We present a case of vertebral osteomyelitis presenting as chest pain. The patient initially underwent a CT chest angiogram to rule out a pulmonary embolism, which incidentally showed a soft tissue vertebral mass at T3-T4 disk space. Subsequent thoracic vertebral MRI was consistent with osteomyelitis with cord compression. Tissue culture from a CT-guided biopsy grew MRSA. The patient was successfully treated with Vancomycin. This is a rare presentation of vertebral osteomyelitis which poses an interesting diagnostic challenge.
A 69-year-old African American male presented to the emergency department with a 4-day history of chest pain. He described the chest pain as band-like pressure across the chest, 10/10 in severity, constant, radiating to the back, worsened with coughing, and without relief by nitroglycerin. His past medical history included hypertension, chronic hepatitis C, prostate cancer s/p prostatectomy, a penile prosthesis removed the prior year due to infection, and several cystoscopies within the past year. Physical exam revealed a normotensive, afebrile patient with tenderness to palpation of the thoracic spine at T4 level. There were no focal neurologic deficits, and peripheral pulses were symmetric. Labs showed an elevated ESR without a leukocytosis. ECG showed normal sinus rhythm without any significant abnormalities. A CT angiogram of the chest ruled out a pulmonary embolism but showed a large soft tissue mass centered on the T3-T4 disk space. Subsequently, an MRI of the thoracic spine demonstrated osteomyelitis (Figure
(a) CT angiogram chest showing a large soft tissue mass at the T3-T4 vertebral space with associated osseous destruction of the T4 vertebral body. (b) MRI of the thoracic spine, T1 weighted, showing T3-T4 disk space narrowing, endplate destruction, and marrow edema. There is also a soft tissue mass extending from the space anteriorly in the prevertebral space.
Vertebral osteomyelitis can pose a diagnostic challenge when unusual symptoms predominate on presentation. Its incidence has been estimated to be approximately 2.4 cases per 100,000 population [
The diagnosis of vertebral osteomyelitis is challenging, considering the rarity of disease, high prevalence of back pain in the general population, and variability of presenting symptoms. Diagnosis is based on clinical, laboratory, and radiographic data, and a high index of suspicion is required for its prompt recognition and improvement in disease outcome.