Very brief history:
47 y/o airline pilot who frequently flies internationally to Mexico, Central, and South America who presented to his PCP with 2-3 months of progressive focal low back pain. An MRI was ordered and he was referred to neurosurgery. The MRI showed L3-L4 disk herniation and "significant inflammation concerning for infection." He was seen in the outpatient neurosurgery clinic for his back pain, and surgery was scheduled for “pain relief.” At the time of that visit, he had noted the new onset of fever to 102, chills, and sweats. His surgery was scheduled for 1 week later.
He was admitted to the hospital and his pre-op CXR was done. I don't have that film, but the rads report follows:
“Ill-defined right upper lobe, anterior segment, airspace opacity with adjacent fibrosis and likely ipsilateral hilar and mediastinal lymph node enlargement. There is an adjacent area of pleural thickening at the right apex”.
His exam was unremarkable. He was put in isolation, and ID was consulted...
Thoughts/next steps? I will give some more information after a brief period for comments, and some imaging will come in a follow-up post.
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Cool case. 2 quick questions: any smoking history? And tell us a bit more about the MRI ("significant inflammation "). Was it mostly a discitis, osteomyelitis? Was more than one body involved?
He is a smoker--about 40 pack-years so far. The MRI findings:
"IMPRESSION:
1. L3-L4 intraosseous disk herniation with adjacent vertebral body
edema and enhancement probably inflammation, but infection cannot be
excluded.
2. L3-L4 disk causing right paracentral thecal sac deformity and
lateral recess stenosis contacting the L4 nerve root."
Very interesting.
I would get a good sputum sample to send for AFB. I presume that I am not alone in worring about active TB with Pott's Disease.
After I have the specimen in the lab, I would start 4 antituberculous drugs because of the pending impingment of the L4 nerve root. Ultimately, I would get 3 total isolates for AFB smear and culture.
Also, a PPD would be a good idea.
If the sputums are negative for AFB, I would bronch and BAL his RUL.
Hold the fort on the surgery for now unless neurosurgery feels the area needs to be stabilized with an operation.
I agree with Lazar. TB would be high on my list. Bronch sounds like a good idea. The MRI description seems to be mostly of bone involvement but not so much interosseous spread. Typical bacteria could presnt like this with a hematogenous spread from a pneumonia could explain the findings. On the atypical bag since he traveles so much I will add Nocardia which cancause the lung findings and bone involvement and Paracoccidioides which is a South American fungus that likes to cause everything that TB may cause. It has a very typical "spokes-wheel" appearance in tissue.
So, I met the patient a few days later when he came down for a bronchoscopy. No sputums had been obtained, and no drugs had been started. Personally, I felt strongly that the patient should have been started on 4 drugs the minute he hit the door. Anyway, some follow-up images are up in a new post...
A lot of posting since I last checked. I will put my belated 2 cents in that I agree I would definitely start the patient on 4 drugs prior to the subequent workup; TB with probable Pott's is way up on the list...
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