CBC was notable for an elevated WBC of 13.3 with 84% neutrophils. His BMP was: Na 139, K 4.5, Cl 102, Co2 24, BUN 14, Cr 1.28, AG 13. CPK was 89, ESR was 15, and CRP was 94. Urinalysis was: spec gravity 1.012, pH 6.0, neg leukocyte esterase, neg nitrite,
Lumbar spine plain films were normal Case Photo #1 and Case Photo #2. Thoracic and lumbar spine MRI revealed abnormal T2 signal enhancement in the paraspinal musculature along the left L1-L3 levels with extension in the the epidural space near L2-L3. No discernable abscess or evidence of osteomyelitis was seen Case Photo #3and Case Photo #4
The Infectious Diseases and Orthopaedic Surgery teams were consulted.
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