When You Hear Hoof Beats, Think Zebras? An Unusual Case Of Low Back Pain In An Adolescent Athlete. - Page #4
 

Working Diagnosis:
Extensive L3-4 discitis and osteomyelitis with extension of infection into the right psoas.

Treatment:
Patient was admitted to the local children's hospital for 7 days. Both Orthopedics and Infectious Disease were consulted. Orthopedics performed bone and disc biopsies (results shown in "other studies"). Per Infectious Disease, patient was treated with IV Clindamycin for empiric MRSA coverage for 6 days. She was then transitioned to PO Clindamycin with plans to continue antimicrobial therapy for 3-6 months. Cultures were pan-negative and she remained afebrile with normal WBC count.

Outcome:
Patient completed 4 months of PO Clindamycin and followed closely with both Orthopedics and Infectious Disease after her hospital discharge. No source of infection was ever identified. After completing her treatment, she had persistent low back pain (rated as 1-2/10) with occasional flare-ups. We anticipate full return to play once cleared by Infectious Disease.

Author's Comments:
Discitis and vertebral osteomyelitis are rather uncommon in the adolescent population. There is a bimodal distribution of ages seen with discitis in particular, with peak incidence at 7 years and 50 years of age. Given the clinical symptoms are variable and nonspecific, definitive diagnosis is often delayed. Some studies even indicate a delayed diagnosis by up to 3 months in 50% of patients. Additionally, there is no consensus pertaining to the optimal diagnostic strategies and treatment of vertebral osteomyelitis and discitis in the adolescent population. When spinal infection is suspected during evaluation, the recommended workup includes CBC, ESR, CRP, urine/blood/sputum cultures, radiographs as well as MRI. MRI has a high sensitivity (96%) and specificity (94%), and is considered the test of choice for identifying a spinal infection. In some cases, biopsy is indicated however culture of the collected material reveals etiology in less than 50% of cases.

In this particular case, the athlete's initial radiographs from the emergency department were read as normal however the images themselves were not available for review. Had the images been more readily accessible to the primary care physician, it may have prompted a more expedited decision to proceed with MRI evaluation given the endplate changes seen at L3-4. Overall, there was a 2 month delay to diagnosis. Fortunately, the patient responded well to treatment with no neurologic sequelae. This case emphasizes the importance of taking the initiative to review diagnostic images and not solely rely upon radiology reports. Furthermore, this case highlights the importance of maintaining a broad differential including spinal infection despite a seemingly benign presentation.

Editor's Comments:
It is always important to visualize the images yourself. Reports are not dependable and often miss subtle changes that could delay diagnosis.

References:
Berbari, E. F. (2015). 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clinical Infectious Diseases, 61(6), e26-e46.

De Moraes Barros Fucs, P. M. (2011). Spinal infections in children: a review. International Orthopedics 36(2), 387-395.

Marcovici, A., et al. (2016, Jan 29). Diskitis. Medscape. Retrieved 4/10/16 from http://emedicine.medscape.com/article/1263845-overview.

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