A hypertense 72-year-old man was evaluated in the Infectious Disease Unit after orthopaedic evaluation for loss of strength in his lower limbs. The CT scan revealed an inflammatory lesion on lumbar vertebrae L2-L3 and a paravertebral abscess (Fig. 1). The patient lives in a rural setting, has contact with goats, and had a 1-year history of pain measuring 4/10 on the numerical scale with an inflammatory pattern. There were no relevant clinical or physical findings.
The patient was admitted, microbiological samples collected, and a CT-guided biopsy of the lesion performed. Empirical therapy with ceftriaxone and vancomycin was started, but on the 11th day the patient presented generalized macular exanthema on the neck, thorax, abdomen and thighs, which disappeared on digital pressure, fever and cytolysis that resolved with the suspension of antibiotic therapy. Biopsy results were insufficient for diagnosis (only musculoskeletal and fat tissue). Levofloxacin was started and suspended due to vasculitis, so meropenem was instituted empirically while microbiological studies were still negative or pending.
Serological testing revealed C. burnetii antibody titres of 1/512 IgG phase I and 1/128 IgG phase II, and were IgM negative. Blood cultures were negative and the patient remained asymptomatic. Echocardiography ruled out endocarditis. Additional studies were negative (Mycobacterium tuberculosis, Brucella and HIV). Serological testing after 8 weeks showed 1/2048 IgG phase I and phase II titres, confirming the Q fever hypothesis. Treatment was adjusted to doxycycline and hydroxychloroquine. MRI imaging revealed advanced L2-L3 spondylodiscitis and empyema with a left psoas major ipsilateral abscess, so CT-guided drainage was performed. Culture of the drainage fluid was negative.
There was minor clinical improvement given the presence of vertebral destruction and empyema, so neurosurgical evaluation recommended surgical fixation of the vertebrae and drainage of the intracanal empyema, which was successful (Fig. 2). Culture of pyogenic material was negative.
The patient is currently undergoing physical rehabilitation in a convalescence unit and has another 12 months of antimicrobial therapy (for a total of at least 18 months). A multimodal strategy is in place to treat non-oncological chronic pain and medical follow-up is being maintained.