A 73-year-old patient with a history of hypertension and polyarthrosis was admitted to the emergency department due to abdominal discomfort and pain associated with constipation and fever.
The symptoms had started three weeks before and worsened during the four days prior to admission.
During this period, a high digestive endoscopy (fibroendostomates, duodenum and stomach) as well as a cyst (with this splenic angle) were performed, with no abnormalities found.
The physical examination revealed fever (37.6o C), abdominal distended, diffusely painful, and auscultation revealed lower chest pain, tympanic to percussion, with low lung butterfly but without data of percussion.
Analyses showed 8.2 x 109 leukocytes / L, hemoglobin 136 g / L, platelets 186 x 109 / L. Except blood glucose (123 mg / dl), serum creatinine phosphomillase 125 antigens calcium phosphate transhydrogenase, urine
ESR and C-reactive protein were elevated, with values of 85 mm / 1st h and 133 mg / L (normal < 5 mg / L), respectively.
The Mantoux intradermal reaction (10 IU RT-23) was positive, with an induration of 25 mm. Chest radiography showed an image compatible with atelectasis of the right lower lobe in the context of an ipsilateral pleural effusion.
There were no signs suggestive of lymphadenopathy or alterations in the cardioperipheral silhouette.
Dorsal-abdominal effusion confirmed the existence of a right pleural effusion and identified prominent degenerative changes along the lumbar spine, but, above all, erosions in the vertebral dysplasia D10 adjacent to the space.
A lumbar MRI showed hyposignal on T1-weighted sequences and hypersignal on T2-weighted sequences on these vertebrae and their corresponding disc, with typical morphological alterations of infectious spondylodiscitisD11.
Three serial blood cultures were negative.
In the samples obtained by aspiration puncture of the D10-D11 space, chains of Gram-positive cocci were observed and subsequently recovered and typified as Streptococcus pneumoniae sensitive to penicillin.
Pleural fluid analysis showed pH: 7.55; leukocytes: 8.4 x 109 / L (58% neutrophils, 26% eosinophils, 16% lymphocytes), proteins: 48 g / L (serum protein/ dl: 125 mg pleural:
Both auramine-rodamine staining and culture in Löstein-Jensen medium of pleural fluid were negative and cytology did not reveal cells.
1.
The patient was initially treated intravenously with the combination of amoxicillin + clavulanic acid (1 g / 200 mg every 8 hours).
After 21 days, the patient was orally administered (875 / 125 mg every 8 hours) for 6 weeks.
The evolution was favorable and he was able to start walking with dorsolumbar corset from the fourth week.
One month after the end of antibiotic therapy, a control chest CT scan still showed a mild pleural effusion, but the patient only complained of mild mechanical back pain of low intensity, the ESR had decreased to 21 mm ambulatory CRP 11
