The patient was a 78-year-old female. Her medical background included dyslipidemia, osteoarthritis, calcium pyrophosphate deposition disease, and osteoporosis complicated by D12 compression fracture following a fall that was treated with cement vertebroplasty two years before the current presentation.
The patient presented to the emergency room with epigastric pain, anorexia, and weight loss during a period of two months, without fever. Prior endoscopic examination performed in an outpatient facility was unremarkable.
Her physical examination was notable for mild right upper quadrant tenderness without any other significant findings. Her white blood cell count was 13.5×103/mL with an elevated C-reactive protein (CRP) of 72.4 mg/L; liver enzymes were within normal limits. Abdominal sonography showed mild hepatomegaly without any other pathologic findings.
Contrast-enhanced abdominal computed tomography (CT) revealed paravertebral collections at the D12 level—the site of her prior cement vertebroplasty (Figure 1). The D12 vertebral body was in mild collapse with cement filling. The rest of her thoracolumbar spine that was included in the abdominal CT scan (levels D9–coccyx) showed mild osteopenia and degenerative changes. Magnetic resonance imaging (MRI) examination revealed T2 and short tau inversion recovery (STIR) hyperintensity in the D11 and D12 vertebral bodies and intervertebral disc, accompanied by enhancing paravertebral collections, findings suggestive of discitis osteomyelitis (Figure 2).
Contrast-enhanced Abdominal Images Computed Tomography Images.
Sagittal Magnetic Resonance Imaging of the Lumbar Spine.
Blood cultures were negative. Percutaneous CT-guided fine-needle aspiration was performed with pus aspiration, without bacterial growth from the specimen. Polymerase chain reaction (PCR) of the pus sample was positive by 16S rRNA that was sequenced to C. burnetii as well as with specific primers of the bacterium. Serology testing performed with indirect immunofluorescent assay (IFA) revealed high antibody titers to C. burnetii with phase I IgG of 3200 and phase II IgG of 1600, which is indicative of chronic Q fever. Echocardiography showed no vegetations.
The patient was started on doxycycline and hydroxychloroquine treatment, which was planned for at least 18 months. The collection was percutaneously drained continuously for 8 months and withdrawn after secretions stopped. On the follow-up MRI, the collection resolved. Clinically, at one-month follow-up, the patient was doing well.