Advertisement

Elderly patient with prostate cancer and back pain

Published:December 30, 2019DOI:https://doi.org/10.1016/j.ejim.2019.12.018
      A 72-year-old man with hypertension came to our hospital with a history of severe posterior chest pain 3 months ago and worsened 1 week before admission. He denied a history of recent trauma but was admitted with dengue infection 3 months ago and was diagnosed with Gleason 3 + 4 prostatic adenocarcinoma in the same period. The patient was taking chlorthalidone, enalapril, bicalutamide, and morphine for pain relief. On admission examination, pain on palpation of the thoracic and lumbar spine was noticed. Axillary temperature: 37.7°; heart rate: 86 bpm; blood pressure: 160 × 90 mmHg. White blood cell count: 12,300 without deviation; hemoglobin: 9.0; platelets: 447,000; C-reactive protein 18.0 (reference value <0.5); erythrocyte sedimentation rate: 78 (reference value <30 mm/h); alkaline phosphatase: 189 (reference value <129); calcium: 8.56 (reference range: 8.6–10); parathyroid hormone: 23.4 (reference range: 12–65); 25(OH) vitamin D: 46 (reference range: 30–100); total prostate specific antigen: 11.6 (reference value <6.0). Normal renal function, without hydroelectrolytic imbalance or acid-base disorders. Magnetic resonance imaging with contrast of the thoracic spine and lumbosacral spine was performed (Fig. 1A and B). A blood culture sample showed growth of methicillin-sensitive Staphylococcus aureus.
      Fig. 1
      Fig. 1(A) T1-weighted MRI of thoracic and lumbar spine with contrast; (B) T1-weighted MRI of thoracic spine with fat suppression.

      1. What is the diagnosis?

      Pyogenic spondylodiscitis.

      2. Discussion

      Magnetic resonance imaging (MRI) of thoracic and lumbar spine (Fig. 1A and B) showed marked edema and enhancement of discs and subchondral bones of both vertebral bodies T7–T8, dural compression, reduction of spinal canal diameter, compression of the spinal cord and narrowing of the conjugate foramina T7-T8, besides L5-S1 disc edema (Fig. 1A), confirming spondylodiscitis.
      Spondylodiscitis in adults is often the result of hematogenous seeding of the adjacent disc space from a distant focus [
      • Berbari E.F.
      • Kanj S.S.
      • Kowalski T.J.
      • Darouiche R.O.
      • Widmer A.F.
      • Schmitt S.K.
      • et al.
      2015 IDSA clinical practice guidelines native vertebral osteomyelitis in adults.
      ]. It is typically diagnosed in the setting of recalcitrant back pain unresponsive to conservative measures and elevated inflammatory markers with or without fever [
      • Berbari E.F.
      • Kanj S.S.
      • Kowalski T.J.
      • Darouiche R.O.
      • Widmer A.F.
      • Schmitt S.K.
      • et al.
      2015 IDSA clinical practice guidelines native vertebral osteomyelitis in adults.
      ]. MRI of the spine is often required to establish the diagnosis. It can be assumed that the previously performed prostate biopsy was the Staphylococcus aureus gateway to the bloodstream. The paravertebral venous plexus and its branches are suggested as the pathway by which the organisms reach the spine bones from the lower urinary tract [
      • Henriques C.Q.
      Osteomyelitis as a complication in urology; with special reference to the paravertebral venous plexus.
      ].
      The patient was surgically treated with T5–T10 thoracic spine arthrodesis + comprehensive T7-T8 decompression due to spinal instability. Oxacillin (antistaphylococcal penicillin available in Brazil) was also administered for 6 weeks with complete improvement of symptoms and negative inflammatory markers and cultures. Antibiotic therapy should be administered for 6 weeks in spondylodiscitis [
      • Bernard L
      • Dinh A
      • Ghout I
      • Simo D
      • Zeller V
      • Issartel B
      • et al.
      Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial.
      ] and surgical intervention is recommended only in patients with progressive neurologic deficits, progressive deformity, and spinal instability [
      • Berbari E.F.
      • Kanj S.S.
      • Kowalski T.J.
      • Darouiche R.O.
      • Widmer A.F.
      • Schmitt S.K.
      • et al.
      2015 IDSA clinical practice guidelines native vertebral osteomyelitis in adults.
      ,
      • Bernard L
      • Dinh A
      • Ghout I
      • Simo D
      • Zeller V
      • Issartel B
      • et al.
      Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial.
      ].

      Declaration of Competing Interest

      No conflict of interest was declared.

      Appendix. Supplementary materials

      References

        • Berbari E.F.
        • Kanj S.S.
        • Kowalski T.J.
        • Darouiche R.O.
        • Widmer A.F.
        • Schmitt S.K.
        • et al.
        2015 IDSA clinical practice guidelines native vertebral osteomyelitis in adults.
        Clin Infect Dis. 2015; 61: e26-e46https://doi.org/10.1093/cid/civ482
        • Henriques C.Q.
        Osteomyelitis as a complication in urology; with special reference to the paravertebral venous plexus.
        Br J Surg. 1958; 46: 19-28https://doi.org/10.1002/bjs.18004619505
        • Bernard L
        • Dinh A
        • Ghout I
        • Simo D
        • Zeller V
        • Issartel B
        • et al.
        Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial.
        Lancet. 2015; 385: 875-882https://doi.org/10.1016/S0140-6736(14)61233-2