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case_images: CT Chest: (A) new multilevel sclerotic vertebral lesions noted at T5-T8 with endplate irregularity (white arrow) (B) and associated paravertebral soft tissue phlegmon (yellow arrow). (C) Sclerosis (white arrow) and (D) soft tissue thickening (yellow arrow) also seen at the manubriosternal junction. (E) No pulmonary nodules, consolidation, or adenopathy demonstrated.
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case_images: However, incidental findings of erosive changes and multilevel sclerotic vertebral and sternomanubrial lesions were noted to be suspicious for spondylodiscitis and osteomyelitis (Fig. 1) respectively which prompted further workup.
case_images: MRI thoracic spine sagittal: (A) T1 fluid attenuated inversion recovery (FLAIR), (B) postcontrast T1 with fat suppression, (C) STIR, and (D) T2. (A&B) Presence of extensive enhancing bone marrow changes at T5-T9 (white arrows) with (B&C) associated paravertebral phlegmon enhancement (yellow arrows). (D) Anterior wedge deformities of T6-T8 (white arrow). Additional skip lesions were noted in the cervical and lumbar spine (cervical involvement shown in Fig. 3).
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case_images: Contrast enhanced thoracic spine imaging demonstrated multilevel enhancing vertebral bone marrow edema with paravertebral soft tissue phlegm most prominent at levels T5-T9 consistent with osteomyelitis (Fig. 2).
case_images: MRI cervical spine sagittal: (A) T1, (B) T1 fat-saturated (FS) post contrast, (C) T2, (D) STIR. (A-D) Additional skipped enhancing and destructive vertebral abnormalities were noted within the cervical spine primarily involving the endplates of C3-C4 (white arrow) and C6-C7 (orange arrow) (B&D) with relative sparing of T2 hypointense discs at the affected levels (green arrows). (D) Associated paravertebral edema which extends inferiorly along the anterior longitudinal ligament to the upper thoracic spine (yellow arrows).
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case_images: Similar noncontiguous abnormalities were also demonstrated throughout the spine in subsequent cervical and lumbar MRI studies predominantly involving the vertebral endplates with relative sparing of the discs suggestive of an atypical infection including tuberculosis (Fig. 3).
case_images: CT Chest 2022 in Column I and CT Chest 2024 in Column II showing progression of spread (A) CT Chest 2022 with bone window showing multilevel vertebral endplate sclerosis at T6-T7 (white arrows) (B) Shows interval increased vertebral sclerosis involving T5-T9 (white arrow). (C) Soft tissue window demonstrating thin paravertebral phlegmon (yellow arrow). (D) Interval increased paravertebral phlegmon (yellow arrow). (E) CT Chest 2022 has a lack of sternomanubrial findings (orange arrow) including sclerosis and soft tissue inflammation. (F) Shows interval development of sternomanubrial sclerosis (orange arrow) and soft tissue phlegmon (better visualized in Fig. 1).
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case_images: Furthermore, retrospective imaging comparisons of previous low dose CT chest from 2022 (Fig. 5), 2 years prior, did not demonstrate sternomanubrial findings but did show irregular endplate sclerosis at T6-T7 with smaller paravertebral phlegmon suggesting general progression of multilevel spine and eventual sternomanubrial involvement (Fig. 4).
case_images: (A) MRI Abdomen 2023 T1 FS contrast enhanced sequence. L2-L5 vertebral bodies (white arrows) are visualized without end plate or soft tissue enhancement. No sagittal images available. (B) Compared to MRI L spine 2024 T1 fat saturated contrast enhanced sequence which shows marrow edema and vertebral endplate enhancement is seen at L1, L3, and L4-L5 (white arrows).
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case_images: MRI abdomen in 2023 showed lack of lumbar spine involvement (Fig. 6).
case_images: Biopsy images. (A) MRI bone biopsy showing location of sample retrieval at the T8 vertebral body. (B) Inferior manubrium CT bone biopsy of sclerosis.
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case_images: Infectious workup included bone biopsies of the sternum and T8 vertebral body (Fig. 7).
case_images: Most recent CT chest (left) compared to prior CT Chest 2 months prior (right). (A) Retrosternal soft tissue stranding (yellow arrow) showed improvement in the most recent follow-up study. T5-T9 endplate sclerosis was unchanged (not shown). (B) Prior CT Chest with retrosternal soft tissue inflammation (yellow arrow).
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case_images: Follow up imaging of the thoracic spine with CT showed unchanged sclerotic changes which is expected in a short time period although there was improvement in retrosternal inflammation (Fig. 8).