The Egyptian Rheumatologist (2014) 36, 105–109

Egyptian Society for Joint Diseases and Arthritis

The Egyptian Rheumatologist

www.rheumatology.eg.netwww.sciencedirect.com

SHORT COMMUNICATION

Profile of infectious sacroiliitis

among rheumatology inpatients in Lome

(Togo): A single center experience

* Corresponding author. Address: BP 14502, Lome, Togo. Tel.: +228 90156634.

E-mail address: owonayo@yahoo.com (O. Oniankitan).

Peer review under responsibility of Egyptian Society for Joint Diseases and Arthritis.

Production and hosting by Elsevier

1110-1164 � 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society for Joint Diseases and Arthritis.

http://dx.doi.org/10.1016/j.ejr.2013.12.005

Owonayo Oniankitana,*, Komi C. Tagbor

a, Lama K. Agoda-Koussema

b,

Eyram Fianyo a, Viwale E.S. Koffi-Tessio a, Kodjo Kakpovi a, Prenam Houzou a,

Moustafa Mijiyawa a

a Department of Rheumatology, CHU Sylvanus Olympio Lome, Togob Department of Radiology, CHU Sylvanus Olympio Lome, Togo

Received 12 October 2013; accepted 22 December 2013Available online 29 January 2014

KEYWORDS

Infectious arthritis;

Infectious sacroiliitis;

Epidemiology;

Black Africa

Abstract Aim of the work: To determine the epidemiological, clinical, bacteriological, and radio-

logical characteristics of infectious sacroiliitis in patients admitted to the Rheumatology Depart-

ment in Lome (Togo).

Patients and methods: A retrospective study was conducted over 21 years on files of hospital

patients admitted for infectious sacroiliitis.

Results: Of the 2995 patients admitted, 359 suffered from infectious arthritis, and 18 cases suf-

fered from infectious sacroiliitis (5%). The mean age at admission of those 18 patients (seven men,

eleven women) was 34.22 ± 13.5 years while the mean disease duration was 22.05 ± 41.9 days. The

onset was sudden in 14 patients. The sacroiliitis was essentially unilateral (17 patients). The pain

which was essentially inflammatory (16 patients), had irradiated in 14 patients. Fever was observed

in 16 patients while weight loss was seen in 11. The infectious gate has been found in 15 patients

(88.3%) with a post-partum period in five patients (27.8%). Limpness has occurred in 12 patients.

Erythrocyte sedimentation rate was high in 13 patients with a mean of 78.83 ± 15.21 mm/1st hour.

Of the 18 patients, pathogenic agents were isolated in 8 (Staphylococcus aureus: 7 cases, Mycobac-

terium tuberculosis: 1) and probable infection by Mycobacterium tuberculosis in another. Patho-

genic agents were detected by cytobacteriological examination of vaginal sample in 5, urine in 2,

sputum in 1 and psoas puncture in another. The mean antibiotic therapy duration was

3.25 ± 3.1 months. Followed up 6-months later the patients improved well.

106 O. Oniankitan et al.

Conclusion: Our series confirmed that infectious sacroiliitis is rare and there is no clinical, bac-

teriological, and radiological particularity.

� 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society for Joint Diseases and

Arthritis.

1. Introduction

Infectious sacroiliitis is rare, involving between 1% and 2% of

septic arthritis cases, which is probably due to the poor vascu-larization of this joint resulting in a low risk of infection via thehaematogenous route [1,2]. Most observations are based onsingle case reports and review of the literature [3–8], small case

series [9,10] or multicentre studies [11].The diagnosis of osteoarticular infection is difficult in these

anatomical sites and may be delayed due to the poor specificity

of clinical signs and symptoms [1,12–14]. Delay in diagnosismay lead to several complications, such as abscess or seques-tration formation, prolonged period of sepsis, and long-term

joint deformity [15]. Studies of rheumatic diseases in Africashowed the paramount place of infectious pathology despitethe progress of antibiotic therapy [16–20].

Despite the frequency of osteoarticular infections in Africa,

infection of the sacroiliac, which is a disorder with sometimesmisleading clinical signs, seems relatively rare [15,16,21,22].

The aim of this study was to determine the epidemiological,

clinical, bacteriological, and radiological characteristics ofinfectious sacroiliitis in patients admitted to the RheumatologyDepartment, University Hospital Sylvanus Olympio of

Lome (Togo).

2. Patients and methods

This is a retrospective study that has been conducted over21 years on the files of patients admitted in the Departmentof Rheumatology, University Hospital Sylvanus Olympio of

Lome; the capital city of Togo (West Africa). The study wasapproved by the ethics committee. The demographic, clinical,bacteriological and radiological data of the patients have beencollected from their files.

The positive diagnosis of the osteo-articular infection hasbeen essentially radiological and clinical while the etiologicaldiagnosis was based on the isolation of the germ, and/or the

underlining of the characteristic histopathological lesions, ora strong clinical suspicion (existence of another infectious loca-tion, namely a pulmonary or spine tuberculosis, response to

antibiotic treatment). The infection was considered certain ifa causal microorganism was isolated or if a specific histopa-thological lesion was observed in the infectious site. On the

contrary, the infection has been considered probable in caseof a strong clinical suspicion (existence of another infectiouslocation, namely a pulmonary or spine tuberculosis, responseto antibiotic treatment).

Sacroiliitis as a clinical feature of spondyloarthritis was ex-cluded from this study. The combination of fatigue, anorexia,weight loss and pallor or the presence of at least three of these

symptoms was considered as an alteration of the general con-dition. Each patient has been submitted to pelvis radiography,a complete blood count, measurement of the erythrocyte sedi-

mentation rate, a retroviral serology. Fever was defined as a

temperature above 37.5 �C and leukocytosis defined as a leu-kocytic count >11,000/ml. Erythrocyte sedimentation rate(ESR) greater than 20 mm in the first hour was considered

to be high. No patient has been subjected to bone scan or mag-netic resonance imaging (MRI) due to the absence of scintigra-phy and MRI in Togo at the time of the study. In case of

underlining of a given infectious entrance, a swab has beendone in view of a cytological and bacteriological test. Dataanalysis was performed by using SPSS software for Windows

(Version 17.0).

3. Results

Of the 2995 patients admitted over the last 21 years, 359 suf-fered from infectious arthritis, and 18 cases suffered frominfectious sacroiliitis (5%). The mean age at admission ofthose 18 patients (seven men, eleven women) was

34.22 ± 13.5 years while the mean disease duration of22.05 ± 41.9 days. The onset of the symptoms was essentiallysudden in 14 patients (77.8%) and insidious in the remaining

four (22.2%).The involvement of the sacroiliac joint was essentially uni-

lateral (n = 17), with the left side involvement in 57.9% of

cases. The site of the pain was varied; the buttock was themost common site of the pain (n = 14), although psoitisgroin pain (n= 2), low back pain (n = 1) and hip pain

(n = 1) were also observed. The pain was essentially inflam-matory in 16 patients (88.9%) and irradiated to the thighin 14 (77.8%). Fever was observed in 16 patients (88.9%)with the highest temperature reaching 38.5� in eight patients

(Table 1). A loss of weight has been identified in 11 patients(61.1%). The infectious gate has been found in 15 patients(88.3%) with a urinary route in 7 patients (38.9%). Five pa-

tients (27.8%) were in the post-partum period. The infectioussacroiliitis was associated with an infectious spondylodiscitisin three patients (16.7%). Fifteen patients (83.3%) had con-

current infectious diseases.The pain increased subsequently to a monopodal pressure

and usually provoked limpness in 12 patients (66.6%). The di-rect pressure of sacroiliac joint was painful in 14 patients

(77.8%). The ESR was high in 13 patients (72.2%) rangingfrom 15 to 115 mm/1st hour and a mean of78.83 ± 15.21 mm/1st hour. Leukocytosis was observed in 12

patients (66.7%) ranging from 11,400 to 17,000/ml.Of the 18 patients, infection was certain and the pathogenic

agents were isolated in eight cases; Staphylococcus aureus in 7

andMycobacterium tuberculosis observed in one patient. Infec-tion was probable (M. tuberculosis) in other patients. Patho-genic agents were isolated from other sites by means of

cytobacteriological examination of vaginal sample (n = 5), ur-ine (n = 2), sputum (n = 1) or puncture of the Psoas muscle(n = 1). Of the 12 patients submitted to retroviral serology,four were infected with human immunodeficiency virus

(HIV), while the other eight were healthy. Those four

Figure 2 Erosions and sclerosis of the banks of the right

sacroiliac joint in a human immunodeficiency virus infected

patient suffering from infectious sacroilliitis.

Table 1 Distribution of the 18 patients suffering from infectious sacroiliitis according to the clinical, laboratory investigations and

radiological data.

Parameter Infectious sacroiliitis (18 cases)

Number Percentage

Type of onset:

Sudden 14 77.78

Insidious 04 22.22

Nature of pain:

Inflammatory 16 88.9

Mechanical 02 11.1

Sacroiliac joint involvement:

Unilateral 17 94.44

Bilateral 01 5.56

Alteration of general condition 16 88.89

High fever (temperature P38.5�) 08 44.44

Leukocytosis (WBC> 11,000/ml) 12 66.66

Elevated ESR (P20 mm/1st hour) 13 72.22

Pathogenic agent isolation 08 44.44

HIV infected patients 04 22.22

Radiological lesions of infectious arthritis 12 66.66

WBC: white blood cells, ESR: erythrocyte sedimentation rate, HIV: human immunodeficiency virus.

Profile of infectious sacroiliitis among rheumatology inpatients in Lome 107

HIV-infected patients suffered from sacroiliitis caused by a

pyogenic microorganism.The standard X-ray conducted at the onset of the symp-

toms was abnormal in 12 patients. The multiple bony erosions

and sclerosis of the banks of the sacroiliac joint were the mainradiographic lesions observed (Figs. 1 and 2). The abdomino-pelvic CT scan that was performed in four patients revealed

likely infectious arthritis of the sacroiliac joint in all patientsand a Psoas abscess in two. None of our patients have associ-ated septic endocarditis or retroperitoneal abscess.

Evolution was favorable in all patients under prolonged

antibiotic therapy. The mean antibiotic therapy duration was3.25 ± 3.1 months with a range from 6 weeks to 12 months.Anti-tuberculosis protocol was associated: Isoniazid (5 mg/

kg/day); Rifampicine (10 mg/kg/day); Pyrasinamide (30 mg/kg/day) and Ethambutol (25 mg/kg/day) for 2 months andIsoniazid (5 mg/kg/day) and Rifampicine (10 mg/kg/day) for

Figure 1 Multiple bony erosions and sclerosis of the banks of

the sacroiliac joints in a 29 year old female suffering from

postpartum infectious sacroilliitis.

10 months. Followed up 6 months later the patients improvedwell without sequelae.

4. Discussion

This study shows the relative scarceness of infectious sacroili-itis in rheumatologic consultations in Lome. During the study

period, 5% of patients admitted for infectious arthritis sufferedfrom infectious sacroiliitis. There is no clinical, bacteriological,and radiological particularity. The staphylococcus aureus is

the most frequent causal microorganism encountered. The rel-ative scarceness of infectious sacroiliitis is probably due to thepoor vascularization of this joint [2]. The demographic, clini-

cal, bacteriological, and radiological characteristics of our pa-tients are comparable to those found in other countries[16,17,19,20,23].

The mean age at the diagnosis in our series is 34.2 yearswhich is almost the same as that found in the studies con-ducted in France [24] and in Tunisia [23]. One factor that pre-disposes to this is sometimes found: transplantation,

108 O. Oniankitan et al.

pregnancy or post-partum, infection by HIV [8,25,26]. In ourseries, the only favorable factors found were the infection byHIV and the post partum. Those results are not in agreement

with other studies and in which toxicomania and corticothera-py [24]; diabetes mellitus and ulcerative colitis [23] have beenthe dominant risk factors. The time from the beginning of

appearance of clinical signs and hospitalization was long inthe olden series [27,28]. In those series the mean disease dura-tion till diagnosis could reach 6 months [27] or even 19 months

[28]. In our series the mean disease duration till diagnosis was25 days which is not far from the one found in recent series[2,11,29,24–26].

The onset of the symptomatology was most of the time

acute in the pyogenic sacroiliitis and more usually insidiousin the sacroiliitis tuberculosis [28], thus explaining the twocases with insidious start and 14 with a brutal start in our ser-

ies. The pain is most of the time located on the bottoms, butalso at the inguinal fold or at the lower lumbar spine [11,28].Radiation of pain to the leg is frequent, and most of the time

taking the form of a truncated sciatic [27], found in 14 cases inour series, and three cases in the series of Hermet et al. [24]. Ingeneral, the infectious sacroiliitis is unilateral, even though

bilateral cases have been reported, with different types of bac-teria [1,2,11]. This is found in our study with bilateral reach inone case. Fever is more common in our series. In the literaturethe presence of fever is variable [8,11]. The pain increased sub-

sequently to a monopodal pressure and usually provokedlameness [29]. In our series the ESR was elevated remarkablyin 72.2% of patients, while in the series of Hermet et al. [24]

it was high in all the patients. Plain radiography has knownlimitations mainly due to poor sensitivity in the early onsetof the disease. The radiographic lesions are not likely to appear

until several weeks after the onset of infection [29,30]. Thusexplaining the absence of radiological signs in some of our pa-tients in which the radiography had been realized in a rela-

tively short time-limit.In the present study, there was an associated Psoas abscess

in two patients as frequently reported in other series on pyo-genic sacroiliitis [11,31,32]. The scarcity of complications in

our series is due to the absence of new diagnostic techniques.The Staphylococcus aureus was the main etiologic bacterialagent identified in our series. This microorganism is the most

common causative agent in all series reported [2,11,27]. Otheretiologic agents such as Streptococcus pneumoniae [33],group B and A Streptococcus [34] and Salmonella species

[35] should be considered in patients with risk factors suchas the immunocompromised children and younger age [36].The duration of antibiotic therapy ranged from 6 weeks to12 months in our study. The duration of antibiotic therapy

is variable according to other studies. No consensus existsas to the duration of antibiotic therapy in infectious sacroil-iitis [11,37].

A rigorous interpretation of the results of this study com-pels to take into account the biases essentially associated tothe mode of selection of the patients and the absence of scin-

tigraphy and MRI in Togo at the time of the study. Thestudy included only the hospital inpatients admitted to therheumatology department thus constituting a bias making it

difficult to generalize our results. Thus, a prospective multi-center study is needed to better study the characteristics ofinfectious sacroiliitis. Diagnosis of infectious sacroiliitis has

been difficult in this study because of the absence of newerdiagnostic techniques such as bone scanning, and MRI.

In conclusion, infectious sacroiliitis is relatively scarce de-

spite the importance of the osteo-articular infections in theBlack Africa and there is no clinical, bacteriological, andradiological particularity. Diagnosis of infectious sacroiliitis

and its complications is difficult to establish due to the absenceof newer diagnostic techniques such as bone scanning andMRI which aid in an earlier diagnosis.

Conflict of interest

The authors have no conflict of interest.

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