We present the case of a 76-year-old male with a history of benign prostatic hyperplasia and bladder cancer diagnosed in 2018. Following a transurethral resection of bladder tumor (TURBT) procedure, he received intravesical BCG. In May 2019, he presented with severe back pain and radiculopathy. A lumbar MRI study showed multilevel degeneration, severe canal stenosis, and morphological changes suggestive of infection for which he received L1-L5 laminectomies and foraminotomies. Three weeks later, he presented with recurrent back and hip pain. A repeat MRI study revealed progressive degeneration and a paraspinal mass. A biopsy showed granulomatous inflammation which stained negative for AFP, malignancy, and neoplasm. In addition, normal blood cell counts were not suggestive of infection. Two weeks later, he returned with night sweats, fever, and severe pain in his back and right lower extremity; imaging revealed nonenhancing psoas abscesses. Pathology from the spinal biopsy demonstrated chronic, necrotizing osteomyelitis/discitis. Biopsy of the psoas abscess showed fragments of the skeletal muscle with severe inflammation and necrotizing granuloma. Labs obtained at that time showed WBC: 8.6 K/uL (3.5-11.0 K/uL), hemoglobin: 11.1 g/dL (13.0-17.0 g/dL), platelet count: 231 K/uL (130-450 K/uL), BUN: 24 mg/dL (6-23 mg/dL), creatinine: 1.19 mg/dL (0.70-1.30 mg/dL), bicarbonate: 24 mmol/L (22-29 mmol/L), ESR: 72 mm/hr (<30 mm/hr), and CRP: 3.30 mg/L (1-3 mg/L).
Cultures and urinalysis for multiple infectious agents were negative, but given his recent intravesical BCG treatment in August 2019, Mycobacterium infection was highly suspected, and the patient was started on empiric treatment with rifampin, isoniazid, and ethambutol.
His back pain, fever, and night sweats improved initially, but after 3-4 weeks, the fever and back pain returned. Repeat labs showed WBC: 7.3 K/uL (3.5-11.0 K/uL), ALT: 81 U/L (8-66 U/L), AST: 75 U/L (13-44 U/L), ALP: 317 U/L (40-129 U/L), bilirubin: 0.4 mg/dL (0.2-1.3 mg/dL), ESR: 79 mm/hr (<30 mm/hr), and CRP: 2 mg/L (1-3 mg/L).
He was started on vancomycin and cefepime in addition to the anti-mycobacterials for wider bacterial targeting. At this time, culture from the prior spinal biopsy returned positive for the Mycobacterium tuberculosis complex, and PCR was positive for M. bovis with pansensitivity. Broad-spectrum antibiotics were discontinued, and a steroid taper was started. In the following days, the patient's fever and back pain slowly improved.
In December 2019, he underwent spinal stabilization surgery and completed ethambutol therapy. His symptoms have since resolved, and he continues to follow-up with Infectious Disease to complete his isoniazid and rifampin therapy.