A 68-year-old woman was admitted to hospital with general malaise, arthromyalgia and fever lasting for 2 months. Ten days prior to admission, she started experiencing dorsolumbar pain radiating to the right rib region. The only abnormalities observed on physical examination were temperature of 37.5 C and pain on palpation of the spinal thoracic apophyses 11 and 12. The results of her blood analysis were as follows: haemoglobin 13.4 gr/dl, 7100 leucocytes/mm3, erythrocyte sedimentation rate 39 mm/hour and albumin 3.3 gr/dl. Other blood tests results were normal. Mantoux was 25 mm (5 UI). Brucella serology and blood cultures were both negative. An echocardiogram showed hypertensive cardiomyopathy. Radiography of the spinal column revealed destruction and crushing of thoracic vertebrae 10 and 12, with an adjacent paravertebral mass. Spinal CT scan showed destructive and erosive lesions in those vertebrae, involving the intervetebral discs and an adjacent paravertebral mass.
CT-guided fine-needle aspiration of the paravertebral mass was performed. Purulent material was extracted, for which both Gram and Ziehl-Neelsen stains were negative. Subsequently, Streptococcus constellatus was isolated in pure culture, using the API 20S system. MIC for penicillin was 0,06 microgr/ml. The patient was treated with penicillin with initial clinical improvement. After 2 months of treatment, her condition suddenly worsened both clinically and radiologically. On physical examination, two soft lumps were detected in the left paravertebral region near the level of thoracic vertebra 11 and pus was extracted. Gram stain revealed no microorganisms and Ziehl-Neelsen stain showed acid-fast bacilli. Concurrently, the culture from the needle aspiration performed during the first admission was received, with an isolation of Mycobacterium tuberculosis. Treatment was initiated with rifampicin, isoniazid and pyrazinamide, resulting in clinical improvement. One month later, the patient was admitted to the hospital with acute myocardial infarction and died a few hours later.