A woman with fever and back pain.

CASE PRESENTATION

An 89‐year‐old female with a history of untreated diabetes mellitus presented with a 1‐month history of fever and back pain. Four months prior, she had a dental extraction. On arrival, her temperature was 38.5°C, blood pressure 108/56 mmHg, pulse 114 beats/min, and oxygen saturation 92% while breathing ambient air. Physical examination showed percussion tenderness of thoracic vertebrae. Laboratory tests revealed leukocytosis, an elevated C‐reactive protein level of 51.4 mg/dL, an elevated serum glucose level of 392 mg/dL, and HbA1c level of 11.6%. Subsequent computed tomography scan revealed intraosseous gas and emphysematous lesions around the spine at the thoracic level (Figure 1). She was administered broad‐spectrum antibiotics. Streptococcus intermedius grew in the blood and urinary cultures, and magnetic resonance imaging of the spine demonstrated Th11 levels of pyogenic spondylitis (Figure 2).

FIGURE 1

Computed tomography scan revealing intraosseous gas (red arrows) and emphysematous lesions around the spine (white arrows) at the thoracic level. (Left; axial view, right; sagittal view.)

FIGURE 2

Magnetic resonance imaging of the spine showing Th11 levels of pyogenic spondylitis (red arrows). (Left; T1 weighted image, right; T2 weighted image.)

DIAGNOSIS

Emphysematous vertebral osteomyelitis

Although appropriate antibiotic therapy was continued, the patient died because of the continuous uncontrolled infection.

Emphysematous osteomyelitis is a rare but potentially fatal infection caused by gas‐forming organisms and is characterized by the presence of intraosseous gas. Predisposing factors include diabetes mellitus, malignant tumors, and alcohol abuse. Streptococcus intermedius, a normal flora of the oral cavity and gastrointestinal tract, can cause systemic infections, abscesses, necrotizing fasciitis, and even gas gangrene. This is the second reported case of emphysematous osteomyelitis caused by this species. With these results, physicians should be aware of emphysematous osteomyelitis if they see intraosseous gases and positive results of blood culture with gas‐forming organisms.