For 4 weeks, a 49-year-old man has had progressively worsening pain between his scapulae and in the lower part of his neck. The pain is now severe, and he takes high doses of acetaminophen and NSAIDs for relief. In the past several days, he has also had paresthesias and weakness in his arms and he has noted pain on swallowing.
About 6 weeks earlier, an abscess in his right thumb was drained and a 1-week course of trimethoprim/sulfamethoxazole was prescribed. Thereafter, the back pain syndrome developed. The patient has also had subjective fevers and a 25-lb weight loss.
He works as a dishwasher in a restaurant and was previously healthy. He drinks alcohol occasionally but does not use illicit drugs.
The patient is very uncomfortable because of the pain in his upper back and neck. Temperature is 36.6°C (98°F). Mouth and pharynx are normal. Exquisite tenderness to tap percussion and motion is noted in the region of C5 through T6. He has paresis of both arms and hands, including the fingers.
LABORATORY AND IMAGING RESULTS
Hemogram is normal; the white blood cell count is 6500/µL. Radiographs of the cervical spine and back reveal discitis and probable osteomyelitis in C6-7 with kyphotic angulation deformity, facet destruction, and widening of the spinous process.
1. Mylona E, Samarkos M, Kakalou E, et al. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum. 2009;39:10-17.
2. Zimmerli W. Clinical practice. Vertebral osteomyelitis. N Engl J Med. 2010;362:1022-1029.
3. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 258 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002;34:1342-1350.
4. Pigrau C, Almirante B, Flores X, et al. Spontaneous pyogenic vertebral osteomyelitis and endocarditis: incidence, risk factors, and outcome. Am J Med. 2005;118:1287.