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).

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Two young males with acne fulminans (AF) are described. In addition to severe skin lesions, they had musculoskeletal symptoms including bacteriologically negative osteolytic lesions in the clavicles. Both patients received antibiotics for suspected septic infections. The response was unsatisfactory in both patients, and combination treatment with prednisolone was started. A favourable response was observed, and a relapse occurring in the first patient was controlled by steroids alone. The possible pathomechanism of bone lesions in AF is discussed.

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