History

• 44 yo male construction worker presents with  2 days of atraumatic low back pain
• Pain is dull, constant, nonradiating, and worse with movmenet/bending/twisting
• No numbness or weakness in legs, no bowel/bladder incontinence, no fevers
• Denies IVDA

Exam

Vitals T: 98.8  HR 129  BP 150/89 Pox 100% on RA

• Appears mildly uncomfortable
• Lungs clear
• +systolic murmur ("since I was a kid")
• Abdomen soft NTND
• MS 5/5 in LE
• Normal rectal tone

Imaging

• Plain film of L spine appears unremarkable

Management

• Dc'd with oral pain medication and instruction to followup with primary care physician

Return visit

• Patient returns 2 days later with worsening pain
• Denies any numbness/weakness/incontinence/fevers

Vitals: T: 97.4 HR 95 BP 145/63 Pox 100%

• Looks uncomfortable and diaphoretic
• Again noted systolic heart murmur
• MS 5/5 in LE, normal patellar reflexes

Management

• Rectal temp: 101.3
• Pt sent for MRI of L and T spine
• MRI results: T12/L1 facet infection
• 2D echo: +vegetation on bicuspid aortic valve with severe regurgitation and perivalvular abscess

Outcome 

• Pt started on IV antibiotics and admitted to critical care
• Had aortic root repair with CT surgery complicated by post op cardiac tamponade requiring repeat surgery
• Blood and intra-op cultures grew strep viridans from an undiagnosed dental infection

Teaching Points

• Both endocarditis and spinal infections are notoriusly difficult to diagnose, with initial misdiagnosis rates as high as 50%
• Failure to promptly diagnose a spinal infection can lead to epidural abscess, spinal cord compression, and permanent paresis
• Fever, elevated WBC count, and inflammatory markers are often normal or only mildly elevated
• Plain films and CT lack the sensitivity to rule out this condition
• Diagnosis is made on MRI - be sure to image the spinal segment above and below the area of pain as well!
• And of course, in this case as in many others, rectal temp for the win

Ziu M, Dengler B, Cordell D, et al. Diagnosis and Management of Primary Pyogenic Spinal Infections in Intravenous Recreational Drug Users. Neurosurg Focus 37(2): 2014.