Working Diagnosis:
Chronic Vertebral Osteomyelitis with Discitis

Treatment:
Treatment with IV daptomycin and Ceftriaxone for a total of 8 weeks of treatment was completed, although social determinants of health caused an unfortunate interruption of treatment for our patient. Neurosurgical evaluation recommended against operative management in favor of serial imaging which demonstrated improvement of endplate and disc edema.
Patient was discharged to home with close follow-up in infectious disease clinic.

Outcome:
After treatment, the patient noted significant improvement in her pain and a normalized neurologic function. She is monitored with regular blood cell counts and inflammatory markers to monitor for acute or worsening signs or symptoms. She has had no recurrence at this time (6 month out) and has been able to cheer for her sports team without issue.
At 1 year follow up upon chart review, patient has had intact neurological function, but continues to have pain in spine at location of infectious insult. However, repeat MRI shows resolution of infection.

Author's Comments:
Chronic vertebral osteomyelitis is a significant comorbidity in the immunosuppressed population. Risk factors for our patient include obesity, HIV, and diabetes. Vertebral osteomyelitis is most commonly caused by hematogenous spread. Spinal tenderness may only be present in 20% of cases, while focal neurologic changes are present in 30% of cases. Traditional pathogens include various strains of staphylococcus, with over 50% of the cases revealing S. aureus, as in our cause. Her antibiotics were appropriately broad spectrum given the above concern for mycobacterium. Recurrence rate for chronic spinal osteomyelitis is greater than 30%. This case was unique given the minimal trauma, absence of adjacent wound, no clinical signs of infection, normal CD4 count, and Hemoglobin A1c at goal. Despite treatment, most patients become permanently disabled with poor quality of life and permanent neurological deficits. A high index of suspicion is required by clinicians as early treatment affords more favorable outcomes.

Editor's Comments:
This case highlights the importance of broadening the differential in patients with risk factors for uncommon disease processes. Patients with a history of immunocompromised state, malignancy, and intravenous drug use all increase the risk for osteomyelitis/discitis. Fortunately in this case, there was some evidence on the initial plain films for possible osteomyelitis/discitis but initial X-rays are often inconclusive. Keeping an elevated clinical suspicion is vital to avoid missing potential significant pathology.

References:
Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis 2015; 61:e26.

Issa K, Diebo BG, Faloon M, et al. The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013. Clin Spine Surg 2018; 31:E102.

Michel-Batot C, Dintinger H, Blum A, et al. A particular form of septic arthritis: septic arthritis of facet joint. Joint Bone Spine 2008; 75:78.

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