1. An Unusual Cause of Back Pain
Sol del Mar Aldrete, M.D.1 Abeer Moanna, M.D.1,2
Division of Infectious Diseases, Emory University SOM , Atlanta, Georgia
Atlanta VA Medical Center, Decatur, Georgia.
Hospital Course
On admission, an MRI lumbar spine showed signs concerning for discitis/osteomyelitis at L4/L5 and a ventral epidural abscess at L4-L5. He was started on vancomycin, ceftazidime and metronidazole empirically and was taken to the OR for lumbar decompression and abscess evacuation.
Infectious diseases team was consulted the following day and his antibiotic regimen was switched to vancomycin + meropenem for better CNS penetration. Unfortunately, his intra-operative cultures failed to grow any pathogen.
Two weeks after his initial surgery, he was taken to the OR again for laminectomy revision and wound VAC placement. More bacterial/mycobacterial/fungal cultures were sent.
He was discharged home on empiric tx with Vancomycin and ertapenem for 6 weeks. Q fever serologies were sent after the patient admitted to the ID team working at a slaughter house in the past; results were not available at the time of discharge from the hospital.
Diagnosis
Learning Objectives
Think of Coxiella burnetti as a cause of discitis/osteomyelitis in patients with a relevant social history.
Imaging
Phase of infection and type of sample
Type of analysis
Results
Acute
Serum
IFA for phase I and II IgG and IgM
PCR
Fourfold change in IgG antibody titer phase II
Chronic (> 6 wks after illness)
IgG titer >1:800 to phase I antigen
Patient Presentation
66 year old white male with history of CAD and HTN presented to the emergency department with acute on chronic low back pain.
He has had chronic low back pain for the last 5-6 months that got acutely worse 10 days before his presentation.
Denied fevers, chills, malaise, LE weakness, and bowel/bladder incontinence. Two weeks prior to his admission he got admitted to an another hospital with abdominal pain and was diagnosed with diverticulitis.
Past Medical History
CAD, HTN and Atrial fibrillation.
Retired truck driver. Distant hx of having work at a slaughter house.
No IVDU.
20 pack year hx tobacco. Occasional ETOH.
Physical Exam
Afebrile, BP: 125/74, HR: 66
NAD
Neurologic: CN II-XII intact, strength 5/5 four extremities, sensation intact. Reflexes 2+
Significant point tenderness at L4-L5
No rashes
Treatment
The majority of cases of acute Q fever resolve spontaneously. If symptomatic, can give doxycycline for 2 weeks.
Chronic Q fever requires a more prolonged duration of treatment with doxycycline and hydroxychroloquine for18-24 months.
Cure is defined as phase I IgG titer <1:200.
Our patient is being treated with doxycyline and hydroxychloroquine with follow up imaging and serologies planned at regular intervals.
MRI T1 Flair sagital
Introduction
Q fever
Coxiella burnetii is an obligate intracellular highly pleomorphic coccobacillus with gram negative cell wall. It’s transmission occurs primarily through inhalation of aerosols from contaminated soil or animal waste (cattle, sheep, goats).
It can cause acute or chronic manifestations and most commonly it causes an acute febrile illness that resolves without treatment.
Chronic Q fever syndromes such as endocarditis or osteomyelitis are rare.
In most cases, serology confirms the diagnosis, but other options are: PCR, IHC or isolation of the organism by culture.
Laboratory
Labs at admission
WBC: 6.4 (67% PMN), Hgb: 13.7, Plt: 181
Creat: 1.0
CRP: 51.1
Microbiology
Blood cx x 2 at admission no growth
1st Tissue cx: ¼ + CoNS, no fungal/mycobacteria grew
2nd Tissue cx: negative for bacteria/fungal/mycobacteria
Pathology: acute inflammation with negative bacterial, fungal, and mycobacterial stains
Serologies
Q fever IgG Phase I: POSITIVE >1: 8192
Q Fever IgG Phase II: POSTIVE =1: 4096
Q fever IgM Phase I&II NEGATIVE
Take home points
A high index of suspicion is necessary to make the diagnosis of Q fever osteomyelitis.
Serology make the diagnosis most of the times.
References
1. Marrie, T et al. Chapter 189. Q fever. Mandell.
2. CDC MMWR. Diagnosis and management of Q fever- United States, Vol 62, num 3
3. Fournier, P et al. Diagnosis of Q fever. JCM. 1998, 36 (7): 1823