Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Vertebral Osteomyelitis
Billings, N, D.O., Alpin, J, D.O.
Kent Hospital, Emergency Medicine, Warwick, RI
Introduction: We encountered a case of vertebral osteomyelitis that proved
profoundly challenging due to the vague history provided by the patient and her
multiple underlying co-morbidities. Osteomyelitis is one of the oldest recorded
diseases with descriptions dating back to the time of Hippocrates (460-370 BC).
Vertebral osteomyelitis is fairly rare and has an incidence of 2.4 cases per
100,000 population. It is typically a diagnosis of older adults and is part of a
large differential diagnosis for back pain.
Case: Our case was a 64 year old female who presented to the Emergency
Department from home with a chief complaint of abdominal pain for the past 7
days. Pain was described as gradual onset, achy, constant, localized to the RLQ
with radiation to right flank, associated with nausea without emesis. The patient
had been evaluated for similar abdominal pain in the past, most recently 2
months ago, at which time she was diagnosed with right ovarian cysts. Review of
systems was positive for proximal RLE pain and weakness as well as lower back
pain seemingly chronic in nature. The patient had history of a remote
appendectomy. Vital signs were normal except for mild tachycardia. Her physical
exam revealed RLQ tenderness, right CVA tenderness, and right adnexal
tenderness on pelvic examination. These findings were most consistent with
kidney stones, pyelonephritis, bowel obstruction, or ovarian cysts, all of which
were at the top of our working differential. Initial lab work revealed a WBC of
21.6. CT scan of the abdomen and pelvis was performed showing no acute
intra-abdominal process but revealing a nonspecific lumbar spine lesion. MRI
was advised to further visualize the lumbar region if clinically correlated, it was
performed and definitively diagnosed osteomyelitis of the lumbar spine.
Discussion: Osteomyelitis is an acute or chronic inflammatory process of the
bone secondary to infection with pyogenic organisms. Spinal osteomyelitis most
often results from hematogenous seeding, direct inoculation at the time of spinal
surgery or contiguous spread from an infection in the adjacent soft tissue. Our
case demonstrates the need for a thorough differential diagnosis in an elderly
patient with back pain. Making a prompt diagnosis of vertebral osteomyelitis
remains challenging particularly due to the insensitive and nonspecific clinical
presentation of this disease process and its insidious course. Treatment and
reliable follow up are crucial components for the resolution of osteomyelitis, and
understanding the route and mechanism of infection helps dictate treatment
regimens. Treatment consists of IV antibiotics that penetrate bone and joint
cavities as well as a referral to an orthopedist or neurosurgeon and a possible ID
consult.