It is Not Always a Bug: SAPHO Syndrome

Document Type


Publication Date



An 18-year-old female, a veterinary medicine student, with no significant PMH presented to the emergency room with a two-month history of left hip and low back pain; and new-onset facial acne. No fever, blurry vision, conjunctivitis, diarrhea, or other joint pain. She had exposure to sick animals.

Upon examination, vital signs were normal. She had severe nodular and pustular facial acne. Musculoskeletal exam revealed significantly restricted range-of-motion of the left hip, and tenderness upon palpating the left sacroiliac joint. She was not able to ambulate secondary to pain.

Laboratory investigations revealed Hemoglobin level of 11. ESR and CRP were elevated, 52 and 3.7 respectively. Anti-DS DNA, ANA, CCP, RF were negative. HLA B27 was positive. With her history of animal exposure, Lyme, Brucella, Coxiella burnetti and yersinia antibodies were negative. X-rays of the left hip, femur, and lumbosacral spine were unremarkable. Pelvis and left hip MRI noted bone marrow edema, small left hip joint effusion, and bilateral sacroiliitis. She underwent left hip-joint aspiration. Fluid analysis for cell count, crystals, and culture was unremarkable.

She was started on Naproxen for pain relief, and Minocycline for acne. Her symptoms were believed to be due to SAPHO (synovitis–acne–pustulosis–hyperostosis– osteitis) syndrome. After being discharge, she was started on Infliximab. She had significant improvement in her symptoms at 8- month follow up.

SAPHO syndrome is a rare and complex disorder, characterized by peculiar combinations of bone lesions and dermatologic manifestations. Prompt SAPHO syndrome recognition, followed by appropriate therapy may result in long-lasting symptom relief.


American College of Physicians (ACP) Resident’s Day, Sterling Heights, MI, May 5, 2017. 47th Annual Residents’ and Fellows’ Research Forum, Royal Oak, MI, May 23, 2017.