An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.A 23 year old man presented to our emergency room with the following complaints: lower abdominal tenderness and pain, and pyrexia of 38°C for 24 hours. On clinical investigation the hypogastrium was found to be painful with guarding. There were no further abnormal findings. Rectal examination was normal. Laboratory examination showed raised inflammatory variables: erythrocyte sedimentation rate was 28 mm in first hour, fibrinogen was 60.9 g/l (normal range 18-40 g/l), and C reactive protein was 269 mg/l (normal value less than 10 mg/l). The white blood count was 11 200/mm 3 (normal range 3500-9800) with 80.4% of neutrophils. A plain abdominal radiograph was normal.An emergency laparoscopy was performed. Peroperatively, free fluid was found in the pouch of Douglas. There was no bacterial growth when this fluid was cultured. The appendix was macroscopically normal and was left in situ. Further diagnostic steps were necessary. Urine culture was negative. Ultrasound examination of the abdomen showed intraperitoneal air, which was due to the laparoscopy. Clinical re-evaluation showed a localised tenderness in the pubic area. A more detailed history was taken at this stage. The patient reported that for the past year he had only be able to exercise twice a week. After exercising he experienced pain in the pubic region and stiffness for two days, which then resolved spontaneously. A radiograph of the os pubis showed sclerosis and bony destruction of the margins of the symphysis pubis, suggesting osteitis pubis (fig 1). A technetium-99m methyl diphosphonate bone scan showed a solitary area of hyperactivity in the left os pubis and symphysis pubis (fig 2). Magnetic resonance imaging (MRI) of the pubic region clarified the diagnosis, with enhanced activity in the symphysis pubis on the T2 images-on the left side of the symphysis more than on the right side (fig 3).

Charcot joint or neuropathic arthropathy is described in certain neurological conditions. We report the case of a man who presented with a swollen ankle 10 days after a long walk, which rapidly progressed to a Charcot joint. A neurological examination revealed areflexia and insensitivity to temperature and pain. Electromyographic analysis showed a mixed sensorimotor polyneuropathy. Besides axonal loss and demyelinisation on sural nerve biopsy, prominent loss of unmyelinated fibres was demonstrated. Despite extensive investigations, no definite cause for this neuropathy could be found.

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The authors describe a 12-year old girl with a painful syndrome at the distal side of the left leg, resulting in limping, incapacity and severe muscle atrophy. Full investigation - no inflammatory laboratory signs, diffuse osteoporosis at the left leg, decreased bone mineral content at the same place, marked hypofixation on bone and vascular scintigraphy - suggested pseudodystrophy (5), which is often induced by psychological factors. Successful treatment was obtained by physiotherapy, hydrotherapy, slight doses of NSAID and psychological assistance. With regard to recent literature, the authors believe that reflex sympathetic dystrophy (RSD) in children is often over-diagnosed, since there are no recognised criteria for diagnosing RSD. Besides the clinical picture, changes on radiography (focal osteoporosis) and on scintigraphy (disturbed vascular scintigraphy with increased pooling in the initial phase and hyperfixation on bone scintigraphy) are necessary. When these are not available, pseudodystrophy is a more correct diagnosis.

D-penicillamine, an agent still used in the treatment of rheumatoid arthritis (RA) may produce inflammatory myopathy or myositis. Some reported cases are documented with muscle biopsy. We report a 34-year old female, receiving the drug for more than 4 years, who consulted us with recently developed proximal muscle pain and weakness. EMG-findings were typical for inflammatory muscle disease; muscle enzymes remained normal. D-penicillamine was stopped and she was started on prednisolone with rapid improvement. The EMG-findings, with follow-up within three months, proved to be a good diagnostic tool, in the absence of laboratory muscle enzymes abnormalities.