a normal
white blood cell count of 5730/mm3. Blood cultures were also
negative. MRI of the pelvis suggested a sacroiliitis rather than
Arch Phys Med Rehabil Vol 88, October 2007
1358 ACUTE BACTERIAL SACROILIITIS, Bindal
Fig 1. CT of the pelvis illustrating widening of the left SIJ with
noted effusion and irregularity of the left SIJ, with a loss of cortex
on the ilial surface of the joint.
a stress reaction injury as a result of left posteroinferior SIJ
effusion with bone marrow edema and a strain of the left
piriformis, gluteus medius, and paraspinal muscles. Computed
tomography (CT) of the pelvis (fig 1) revealed widening of the
left SIJ with effusion and irregularity, and loss of cortex on the
left ilial surface of the joint. In addition, there was an irregu-
larity on the sacral side of the joint but no visible abscess. A
CT-guided biopsy of the SIJ (fig 2) showed inflammation in the
bone, which is most consistent with an osteomyelitis. SIJ fluid
aspirate was negative for acid-fast bacilli, bacteria, fungi, and
mycobacteria. The patient was treated with surgical débride-
ment of the SIJ. After further discussion regarding the patient’s
clinical symptoms, low-grade temperature, and biopsy find-
ings, we decided to treat her with a 6-week course of intrave-
nous levofloxacin (Levaquin) and clindamycin, plus oral levo-
floxacin and clindamycin for another 6 weeks for a presumed
septic sacroiliitis. The patient’s pain symptoms quickly im-
proved over the 12-week course of antibiotics, with normal-
ization of her laboratory values. She regained full range of
motion in her left hip joint and repeat MRI and CT showed
complete resolution of the SIJ irregularities. She was able to
return to full normal activity without any subsequent symp-
toms.
DISCUSSION
Bacterial septic sacroiliitis is more typically seen in children
and young adults than in middle-aged or elderly persons.5 In
adults, there is often a history of intravenous drug use, skin and
respiratory infections, or genitourinary tract infections. It is
thought that the majority of septic sacroiliitis cases occur
through hematogenous seeding from a preexisting infection
from a distant site.2,5 Others have suggested it is the result of
local spreading of infection from a spinal or pelvic infection, or
direct implantation during trauma or invasive procedures.2,5 In
our case, the patient’s only trauma was lifting a suitcase and
receiving a corticosteroid injection to the SI region while
placed on oral steroids. Although it is unclear, perhaps these
potential immune-suppressing interventions contributed to her
SIJ infection.
Septic sacroiliitis often presents with a triad of fever, an
antalgic gait, and buttock pain that may be acute or chronic at
Arch Phys Med Rehabil Vol 88, October 2007
its onset.2 Almost 75% of cases present with an acute onset of
fever and severe low back pain that is exacerbated by motion
or weight bearing. The remaining 25% have symptoms that
emerge gradually with less pain and low-grade or absent fever.5
Unfortunately, the physical examination is often unreliable in
reaching a diagnosis. Such tests as Gaenslen and FABERE
(flexion, abduction, external rotation, and extension) may lo-
calize the pain to the SIJ, but they are inadequate for differen-
tiating pyogenic sacroiliitis from muscular pain, pelvic frac-
ture, disk disease, or an intra-abdominal process.3-6 Other
studies6-9 show a poor interrater reliability in identifying pos-
itive findings on some of the tests used to localize pain to the
SIJ. Overall, such maneuvers suggest only that such examina-
tion techniques can simply enter SIJ pain into the differential
diagnosis.7
Several tests may be used to diagnose sacroiliitis. Al-
though abnormalities may not be seen for several weeks
after the onset of infection, plain radiographs may show
widening of the joint space and blurring of the subchondral
plate. Ultrasound has not been helpful except to exclude
hip-joint effusions.10 Bone scans can be positive as early as
3 days after onset of symptoms, but are not specific for
bacterial septic sacroiliitis.1,11,12
MRI and CT appear to be the most useful in evaluating for
SIJ pathology. CT is useful in identifying bony pathology and
guiding aspiration or biopsy. MRI can delineate fluid in the
sacroiliac joint, bone marrow edema, and soft tissue abscesses
that may extend into the pelvic cavity,13 although it has been
shown to have a diagnostic sensitivity of 54% for sacroiliitis.14
MRI is better than CT for evaluating cartilage integrity and
detecting osseous erosions in patients with inflammatory and
infectious sacroiliitis.13,15,16 As in our case, unilateral disease
and edema in the soft tissue and marrow adjacent to the SIJ
helps to distinguish infectious from noninfectious sacroiliitis
(ie, some seronegative spondyloarthropathies).17
Laboratory data may be helpful in diagnosing bacterial sac-
roiliitis, but they do have their limitations. ESR and CRP may
be elevated in the majority of cases, but while they are sensi-
tive, they may not be specific.3 Cultures of SIJ fluid from either
surgical exploration or percutaneous arthrocentesis with CT
guidance are only positive in 50% to 88% of cases.2 And
positive blood cultures have been reported in 23% to 67% of
Fig 2. Biopsy of the SIJ shows bone and fibrous tissue with in-
flamed marrow suggestive of osteomyelitis. NOTE. Hematoxylin
and eosin stain, original magnification 100 times.
 ACUTE BACTERIAL SACROILIITIS, Bindal
cases.2 Despite the best attempts at diagnosis, 40% of reported
cases have no identified primary source of infection.5 In our
case, the patient had positive ESR and CRP, but negative
sacroiliac joint fluid and blood cultures.
Given the above laboratory limitations, several organisms
can be seen in sacroiliitis. Greater than 80% of reported cases
are caused by gram-positive bacteria, with Staphylococcus
aureus being the most common.3,4,18 Seventeen percent are
caused by the gram-negative organism Pseudomonas aerungi-
nosa, most notably in association with intravenous drug use,
primary or secondary immunodeficiency, underlying chronic
diseases, prior prolonged broad spectrum antibiotic use, or in
people with genitourinary or other invasive procedures.19 Esch-
erichia coli was cited in 8 cases in 1 study, usually in conjunc-
tion with urinary tract infections.5 Other strains of Staphylo-
coccus, Streptococcus salmonella, Klebsiella, Neisseria
gonorrhoeae, gram-negative enteric organisms, and anaerobes
have also been reported in the literature.2,20
Treatment of septic sacroiliitis includes 4 to 8 weeks of
parenteral antibiotic therapy, occasionally followed by a course
of oral antibiotics to prevent recurrence. Antibiotics result in
resolution of symptoms in 1 to 2 weeks, with few long-term
sequelae. Delayed diagnosis and treatment of septic sacroiliitis
increases the risk of the formation of abscesses, septicemia, and
hematogenous or seeding of infection to distant sites, espe-
cially in patients with total arthoplasties.2,5 Fortunately, distant
metastasis via hematogenous spread is rare, with 2 reported
cases of septic spread to the glenohumeral joint and 1 case of
meningitis.20 Surgical intervention is warranted, especially in
those patients with abscess formation, evidence of contiguous
osteomyelitis, sequestrum of necrotic bone, and failure to re-
spond to antibiotic therapy.5 In our case, given the patient’s
clinical symptoms, low-grade fever, and imaging findings, we
elected to proceed with antibiotic treatment and surgery. Too
often, these findings are ignored and the pain is treated with
nonsteroidal anti-inflammatory drugs, therapy, or an injection.
We believe the dramatic and rapid improvement of our pa-
tient’s symptoms after antibiotic therapy was initiated strongly
supports the diagnosis of bacterial septic sacroiliitis. Physicians
must be aware of the possibility of an SIJ infection early on and
proceed with the appropriate laboratory and imaging studies
before initiating treatment.
CONCLUSIONS
Infectious SIJ disease can be difficult to diagnose, given the
nonspecific symptoms and physical examination findings. Cli-
nicians should be aware of the diagnosis, however, even in the
acute setting or in unilateral cases. With appropriate laboratory
and imaging workup, the appropriate treatment can be initiated
without delay and without any long-term complications. As
was true for our patient, the proper identification of bacterial
septic sacroiliitis frequently leads to a positive outcome.
1359
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Arch Phys Med Rehabil Vol 88, October 2007