A Case of Confounding Back Pain

Abstract

BACKGROUND Acute back pain is common in primary care settings (>60% lifetime prevalence). Patients can also have associated red flag signs, such as fever, spinal tenderness, and neurologic deficits, that warrant further evaluation and investigation to optimize diagnosis and treatment. CASE REPORT A 70-year-old man with a history of benign prostatic hyperplasia and hypertension sought care for midthoracic back pain. He had been recently admitted to the hospital for sepsis from a urinary tract infection (UTI) caused by multidrug-resistant (MDR) Escherichia coli. Initial treatment was conservative management with physical therapy, given the lack of red flag signs on physical examination and the likelihood that his pain was musculoskeletal, resulting from immobilization during hospitalization. At follow-up, thoracic spine radiography showed no fracture or other acute abnormalities. After persistent pain, he underwent magnetic resonance imaging, which showed T7-T8 osteomyelitis and discitis with substantial paraspinal soft tissue involvement. Computed tomography-guided biopsy showed MDR E. coli, which indicated hematogenous spread from his recent UTI. Pharmacologic treatment included intravenous ertapenem for 8 weeks, with consideration for discectomy if later indicated. This case highlights the value of maintaining a broad differential diagnosis and high alert for red flag symptoms during routine office visits with a chief concern of back pain. CONCLUSIONS A high clinical suspicion for vertebral osteomyelitis must be maintained for patients with acute back pain associated with red flag signs. Detailed assessment with appropriate investigations and close follow-up is recommended to support the diagnosis and to allow timely management to prevent complications.

Figure 1.

Progression of T7-T8 osteomyelitis/discitis on T2-series magnetic resonance imaging (MRI), sagittal sections. (A) Initial MRI showing T7-T8 osteomyelitis and discitis with paraspinal soft tissue involvement (arrow). (B) MRI of T7-T8 after readmission with worsening back pain showing progressive discitis/osteomyelitis, phlegmonous changes, and a small, left-sided paraspinal abscess (arrow). (C) MRI after completion of the second round of intravenous antibiotics showing improvement of the T7-T8 discitis/osteomyelitis and decreased soft tissue inflammation (arrow), which was coupled with clinical improvement.

Figure 2.

Susceptibility test results. MIC – minimum inhibitory concentration.

Figure 3.

T2-series magnetic resonance imaging, sagittal sections, showing interval resolution of T7-T8 osteomyelitis.