Unrecognized Staphylococcal Vertebral Osteomyelitis and Epidural Abscess Leading to Meningitis, Infective Endocarditis, Cerebrovascular Accident, Sepsis and Death in a Previously Healthy Patient

Yazan Zayed, MD1, Rahul Gupta, MD2, Bakr Swaid, MD3, Danielle Osterholzer, MD4, 1Hurley Medical Center/ Michigan State University, Grand Blanc, MI; 2Hurley Medical Center/ Michigan State University; 3hurley Medical Center/ Michigan State University; 4Hurley Medical Center/Michigan State University

Meeting: Hospital Medicine 2018; April 8-11; Orlando, Fla.

Abstract number: 928

Categories: Adult, Clinical Vignettes, Uncategorized

Keywords: ,

Case Presentation: A 71-year-old Caucasian female with no known past medical history complained of insidious onset low back pain that became constant and severe, associated with generalized weakness and diffuse pain over the course of few days. The patient sought medical care at other facilities on two occasions and each time was prescribed symptomatic treatment including narcotic pain medications and a course of oral steroids. She had no fever or chills. Her family noted that she was increasingly confused therefore; they brought her to this hospital after 2 weeks of initial complaints. On examination, she was afebrile with tachycardia. She was lethargic but arousable. No meningismus was present. A pan-systolic murmur was present as well as a red painless raised lesion on the pad of her left fourth finger. She had midline lower back tenderness with preserved power and sensation in her lower limbs.
Laboratory investigations showed leukocytosis with a left shift, elevated C- reactive protein and erythrocyte sedimentation rate as well an acute kidney injury. A lumbar puncture revealed 100 white blood cells (100% monocytes) with elevated protein and low glucose. Both her blood and spinal fluid grew methicillin sensitive Staphylococcus aureus in less than 12 hours. She was treated with nafcillin. Computed tomography (CT) of the spine revealed a fluid collection in the retroperitoneum concerning for psoas abscess. Echocardiography showed mitral valve vegetation with severe regurgitation. Numerous foci compatible with acute embolic infarcts were evident on brain magnetic resonance imaging (MRI) while lumbar spine MRI showed vertebral osteomyelitis and discitis with an epidural abscess displacing the spinal cord.

Patient’s condition deteriorated rapidly as she developed severe septic shock with multi-organ failure. She was not a candidate for spinal or cardiac surgery given her severity of illness. Unfortunately, she died just shy of a month after her initial complaints began.

Discussion: The incidence of vertebral osteomyelitis (VO) increases with increasing age occurring more commonly after age of 50 years. Low back pain is the most common symptom and fever is present only in 35-60% of cases so fever absence doesn’t exclude the disease. Staphylococcus aureus is the most common causative agent and accounts for 32-67% of cases. Hematogenous seeding being the most common mode of acquisition and the source of primary infection can be detected in about 50% of the cases. Interestingly, Infective Endocarditis is diagnosed in up to a third of cases with VO. Less commonly, patients who are known to have endocarditis are found secondarily to have VO. Most patients with hematogenous pyogenic VO have underlying medical condition or intravenous drug abuse.

This case highlights the sometimes occult nature of VO. Hematogenous seeding of the spine with staphylococci can occur even through small violations in skin integrity and the initial portal of entry may not be evident. Patients may complain only of worsening back pain without fever or other signs of infection. Prednisone given for a presumed diagnosis of sciatica or muscle inflammation can lead to acceleration of occult infection. In this case, spinal osteomyelitis progressed to epidural and psoas abscesses, meningitis, endocarditis, embolic stroke and death.

Conclusions: Vertebral Osteomyelitis requires a high index of suspicion to diagnose and failure to do so can have dire consequence including widespread infection and bacteremia that can lead to fatal outcome.

IMAGE 1: Janeway lesion of patient's left hand.

IMAGE 2: Left: Psoas abscess. Right: Mitral valve vegetations on Echocardiography.

To cite this abstract:

Zayed, Y; Gupta, R; Swaid, B; Osterholzer, D. Unrecognized Staphylococcal Vertebral Osteomyelitis and Epidural Abscess Leading to Meningitis, Infective Endocarditis, Cerebrovascular Accident, Sepsis and Death in a Previously Healthy Patient. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 928. https://www.shmabstracts.com/abstract/unrecognized-staphylococcal-vertebral-osteomyelitis-and-epidural-abscess-leading-to-meningitis-infective-endocarditis-cerebrovascular-accident-sepsis-and-death-in-a-previously-healthy-patient/. Accessed April 1, 2020.

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