The 55th meeting: "Back to the History"


Ciao, this is Hakodate Ryouhoku Hospital. I'm Dr. Daisy. Today we present an abstract of the CLINICAL PROBLEM-SOLVING article, “Back to the History".
An 82-year-old man presented to the emergency department with a 6-month history of worsening back and left hip pain.
This patient has chronic back pain. Demographic and clinical features, including age, the presence of constitutional symptoms, pain awakening him from sleep, and persistence and worsening of the pain, indicate the need for imaging.
The imaging findings arouse suspicion for vertebral osteomyelitis. Involvement of two contiguous vertebrae is more consistent with osteomyelitis than with cancer. Vertebral osteomyelitis is primarily the result of hematogenous seeding, direct infection after spinal surgery, or extension from an infected adjacent tissue. The most commonly isolated organism is Staphylococcus aureus, followed by gram-negative bacilli and streptococcus.
Other possibilities include infection with endemic fungi, such as Cryptococcus neoformans, Histoplasma capsulatum, Blastomyces dermatitidis, or Coccidioides immitis.
Coccidioidomycosis, which is caused by the fungi C. immitis and C. posadasii, is endemic to the southwestern United States. Infections occur after the inhalation of spores. The majority of infections are acquired in southern Arizona, central California, New Mexico, and Texas.
Up to two thirds of persons with coccidioidomycosis have an asymptomatic or mild illness and do not present for medical care. Of persons who seek care, the majority present with a self-limited subacute pulmonary process or flulike illness, often referred to as valley fever.
This case highlights an uncommon cause of vertebral osteomyelitis that manifested as chronic low back pain in an elderly man. It is important to consider the possible presence of C. immitis in the differential diagnosis of vertebral osteomyelitis, even in areas in which coccidioidomycosis is not endemic, since patients may have previously lived in, or even briefly visited, endemic areas.
Thank you for listening, ciao.

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