Image Quiz
Suprapubic Pain Following Strenuous Physical Activity1
A twenty-year-old male soldier was admitted to the Department of Internal Medicine with suprapubic pain, fever, and an erythematous rash on his chest, which had developed five days prior to admission. During the month before the onset of the disease, he had been engaged in strenuous physical activity associated with his military service and in additional exercise that included playing basketball and taking a two-mile daily run. The medical history was notable for chronic Leishmania skin lesions, which had appeared during his service in the desert. These lesions, caused by Leishmania tropica, which is endemic in the Middle East, developed gradually and manifested a characteristic dry, crusted, ulcerative appearance. The cutaneous lesions had persisted for three months before his admission. There was no history of drug abuse.
The patient had a temperature of 38.5°C, a blood pressure of 100/60 mm Hg, and a regular pulse of 90 bpm. He had an erythematous rash on his face and neck and minimal neck lymphadenopathy. Three erythematous concave, raised, and crusted lesions of 0.5 cm in diameter, typical of cutaneous Leishmaniasis, were found on the right cheek and right hand. The lungs were clear, and the heart sounds were normal. The abdomen was not tender, and the liver and spleen were not enlarged. There was extreme suprapubic tenderness extending to the left groin without local edema, heat, or discoloration. Small, nontender bilateral inguinal lymph nodes were palpated. There were no signs of thrombophlebitis of the lower extremities.
The peripheral white blood-cell count was 6300/mm3 with 65% granulocytes, the sedimentation rate was 66 mm, and the findings on urinalysis were normal. A skin biopsy specimen from one of the lesions confirmed the diagnosis of cutaneous Leishmaniasis. A pelvic radiograph (Fig. 1), technetium-99m bone scan (Fig. 2), and a computed tomography scan of the pelvis (Fig. 3) were acquired.
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A needle aspiration of the left pubic ramus was then performed.
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