A 57-year-old obese (body mass index = 39) afebrile male patient, with breathing, constrained disturbances, resident of the province with domestic animals was transferred to our clinic from another hospital, where he was treated with bed rest for 2 weeks for spine fracture (Fig. 1) due to misdiagnosis. On admission, he claimed dyspnea, severe back pain of 2-month duration, left knee pain and swelling. He mentioned recent (2 months before) asymptomatic consumption of domestic poultry. Physical examination revealed no pathologic neurological findings. His left osteoarthritic knee was swollen, while chest roentgenogram showed pleural effusion on the left side (Fig. 2). Lateral plain roentgenogram (Fig. 3) and computed tomography (CT)-scan (Fig. 4) of the spine revealed destruction of the T12-vertebral body and intervertebral discs T11-T12 and T12-L1 associated with paravertebral abscess formation (Fig. 5). White blood cells (WBC's) were 17.5 k/Mul (normal limits: 4-10.0 k/Mul), C-reactive protein (CRP) was 23.1 mg/dL (<0.3 mg/dL), and ESR was 86 mm/1st h (0-20 mm/1st h). Tuberculosis antibody test, virological, rheumatologic laboratory tests, Widal-Wright, urine and stool cultures were within normal limits. Blood cultures revealed SE. A thoracic drainage tube was inserted for 10 days, and a total 3000 cc of seropurulent fluid was evacuated with gradual improvement of respiratory function. Knee puncture evacuated 120 cc of purulent fluid. Under local anesthesia percutaneous transpedicular biopsy and specimen culture were taken from T12 vertebra. All cultures (pleural fluid, spine, knee joint fluid and specimens) isolated SE. Unfortunately, phage typing is not available in our laboratory. T12 biopsy disclosed chronic osteomyelitis. On the basis of antibiograms, quinolone and 3rd generation cephalosporin were intravenously (IV) given.
Through the left thoracotomy with resection of the 11th rib, left lung was found stuck to the parietal pleura with residual empyema and meticulously mobilized. 7 ml of purulent material was evacuated from the paravertebral space. A T12-vertebrectomy was performed with disc resection and bone debridement to healthy tissue. An expandable titanium mesh cage (TMC) filled with resected rib bone graft was inserted, and the spine was stabilized through a minimally invasive posterior instrumentation (Fig. 6). Our patient was neurologically intact, although the severe back pain, the obesity, the breathing constrained disturbances and the pleural effusion with the chest tube made our patient's breathing unable to cope with his needs. Paravertebral abscess formation, instability, and breathing difficulty were the main reasons for the surgery decision. After consensus with our patient, his knee was fused 1 month following admission with an Illizarov device. The post-operative course was complicated with superficial wound infection at the thoracotomy skin incision, knee arthrodesis incision and the insertion of the left L2 screw close to the thoracotomy wound with Acinetobacter. All sites required local debridement and secondary closure. The left knee fused completely 3 months following surgery. On the basis of antibiotic susceptibility pattern, quinolone and ceftriaxone were IV given. The patient received 3 months IV antibiotic treatment and was discharged with instructions for a monthly check of inflammatory markers. Antibiograms is the safe way for the antibiotics selection, although ciprofloxacin, 3rd generation cephalosporin, ampicillin, and chloramphenicol are the most common antibiotics in such infections. The IV administration was combined with our patient hospitalization due to his impaired general condition and the post-operative complications. The duration of the antibiotic treatment was determined on the basis of the evidence-based guidelines, to minimize relapse possibility. At the 6-month follow-up, CRP and ESR remained within normal limits. Radiograms and CT scan showed a good result of fusion in both sites (Fig. 7 and 8). The patient was free of pain, and he had started to return to his daily routine. There was not any sign of recurrence. Although 2 months later, our patient became anxious and his family found him with an altered state of consciousness and cognition. On admission to the hospital, our patient lost his consciousness and had to be intubated and transferred to intensive care unit. Brain CT scan revealed edema and hydrocephalus that required drainage tube installation (Fig. 9). The lumbar puncture of cerebrospinal fluid was indicative of viral infection. EEG showed slow waves and based on the previous medical history all possible cultures were taken. Blood cultures revealed again SE. Our patient did not recover from this meningoencephalitis, and his relatives decided to disconnect him from the ventilator on the day 11th being clinically dead. We believe that SE infection recurrence caused immunosuppression to this impaired patient making him unable to manage this central nervous system viral infection.