This patient is a 74-year-old Thai woman who presented with worsening low back pain and fever. MRI showed discitis and spondylitis at L2-L3 with an epidural abscess, psoas abscess, and paravertebral abscesses. Culture of pus from the psoas abscess grew Streptococcus constellatus. She underwent laminectomy and abscess drainage. Her symptoms improved with long-term antibiotic treatment.

1. Interesting case Mar 23 rd , 2011

2. Patient profiles Female 74 yrs old Retired Hometown and Current City: Bangkok 1 st admission KCMH (12/2/11) Data from patient and her husband Reliable Data Chief complaint: Fever with chill 3 days PTA

3. Present illness 2 weeks PTA She developed more aggressive low back pain (dull-aching pain). Recently, she had severe pain and limit her daily activities. She did not have fever, weakness, radiating pain or numbness. She went to a private hospital. A doctor diagnosed she got low back pain and gave her Etoricoxib and muscle relaxant. After she took the drugs, the symptom did not improved. 3 days PTA She had high grade fever with chill in the morning, so she was admitted at the private hospital.

4. Graphic data from private hospital During admitting the private hospital, she still had fever. (BT 38-38.5°c) Her low back pain did not improved. So, she went to KCMH. She did not receive any dental treatment in recent period. Ceftriaxone 1g IV q 12hr

5. Past history Hypertension on Diltiazem HCl (90) 1 tab PO OD Dyslipidemia on Atorvastatin (20) ½ tab PO hs Impaired fasting glucose (IFG) last HbA1C (9/2/11) 6.4% No smoking No alcohol drinking No history of herbal use No drug allergy

6. Physical examinations A Thai female Good consciousness Co-operative V/S: BT 36.5 °c HR 70/min BP 150/80 RR 20/min HEENT: Not pale No jaundice Heart: Normal S1S2 No murmur Lungs: Clear Abd: Soft Not tender No hepatosplenomegaly Ext: No edema

7. Neurological examinations Good consciousness Pupils 3mm RTLBE Full EOM No facial palsy Motor grade V all Normal pinprick sensation DTR 2 + all Babinski: Plantar flexion, clonus: negative

8. Problem lists more aggressive low back pain (dull-aching pain) 2 weeks PTA high grade fever with chill 3 days PTA Underlying diseases: - Hypertension - Dyslipidemia - Impaired fasting glucose

9. Causes of back pain Infection/inflammation - Vertebral osteomyelitis - Spinal epidural abscess - Lumbar arachnoiditis Developmental - Spondylolysis - Spondylolisthesis - Kyphoscoliosis Degenerative - Disc-osteophyte complex Arthritis - Spondylosis Metabolic - Osteoporosis - Osteosclerosis Minor trauma - Strain or sprain Fractures - Traumatic - Atraumatic: Osteoporosis, neoplastic infiltration, exogenous steroids Neoplasms - Metastatic, hematologic, primary bone tumors

10. Graphic data

11. Graphic data

12. Graphic data

13. Graphic data

14. Graphic data

15. EKG

16. CBC 9/2/11 12/2/11 21/2/11 26/2/11 7/3/11 21/3/11 Hb 12.4 12.5 11.3 11 11 10.4 Hct 36.7 36.5 35.1 32.3 34.8 33.1 WBC 16,250 13,870 13,200 10,560 9,640 6,910 PMN 96 86 86 86 77 70 Lym 2 7 7 6 7 7 Platelet 443,000 476,000 569,000 453,000 448,000 385,000

17. MRI lumbosacral spine (10/2/11) Discitis-spondylolitis at L2 and L3 A 2.5cm anterior epidural abscess

18. MRI lumbosacral spine (10/2/11) A 6cm Rt psoas abscess

19. MRI lumbosacral spine (10/2/11) Microabscesses with phlegmon in the paravertebral soft tissue

20. MRI lumbosacral spine (10/2/11) Discitis-spondylolitis at L2 and L3 , accompanying with a 2.5cm anterior epidural abscess , a 6cm Rt psoas abscess and microabscesses with phlegmon in the paravertebral soft tissue at this region. Diffuse leptomeningeal enhancement concerning for dissemination of infection into the CSF space. Mild lumbar spondylotic change.

21. CT guided FNA of Rt psoas muscle (11/2/11) Using a 18G Chiba needle under local anesthesia. About 5mL of frank pus was received. No immediate complication.

22. Pus from Psoas abscess (11/2/11) Gram stain:  gram positive cocci in pair AFB: not found Aerobic culture: NG

23. Pus from Psoas abscess (11/2/11) Anaerobic culture: Streptococcus constellatus Valuation MIC Clindamycin S .125 Piperacillin/tazobactam S .38 Imipenem S .047 Cefoxitin S 4.0 Metronidazole R >256 Penicillin G S .064

24. Operation at KCMH (13/2/11) Total laminectomy L3 with L2-3 dissecting Partial laminectomy L2 with removal abscess

25. Investigations from Epidural abscess Pus - Gram stain - AFB - mAFB - C/S for aerobe  all negative Tissue - Gram stain - AFB - PCR for TB  all negative

26. Pathology report Microscopic examination: - Fibroconnective tissue - Neutrophilic infiltration is seen. - No granuloma or tumor is detected. Acute inflammation, consistent with clinically abscess. GMS stain for fungi is negative.

27. CXR (12/2/11)

28. LS spine (12/2/11) Narrowing disc spaces of L3-4, L5-S1 and spondylosis with mild lumbar scoliosis.

29. LS spine (1/3/11) Compression fracture L2

30. MRI lumbosacral spine (4/3/11)

31. MRI lumbosacral spine (4/3/11) Anterior wedge compression fracture of L2 vertebral body causing focal kyphotic change at L2/3 level. Mild Lt lateral subluxation of L2 on L3 Mild Rt lateral subluxation of L3 on L4 Spondylodiscitis of L2 to 3 level associated with surrounding enhancing soft tissue, epidural extension and abscess formations extending from superior border of L2 vertebral body down to mid L4 vertebral body causing severe spinal stenosis and crowding of intrathecal nerves at L2 to L3 levels. Paraspinal and subcutaneous abscesses at L2 to L4 levels. Myositis with small abscess collections at bilateral psoas muscles form L2 to L4 levels. Lumbar spondylosis with degenerative bulging disc

32. LS spine (7/3/11)

33. LS spine (14/3/11)

34. LS spine (21/3/11)

35. 28/2/11 7/3/11 14/3/11 21/3/11 ESR (0-28 mm/hr) 94 92 61 68 CRP (< 5 mg/L) 108 53 45 49

36. Management Antibiotic Ceftriaxone 1g IV q 12hr (9/2/11- 6/3/11; 26 days) then switch to PGS 3mU IV q 4hr (7/3/11- now) Other drugs - Pregabalin (75) 2 tabs PO b.i.d - CaCO3 (1g) 1 tab PO OD - Vitamin D 1 tab PO OD

37. Vertebral osteomyelitis

38. Pathogenesis Microorganisms enter bone by hematogenous dissemination - spread from a contiguous focus of infection - penetrating wound Trauma, ischemia, foreign bodies  enhance the susceptibility of bone to microbial invasion Phagocytes attempt to contain the infection  release enzymes that lyse bone Pus spreads into vascular channels  raising intraosseous pressure  impairing blood flow  chronic, ischemic necrosis of bone  sequestra Histologic findings Acute osteomyelitis  Microorganisms  Infiltrates of PMN  Congested/thrombosed blood vvs Chronic osteomyelitis  absence of living osteocytes  organisms may be to low to be seen on staining Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

39. Microbiology More than 95% of hematogenous osteomyelitis are caused by a single organism - S.aureus 50% - E.coli, other enteric bacilli 25% IVDU - S.aureus - P.aeruginosa - Serratia - Candida albicans Hemoglobulinopathies - Salmonella spp. - S.aureus Immunocompromised persons - Atypical mycobacteria - Bartonella henselae - Opportunistic fungi Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

40. The vertebrae are the most common sites of hematogenous osteomyelitis in adults. Organisms reach the well-perfused vertebral body via spinal arteries and quickly spread from the end plate into the disk space  adjacent vertebral body In pyogenic infections: Symptoms are localized to Lumbar > Thoracic > Cervical Tuberculous spondylitis (Pott’s disease):  Thoracic spine is involved most commonly Whenever pyogenic osteomyelitis is found, the possibility of bacterial endocarditis should be considered. Vertebral osteomyelitis Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

41. Source of bacteremia - Urinary tract (esp. men over age 50) - Dental abscesses - Soft tissue infections - Contaminated IV lines  is not evident in more than half of patients!! Risk of spinal infection - DM required insulin injection - Recent invasive medical procedure - Hemodialysis - Injection drug use - History of degenerative joint disease involving the spine - Penetrating injuries/surgical procedures involving the spine Vertebral osteomyelitis Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

42. Back pain exacerbated by motion & unrelieved by rest Fever is usually low grade or absent Some patients  fever with chills prior to or at the onset of pain The most common findings: - Spine tenderness over the involved spine segment - an elevated ESR Fever or an elevated WBC  found in minority of pts. Blood cultures are positive only 20-50% of the time. Vertebral osteomyelitis Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

43. Plain radiographs - a narrowed disk space with irregular erosions in the end plates of adjacent vertebrae - insensitive (esp in early osteomyelitis) - may show periosteal elevation after 10 days - lytic changes after 2-6wks  useful to look for anatomical abnormalities, foreign bodies, soft tissue gas Vertebral osteomyelitis MRI and CT  sensitive and specific  demonstrate epidural , paraspinal, retropharyngeal, mediastinal, retroperitoneal or psoas abscesses Jeffrey Parsonnet, Associate Professor of Medicine and Microbiology Dartmouth Medical School, Lebanon 17 th edition Harrison’s Principles of internal medicine

45. Werner Zimmerli, M.D. Basel University Medical Clinical Liestal Kantonsspital Liestal, Switzerland. N Engl J Med 2010; 363:1022-9