2. CASE PRESENTATION
A 72-year-old man was diagnosed with pyogenic spondylitis, low back pain, and fever. After unsuccessful control of the inflammation with the use of antibacterial medication for more than 12 months, the patient was referred to our department. At the first visit to our department, the patient had no fever, low back pain, or abnormal neurological deficits.
Plain radiographs showed spinal ankylosis from T4 to T11 and from T12 to L1. Sagittal MRI demonstrated that the T11–12 vertebral bodies showed heterogeneously high signal intensity on both T1-weighted images (WI) and T2WI. The intervertebral disc at T11–12 was clearly enhanced on gadolinium (Gd)-enhanced T1WI (Figure 1). Sagittal reconstructed computed tomograms (CT) showed diffuse idiopathic skeletal hyperostosis between T9 and L3 without obvious vertebral destruction (Figure 2). T11 and T12 vertebral bodies indicated osteosclerosis. A chronic pyothorax was also found on a chest CT scan but was not indicated for therapeutic intervention by a respiratory physician. CT-guided biopsy of the T11–12 intervertebral disc revealed a negative culture study with a histopathological diagnosis of chronic inflammation. The antibiotic medication was discontinued because the patient was asymptomatic, and the patient’s serum C-reactive protein (CRP) value ranged between 1 and 2 mg/dL.
One year later, the patient was admitted to the Department of Respiratory Medicine with rapidly deteriorating pyothorax and pneumonia. Thoracic drainage was performed, and Pseudomonas aeruginosa was detected. CT showed marked destruction of the T11–12 vertebral bodies, which indicated “rim enhancement” on Gd-enhanced T1WI MRI (Figure 3). We diagnosed the patient with progressive pyogenic spondylitis and planned surgical treatment after improvement of pyothorax and pneumonia.