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Title : 53 year-old male w/ neck and back pain
Date : April 16, 2012
Contributed by

Kyungmin Huh, M.D., Samsung Medical Center, Korea

Patient History
Age/Sex 53 year-old male
Chief complaint Neck and back pain
Present illness A 53 year-old male visited to the ER complaining back pain which had started a month ago. He had worked in office, but he became to be involved in strenuous physical activity at work due to financial difficulty of his company since mid-January 2012. His back started to ache since then, and he was admitted to other hospital on February 2. Abdomen non-enhanced CT showed no abnormality in his spine, so psoas muscle block was done to alleviate pain. He was discharged with painkillers after 6 days. But his back pain had aggravated gradually, and he visited the ER of our hospital on February 25.
Past medical history He had been diagnosed of chronic hepatitis B 5 years prior to the administration and was taking entecavir and adefovir due to lamivudine resistance. He had no other significant medical history. He was living in urban area, and denied any recent contact with cattle. 
Physical examination He had tenderness on cervical and thoracic spines, but not on lumbar spines. Lt. ankle was erythematous, swollen, and tender. No motor weakness, sensory change, or limitation of motion was noted. Physical exam was otherwise not remarkable. The initial vital signs were: blood pressure 167/100 mmHg, heart rate 93 beats per minute, respiratory rate 18 per minute, body temperature 38.5’C.
Initial laboratory findings CBC 15750 (segmented neutrophil 85.6%) – 12.1 – 216K, total bilirubin 0.4 mg/dl, AST/ALT 43/45 U/l, ALP 158 U/l, BUN/Cr 14.7/0.65 mg/dl, CRP 19.16 mg/dl. Urinalysis showed positive leukocyte esterase and pyuria.
Radiologic findings

Abdomen enhanced CT revealed soft tissue thickening with fluid collection in the paravertebral spaces of L3-S3 and L5-S1 spines. Multifocal decrease of perfusion in bilateral kidney was noted. In spine MRI, signal change and abnormal enhancement was noticed in the vertebral bodies of C3-4, T4-6, T8-9, and L3-4 spines. Extension of enhancement with air bubble along the paravertebral and epidural space around L3-4 and T5 spines suggested the formation of epidural abscesses. A small abscess was also seen in the left psoas muscle.

Pathologic finding
Bone biopsy of the vertebral body of the L4 spine showed granulomatous necrotizing inflammation


Hospital course Vertebral osteomyelitis, cellulitis of the left ankle, acute pyelonephritis was suspected. Ceftriaxone, vancomycin, and nafcillin were started. On the hospital day 3, methicillin-susceptible Staphylococcus aureus was identified from the blood culture, so ceftriaxone and vancomycin were discontinued. Transesophageal echocardiogram showed a small fibrous material attached to the mitral valve. The patient became afebrile after hospital day 5. Despite the definite bloodstream infection, MRI findings were incompatible with bacterial vertebral osteomyelitis. CT-guided bone biopsy of the L4 spine was done in the hospital day 14. 

Question - ID Case of the Week ( April 16, 2012 )
What is your presumptive diagnosis for this patient?
Please send us your answer to the following e-mail address ( nuove@ansorp.org ).
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The true answer of this case and a brief review will be presented next week.
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