MOC November 2014: A Harrowing Tale of Hernias, Methadone, and Abdominal Pain

Patient is a 58 year old who presents complaining of abdominal pain. He reports the pain has been present for a month, initially intermittent and now more persistent. It started as back discomfort and has evolved into bilateral flank pain radiating to his umbilicus. His symptoms seem worse he takes a deep breath. He has had a previous umbilical hernia repair but no other abdominal surgeries. He was seen at an outside facility for this same pain twice in the past 7 days. He reports that they did not do labs or imaging but diagnosed him with constipation and sent him on prophylaxis. He's had 2 large bowel movements since that visit but has not had any change in his symptoms.

He denies any fevers or chills, vomiting or diarrhea and has not had any urinary symptoms including frequency or dysuria. He does not have any history of gastric ulcer or pancreatitis nor does he have symptoms of early satiety.

His past history is significant for a previous umbilical hernia repair. He also has a distant history of IV heroin abuse and currently takes methadone daily. He reports no IV heroin use for the past year.

Medications: Methadone 110 mg daily, Seroquel 250 mg QHS

Allergies: NKDA

Physical Exam:

Vital signs: BP 135/80  HR 90  RR 18  temp 98 F

General: Male, generally looks mildly uncomfortable. Appears stated age and in appropriate dress and hygiene

Cardiovascular exam: unremarkable with no murmur

Pulmonary exam: unremarkable with clear lung sounds and normal respiratory rate

Abdominal exam: large midline incision that is old and well-healed, he has a small easily reducible recurrent hernia. He has no focal tenderness though there is some minimal distention of his abdomen with normal bowel sounds.

Skin exam: Unremarkable without evidence of infection or injection sites

Neuro: Symmetric motor strength and sensation diffusely, alert and oriented

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Differential diagnoses: Colitis, UTI, urinary retention, pancreatitis, hepatitis, gastritis, intra-abdominal mass, symptomatic umbilical hernia.

Work up:
WBC 3.8. Electrolytes, liver, lipase, and urine are all normal.

Care everywhere accessed and there was a plain film at the outside facility showing moderate amount of stool is abdominal x-ray, unremarkable labs and no definitive diagnosis. 

Question: With negative exam and unremarkable labs, is more imaging indicated?

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Imaging:

Abdominal CT results:
Prominent disc space narrowing at T9-10 with irregularity and some sclerosis and prominent spurring of the adjacent endplates.  This is associated with some fullness of the adjoining paraspinal soft tissues.  Findings are nonspecific.  A underlying discitis or disc space infection are not excluded on the basis of this exam.  Further clinical correlation is recommended with consideration for a MRI of the thoracic spine if warranted clinically.

MRI thoracic spine:
Acute discitis/osteomyelitis at the T9-10 interspace with epidural spread of infection and phlegmon formation extending from the level of T8-9 through T10-11.  This epidural component results in severe spinal canal narrowing at the level of T9-10.  Abnormal enhancement extends into the bilateral neural foramina with loss of the normal perineural fat.  There is paravertebral soft tissue extension of infection from the level of T8-T11 with a likely small abscess within the left paravertebral soft tissues at the level of the T9 body.

The patient later disclosed, to the hospitalists, that he had been injecting his methadone into his veins for the past 2 months...

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Questions

1. What percent of patients with osteomyelitis of the spine have an elevated ESR

    a. 40%

    b. 50%

    c. 70%

    d. 80%

2. True or false: Though the most common bacteria associated with osteomyelitis of the spine is Staph aureus, Pseudomonas aeruginosa is often found in patients whose infection is likely caused by IV injections.

3. What is the recommended timing for initiation of antibiotics?

    a. Immediately upon suspicion of diagnosis

    b. Once biopsy cultures have resulted so therapy can be directed specific to the infectious agent

    c. Not until after biopsy so as not to alter biopsy results

    d. Once confirmation is made via advanced imaging

4. All of these are considered causes of vertebral osteomyelitis. Which is by far the most common?

    a. Hematogenous spread from a distant site or focus of infection

    b. Direct inoculation from trauma or spinal surgery

    c. Contiguous spread from adjacent soft tissue infection