A 65-year-old farming lady admitted to the hospital having three-month history of on and off dysuria and renal colic. She was continuously afebrile. While being in hospital, she has developed sudden onset bilateral lower limb weakness and severe backache. There were no history of trauma and fall and no recent weight loss. Her apatite was good. There was no past or contact history of tuberculosis. Physical examination revealed tenderness to palpation over the tenth and eleventh thoracic vertebrae. The neurologic examination reveals spastic paraparesis with hyperreflexia. Her cranial neuron examination was normal and she is well oriented (Glasgow Coma Scale 15/15).
Her total white cell count was 16,900/cmm (normal: 4.400-11,300/cmm) with 90.45% granulocytes, 5.6% lymphocytes, and 1.0% monocytes. Erythrocyte sedimentation rate (ESR) was 120 mm/hr. (normal: 0-10 mm/hr.). C-reactive protein (CRP) was 42 mg/dL (normal: <0.6 mg/dL). Magnetic resonance imaging (MRI) and CT of the thoracic spine revealed severe thoracic (T10-T11) discitis with minimal soft-tissue component and vertebral body destruction (Figures 1 and 2). Features are suggestive of Asian variety of tuberculous spondylodiscitis rather than pyogenic spondylodiscitis. No contiguous spread and no epidural and psoas muscle abscesses were found. So, we were in doubt to use the trial of antituberculous therapy or empiric antibiotic to cover common microbes causing pyogenic spondylodiscitis. Blood culture revealed Enterobacter agglomerans with 41-hour incubation in 99.9% probability from Ramel identification system. Isolate was susceptible to ciprofloxacin, carbapenems, and aminoglycosides and resistant to ceftazidime and aztreonam. We have started intravenous ciprofloxacin 400 mg 12 hourly with weekly monitoring of ESR and the clinical response (Table 1).
Computed topography- (CT-) guided biopsy culture was negative for bacteria, fungi, and tuberculosis. Histology shows possible bacterial infection. Chest X-ray radiography is normal and Mantoux test was negative.
Imaging study of genitourinary system shows calculus over right renal pelvis. Urine culture was negative for bacteria. Patient was successfully treated with intravenous ciprofloxacin, 400 mg 12 hourly for 3 weeks followed with 3 weeks of oral ciprofloxacin. Follow-up examination on 6th week on completion of treatment showed mild residual bilateral lower limb weakness and ability to walk with aid. Follow-up CT in 6 weeks shows T10-T11 vertebral body and disc regeneration (Figure 3).