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A 46-year-old man presented to the emergency department with 3 months of upper back pain and 2 weeks of dry cough and subjective fevers that did not improve with empirical azithromycin. He had immigrated from India to the US 15 years prior and worked as a software engineer. He last traveled to India 4 years earlier and had negative results for interferon gamma release assay on return. He reported no smoking history, recent animal contact, or unpasteurized animal product ingestion.
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Pott disease (tuberculous spondylitis)
A. Place the patient in airborne isolation and begin ethambutol, isoniazid, pyrazinamide, and rifampin
The keys to the correct diagnosis were MRI findings of a paraspinal mass with signal abnormality and extensive contrast enhancement in the lower thoracic vertebral bodies and relative sparing of the intervertebral disks (consistent with Pott disease), along with fever, cough, and consolidation on chest computed tomography in a patient who had traveled to a country with a high prevalence of tuberculosis.1 The combination of ethambutol, isoniazid, pyrazinamide, and rifampin (choice A) is first-line treatment for drug-susceptible tuberculosis.
Cefepime and vancomycin (choice C) would be appropriate empirical antibiotics for bacterial vertebral osteomyelitis, characterized by contrast enhancement of the vertebral bodies along with signal abnormalities within the intervertebral disks. Empirical therapy for Brucella spondylitis (choice D) could be considered if there was exposure to animals or unpasteurized animal products. Metastatic spinal tumors are included in the differential diagnosis of multiple spinal lesions on MRI, particularly in the absence of disk involvement; however, osteoblastic metastases from prostate cancer (choice B) do not enhance on MRI and are characterized by very-low-signal intensities in all sequences.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Kathryn Whitaker, MD, Division of Infectious Diseases, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 (Kathryn.Whitaker@pennmedicine.upenn.edu).
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for providing permission to share his information. We would also like to thank Eileen Shanahan, MD (Pathology Associates of Princeton), for kindly providing the histopathology images and Laurel Glaser, MD, PhD (Department of Pathology and Laboratory Medicine, University of Pennsylvania), for her input in the preparation of the report. Neither of these individuals received any compensation for their contributions.
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