Thoracic paravertebral abscess and osteomyelitis

Case contributed by Dr Bruno Di Muzio

Presentation

Back pain.

Patient Data

Age: 70 years
Gender: Male
X-ray

Chest radiograph

Mediastinal opacity at the level of the right hilum. 

CT

CT Chest and Thoracic Spine

Within the superior segment of the right lower lobe, together with the pleural surface, and at the level of T4-T7, there is a well-defined mass characterised by a thick enhancing capsule and homogeneous hypoattenuating content, with an estimated volume of -60 ml. It causes mild surrounding ground glass opacities and adjacent pleural thickening. The surrounding inflammatory process appears to spare the fat in between the parietal pleura and the thoracic spine. No evidence of vertebral periosteal reaction, thoracic disc spaces are preserved. A few small peripheral and subpleural nodules measuring up to 4 mm are identified scattered and are of low suspicion. The lungs and pleural spaces are otherwise clear. The airways are normal. There is no mediastinal abnormality. No lymph node enlargement. No suspicious bony abnormality identified.

MRI

MRI Thoracic spine

There is abnormal marrow signal within the T5 and T6 vertebral bodies, with adjacent discontinuity of endplates adjacent to the T5/6 intervertebral disc as well as abnormal enhancement. Abnormal enhancement also involves the anterior T5-6 disc and this is contiguous with a peripherally enhancing linear low signal tract which extends outward beyond adjacent T5-6 anterior osteophytes into the prevertebral tissues and then tracks into the right pleural cavity as a larger, centrally non-enhancing collection. This right paravertebral/pleural collection is similar in size to the prior CT. The adjacent lung parenchyma is collapsed and hyperenhancing, favoured to reflect a reactive change. Small focus of altered marrow signal and enhancement within the adjacent right inferolateral aspect of T4, possibly a further focus of infection secondary to subligamentous spread. No other abnormal focus of enhancement. The imaged thoracic cord maintains normal signal and contour. Partially imaged renal cysts. 

Case Discussion

MRI and CT findings are consistent with T5-6 osteomyelitis-discitis with contiguous right prevertebral/right pleural collection. MRI hasn't shown epidural collections. 

Drainage confirmed a purulent content within the collection: S . aureus

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Case information

rID: 44923
Case created: 9th May 2016
Last edited: 21st Jun 2017
System: Spine
Tag: rmh
Inclusion in quiz mode: Included

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