1. A PATIENT WITH INFECTIOUS BACK PAIN: CLINICAL AND THERAPEUTIC ISSUES.
Di Nuzzo M, Grilli A, Picchi G, Maritati M, Fabbri G, Cultrera R, Contini C.
Sezione di Malattie Infettive, Dipartimento di Scienze Mediche, Università di Ferrara
INTRODUCTION: Back pain is a common and generally benign symptom. However, serious conditions, such as infectious aortitis (IA) and spondylodiscitis (SD), could present with dorsal and lumbar pain. IA and SD are rare, clinically non-specific conditions which require long term antibiotic therapy, although there is no consensus regarding antibiotic treatment duration.
CASE DESCRIPTION: We present a case of an ex-smoker 73-year-old male with a history of hypertension, L4-L5 and L5-S1 disk herniation, and two episodes of pulmonary embolism (PE) 12 years before and a month before, respectively. The previous month he was treated with intramuscular analgesic injections because of severe back pain. The patient was admitted emergently with lumbar and dorsal pain, leg weakness, fever, and dyspnea. A contrast enhanced chest computed tomography angiography (CTA) performed at admission revealed a localized perforation of thoracic aorta and a contained leak in the surrounding tissue (Figure 1). Emergent surgery was performed and IA was identified. Intra-operative findings showed a severe atherosclerosis of the thoracic aorta with numerous ulcerated plaques. Ascending aorta and aortic arch were removed and replaced with an in situ prosthetic graft. Left carotid and brachiocephalic arteries were re-implanted into the graft. Cultures of the surgical materials showed a meticillin-sensitive Staphylococcus aureus (MSSA) infection.
Figure 1: localized perforation of thoracic aorta.
Antibiotherapy was empirically started with piperacillin/tazobactam and teicoplanine, replaced by oxacillin once obtained culture results. Further imaging examinations showed a L4-L5 SD and involvement of pre and para vertebral muscles, left and right psoas muscles, and the epidural soft tissue (Figure 2). Moreover, two abscesses of left and right buttock were observed (Figure 3). A percutaneous sonographically-guided drainage of both abscesses was performed, and cultures did isolate MSSA. After 5 weeks of intra-venous antibiotherapy, oral antibiotic therapy (ciprofloxacin and amoxicillin/clavulanate, was started, but then modified with rifampicin and trimethoprim/sulfamethoxazole) which targeted the pathogen and the site of infection (aorta, lumbar vertebrae and the interposed disk).
The patient responded to antibiotherapy with rapid defervescence. Abscesses were probably caused by intramuscular injections and represented a focus of continuous bacteremia that led to aortic and vertebral infection. During the monitoring, the patient complicated with pneumonia and uveitis treated with linezolid and steroids, respectively. At the moment, 18 weeks after surgery, the patient is asymptomatic, but still on antibiotherapy.
CONCLUSIONS: This case is of interest for several reasons. No cases of IA associated with SD and buttock abscesses are reported so far. Moreover, guidelines on therapy are missing. Emergent surgery, long-term antibiotic treatment, collaboration among health care workers and close monitoring, achieved a good outcome.
Figure 2: L4-L5 spondylodiscitis.
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Figure 3: abscesses of the left and right buttock.