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Abstract: The patient visited a local hospital in April before admission due to a fall, and a lumbar MRI showed “compression fracture of the lumbar spine at 4 and 5 segments”, and 2 weeks before he came to the hospital, he suddenly developed significantly worse back pain with fever, and a repeat lumbar MRI showed “lumbar abscess “The MRI of the lumbar spine showed a lumbar abscess, which was caused by a bacterial infection, and the blood culture showed Staphylococcus aureus. Through the administration of antibacterial drugs and symptomatic treatment, the condition improved, with no fever, and the lumbar pain improved significantly, allowing her to get out of bed and walk upright and slowly.
Basic information】Female, 85 years old
Disease Type】Lumbar spine abscess
Hospital】Huashan Hospital of Fudan University
Date of Consultation】May 2021
Treatment plan】Medication (vancomycin hydrochloride for injection, phosphomycin sodium for injection, linezolid injection, daptomycin for injection, moxifloxacin hydrochloride tablets)
[Treatment Period] Hospitalization for more than 4 months, review 2 weeks after discharge
Treatment effect】The condition improved, no fever, back pain significantly improved, can get out of bed and walk slowly
I. Initial consultation
In April before admission, the patient fell down in the bathroom at home and was sent to the local hospital for emergency treatment. However, 2-3 weeks later, the patient developed recurrent fever with a low temperature of 38℃ or less, and the lumbar pain was worse than before, and he was given oral analgesics such as Celecoxib capsules to relieve pain at the local hospital, and his temperature basically returned to normal. Two weeks before admission to the hospital, there was a sudden increase in lumbar pain, and the pain was very severe and unbearable when lying in bed and turning over slightly, while the body temperature increased significantly, reaching 38.7℃ on the day of consultation. The patient first went to the orthopedic department on the same day, which showed “lumbar spine abscess” on emergency lumbar spine MRI and significantly elevated white blood cells on routine blood tests, and was referred to the infection department for further treatment with “lumbar spine abscess”.
Magnetic resonance imaging of the patient’s lumbar spine, with the red circle area showing abscess formation in segments 4 and 5 of the lumbar spine
II. Treatment history
The patient’s blood culture was drawn immediately after admission, and intravenous rehydration treatment with vancomycin hydrochloride for injection combined with phosphomycin sodium for injection was given according to the diagnosis, and the patient’s body temperature returned to normal after 3 days, and the blood culture was reported positive after 3 days, showing the growth of Staphylococcus aureus, which is a common pathogen of spinal abscess. Considering that the currently selected antimicrobial drug is sensitive and has good therapeutic effect, the antimicrobial drug vancomycin hydrochloride for injection was continued for nearly 2 months, after which the patient’s back pain further improved, but the lumbar spine abscess was still not completely absorbed on reexamination of magnetic resonance, and at the same time the patient developed renal insufficiency, which was considered to be a drug side effect, and the treatment was changed to intravenous rehydration with linezolid injection for more than 2 weeks, and the patient again developed reduced white blood cells and platelets, which was considered to be a The patient was discharged from the hospital with oral moxifloxacin hydrochloride tablets instead of intravenous rehydration with intravenous rehydration with intravenous rehydration with intravenous daptomycin.
III. Treatment effect
Although the patient experienced frequent drug changes and a long course of illness during the treatment, after more than 4 months of intravenous anti-infection treatment, the condition improved, no fever, lumbago significantly improved, no pain when lying flat in bed and turning over, and could get out of bed and stand and walk about 10m holding the auxiliary walking apparatus. At this time, stop using intravenous medication and switch to moxifloxacin hydrochloride tablets for oral administration.
IV. Precautions
We are glad that the patient’s symptoms have improved after treatment, but we still need to pay attention to the fact that the course of treatment for lumbar spinal abscess is very long, and the fact that the patient stops using intravenous antibacterial drugs does not mean that the course of treatment is over. Before discharge, we instruct the patient to take oral moxifloxacin hydrochloride tablets for a long time, and we need to review the MRI after 2 weeks to understand the efficacy of oral drugs, and we also need to review the blood routine and liver and kidney function at least once in 2 weeks. If serious side effects are found, the drug needs to be discontinued, visit the hospital, and switch to other oral antibacterial drugs under the guidance of the doctor. At the same time, it is necessary to pay attention to the rehabilitation exercise of limb function in order to recover more quickly.
V. Personal insight
This is a typical case of misdiagnosis of lumbar pain as lumbar compression fracture. Reviewing the patient’s medical history, the patient was diagnosed with lumbar compression fracture by MRI due to a fall 4 months ago, but the patient developed recurrent fever 2-3 weeks later, with a low temperature of 38℃ or less, and the lumbar pain was aggravated. The patient’s condition was aggravated by the delay. In conclusion, it is important to remind doctors and patients that when the pain in the low back increases beyond explanation, routine blood tests and MRI should be performed promptly to clarify or exclude the diagnosis of lumbar spinal abscess as early as possible.