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Case 311

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A 69-year-old female patient reports abdominal and lumbar high-intense piercing pain with radiation to the medial and the lateral face of the lower limbs, exacerbated with a passive mobilization of the limb that started about one month ago. In use of ciprofloxacin for treatment of urinary tract infection. At examination: preserved general condition, afebrile, hemodynamically stable, muscle strength in limbs quantified in 4 (0-5) by Medical Research Council (MRC) scale and allodynia in the soles of the feet. CRP: 249 mg / dL.

According to the case and the exposed images, the probable diagnosis is:

a) Complicated pyelonephritis

25%

b) Pyogenic spondylodiscitis

25%

c) Pott's disease (vertebral tuberculosis)

25%

d) Age-compatible degeneration of L1 and L2 vertebrae

25%
   

Image analysis

 

Figure 1: Magnetic resonance imaging (MRI) of the thoracolumbar spine, sagittal T1, without contrast. A high signal in sagittal T1 shows segmental involvement of the vertebral bodies of L1 and L2 (red contoured area).

 

 

Figure 2: MRI of the thoracolumbar spine, sagittal T1 FAT, with intravenous contrast (gadolinium). The vertebral bodies of L1 and L2 present high signals in T1 FAT, exhibiting significant contrast impregnation. The presence of irregularities of vertebral plateaus are suggestive of bone destruction (contour between L1 and L2 in yellow). There is a thickening of the dura mater that is impregnated intensely in all the visual extension (contour in red). The anterior epidural collection is delimited, in the median line, in the segment comprised between T12-L1, exhibiting a low sign (red arrow).

 

 

Figure 3: MRI of the thoracolumbar spine, sagittal T2. The L1 and L2 vertebral bodies and the intervertebral disc interposed between L1 and L2 presents a high signal, indicating inflammation (red arrows). An anterior epidural collection is delineated in the midline, in the segment comprised between T12-L1, characterized by a high, contrast-sensing border, which exerts compression on the medullary cone and the underlying segment of the roots of the equine tail (yellow arrow).

 

 

Figure 4: MRI of the spine in the segment comprised between T12-L4. Axial T2 (upper) and axial T1 FAT (lower). The right psoas muscle (red circles) has a volumetric increase, a heterogeneous T2 signal and a contrast impregnation, visible on T1 FAT, in the segment comprised between T12-L4. Presence of epidural abscess (red arrows).

Highlights

- Lumbar or cervical pain with progressive worsening, especially when associated with fever and the presence of bacteremia or infective endocarditis raises the diagnostic suspicion of discitis;

- Fever associated with peripheral neurological symptoms such as paresis, folds and alterations of sensitivity and elevation of serum inflammatory markers increase the clinical suspicion of discitis;

- MRI has a high degree of sensitivity for the diagnosis. Plain radiography is insensitive to the early changes of discitis/osteomyelitis;

- The etiological diagnosis requires computed tomography guided biopsy and culture of the aspirated material;

- Initially, pain responds to rest and conservative measures, leading erroneously to a noninfectious diagnosis;

- History of degenerative spine disease or recent trauma are also confounding factors in the diagnosis. 

References

- M Hooton T. Acute complicated cystitis and pyelonephritis [Internet]. UpToDate. 2017. [Access in May 2017];

- McDonald M. Vertebral osteomyelitis and discitis in adults [Internet]. Uptodate. 2017 [Access in May 2017]. Available on: https://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis-in-adults;

- Matos Queiroz J, Alves de Assis Pereira P, Figueiredo E. Espondilodiscite: revisão de literatura. Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery. 2013;32(04):230-236;

- Wheeler S, Wipf J, Staiger T, Deyo R, Jarvik J. Evaluation of low back pain in adults [Internet]. Uptodate. 2017 [Access in May 2017]. Available on: https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults;

- Tamm A, Abele J. Bone and Gallium Single-Photon Emission Computed Tomography-Computed Tomography is Equivalent to Magnetic Resonance Imaging in the Diagnosis of Infectious Spondylodiscitis: A Retrospective Study. Canadian Association of Radiologists Journal. 2017;68(1):41-46. 

Authors

Joice Carneiro Dias Prodígios, 6th year medical student at Universidade de Minas Gerais (UFMG).

Mail: Joicecdp[at]hotmail.com

Ariádna Andrade Saldanha da Silva, 5th year medical student at UFMG

Mail: ariadna.andrade[arroba]hotmail.com

Supervisor

Dra. Fernanda Moura Teatini, Neuroradiologist at Hospital das Clínicas da UFMG.

Mail: fernandateatini[arroba]live.com

Reviewers

Fernando Bottega, Giovanni O. Carvalho, Professor José Nelson Mendes Vieira and Professor Viviane Santuari Parisotto Marino.

Translated by

Joice Carneiro Dias Prodígios, 6th year medical student at UFMG.

Izabella Costa Neves Silva, 4th year medical student at UFMG.

Test question

Secretary of State for Health - ES (SESA / ES) 2013. Center for Selection and Promotion of UnB Events (CESPE)

In relation to low back pain, one of the pathologies that most incapacitate the individuals of economically active age, mark the correct option.

 

a) For patients with unilateral lumbar pain radiating to the ipsilateral flank, urinary symptoms, fever and pain to lumbar percussion, the main diagnostic hypothesis is infectious or septic discitis.

25%

b) Most episodes of low back pain are limited and have muscular origin (mechanical or idiopathic low back pain).

25%

c) Pain in the spine is always related to inflammatory rheumatism.

25%

d) Arthrosis of the spine reach only the elderly.

25%

e) Most patients with low back pain due to disc herniation present symptoms of medullary compression and pain that evolves with sphincter dysfunction and paraparesis.

25%
   

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