Kris Foley, MD
Resident
Mount Sinai Hospital
New York, New York, United States
Sal Girardi, MD
Attending
Mount Sinai West
New York, New York, United States
Carley Trentman, MD
Attending Physician
Mount Sinai Hospital
NYC, New York, United States
A 64-year-old man with PMHx of Tetralogy of Fallot s/p 2 valve replacements, bacteremia secondary to infected tattoo, and recent left scaphoid fracture was evaluated in the ED with fever, sore throat, neck pain x 4 days. He was started on doxycycline for suspected Lyme disease and discharged. He presented one week later with worsening symptoms. MRI demonstrated discitis and osteomyelitis centered at C4-C5 and epidural and prevertebral abscesses. He required C4-C5 discectomy, fusion, irrigation and debridement of abscesses. TTE was without vegetations and cultures without growth. No other source of infection could be identified raising suspicion to seeding from prior infected tattoo. He was placed in a Miami J collar after surgery, started on an 8-week course of IV daptomycin, ceftriaxone, and metronidazole, and began therapies in acute rehabilitation.
Discussions:
The incidence of vertebral osteomyelitis and discitis is increasing, believed to be due to higher rates of implanted devices, injection drug use, and immunocompromised state which increase the risk of bacteremia and further spread to the spinal column. Overall, osteomyelitis is most frequently seen in the lumbar vertebrae, followed by thoracic, and least commonly in the cervical region1. Hematogenous spread is the most common form of spread, but contiguous spread from adjacent tissue is also observed2. This patient had no clear source of infection, aside from prior tattoo infection. The tattoo was located on the upper arm and chest, raising possibility for hematogenous vs contiguous spread to the neck and cervical region.
Conclusions:
This case illustrates the importance of prompt recognition of vertebral osteomyelitis/discitis and prevertebral abscesses to prevent further spread through the spinal column or risk of airway compromise despite definitive inciting event. This patient had a successful outcome after surgical decompression and fusion, extended course of IV antibiotics, and completion of acute rehabilitation.
