A 52-year-old male presented to the emergency department with complaints of back pain that started after approximately one hour of heavy lifting. He stated that the pain was located in his lower back, characterized it as dull, and specified that it did not radiate. The back pain was said to have had an insidious onset and progressively worsened. The patient denied noticing any aggravating or relieving factors, as well as having similar pain in the past. He had not experienced any trauma to the affected area prior to the onset of symptoms, nor did he have a history of associated fever, numbness, tingling, weakness of his extremities, constipation, or urine retention. Additionally, he complained of chest pain that started roughly the same time as the back pain. Although, he endorsed previously experiencing the same type of chest pain recurrently for several months. The chest pain was described as sharp, pleuritic in nature, moderate severity, and had no known relieving factors. He denied chest pain with exertion, cough, sputum production, and shortness of breath.
The patient's past medical history was notable for hypertension, schizophrenia, hepatitis C, questionable COPD/asthma, and alcohol abuse. He had a 30 pack-year smoking history and was still smoking at the time of presentation. His medications included amlodipine, hydrochlorothiazide, lisinopril, and naproxen for pain, and he had no known drug allergies. He was unemployed at the time of presentation but had worked as a mechanic previously. His diet consisted mainly of well-cooked meats, potatoes, and beans. Notably, the patient had no history of eating raw fish or fishing.
Physical examination at time of arrival was significant for low grade fever and tachycardia. No obvious neurological deficits were appreciated. Laboratory tests collected included a complete blood count, a comprehensive metabolic panel, and blood cultures. A computerized tomography (CT) scan of the lumbar spine was obtained and revealed an L3-L5 epidural abscess with L5-S1 discitis. A CT scan of the thorax showed a right upper lobe pulmonary nodule measuring 4.2 x 3.2 cm. This nodule was seen a year earlier and measured about 1.7 x 0.9 cm, but the patient had elected against further surveillance/workup at that time. Other, less characterized, findings on the CT scan included a small liver nodule and a small mass in the pancreatic head (imaging not published per patient's family request). General serum tests including blood cultures, inflammatory markers, complete blood count, and metabolic profile were collected. They were significant for elevated values of ESR (78 mm/h), CRP (33 mg/dl), and white blood count (17.1 x 10[9]/L).
Overnight, the two sets of blood cultures grew with 4 of 4 bottles showing Enterococcus species. Subsequently, the patient was started on intravenous (IV) vancomycin, and L3-L5 hemi-laminectomies were performed for evacuation of the abscess and culture of aspirate. An acid-fast bacillus concentration and smear with mycobacterium tuberculosis by polymerase chain reaction (PCR) came back negative. The remaining laboratory results were unremarkable. Over the next 2 days, blood cultures further speciated to L. Garvieae (identified by MALDI-TOF). In addition, the epidural abscess culture also grew L. garvieae, likely from hematologic seeding. Susceptibility testing showed it was susceptible to penicillin (MIC 0.8 mug/ml), ceftriaxone (MIC 0.6 mug/ml), vancomycin (MIC 0.8 mug/ml) and levofloxacin (MIC 2.2 mug/ml). The patient's antibiotic regimen was then switched to IV ceftriaxone and azithromycin and repeat blood cultures returned no growth. A transthoracic echocardiogram was obtained and was negative for any vegetation. In view of the spinal involvement, the patient was prescribed a total of 6 weeks of antibiotics to be completed outpatient as recommended by the infectious disease team.
CT guided biopsy of the lung nodule was also performed, and pathology results showed invasive adenocarcinoma of the lung. Upon discharge, the patient was scheduled for a PET scan with further treatment recommendations to be provided based on imaging results. In view of the L. garvieae bacteremia, an outpatient colonoscopy was scheduled to rule out colon cancer, as the patient had never been scoped, and the organism had been reported in numerous patients with occult colon cancer. However, shortly after being discharged to complete antibiotics outpatient, the patient unfortunately and unexpectedly passed away from unrelated causes before further workup could be obtained.