Patient is a 66-year-old female with a medical history of peripheral arterial disease status after prior left common iliac stenting and neurogenic claudication secondary to L3-L4 spinal stenosis who presented to the hospital for generalized weakness, fatigue, and headache for 3 weeks. She also complained of intermittent back pain, fever, chills, and night sweats. She described new onset migraine like headache with photophobia in the last month. She denied coughing, shortness of breath, history of headaches, or any other new symptoms. She recently had minimally invasive L3-L5 lumbar fusion surgery with allograft bone graft placement 4 months ago. Her family history was unremarkable. Her social history was positive for 20 pack years of prior tobacco abuse. She quit smoking 2 years ago. She denied any alcohol or recreational drug use. On admission, her vitals including temperature were unremarkable. Her physical showed that patient was oriented to person and place, but not time. She was aware of her reasoning for admission but could not answer all questions appropriately. Healed incisions without any erythema, pus, or drainage were noted in the lower back at the L3-L5 level. Cranial nerves II-XII were grossly intact. Bilateral lower extremity strength was 4/5, unchanged from before, and no other focal deficits were noted. Laboratory evaluation was significant for sodium level of 117 mmol/L from 129 mmol/L two months prior, chloride of 77 mmol/L, and elevated platelet count of 425,000/muL. ESR and CRP were elevated at >130 mm/h and 61.8 mg/L, respectively. TSH was normal at 2.4 mIU/mL. The random cortisol level was elevated at 29.5 mug/dL. Serum osmolality was 256 mOsm/Kg. Urine osmolality was 487 mOsm/kg. Urine sodium and potassium were 32 mmol/L and 47 mmol/L, respectively. Urine toxicology and HIV test were negative. At this time, the treatment team and neurosurgeon who performed the lumbar surgery were informed by the Center for Disease Control (CDC) that the bone graft used in her surgery was contaminated with Mycobacterium tuberculosis. A chest X-ray (Figure 1) was done and showed diffuse miliary nodular pattern of both the lungs, which was confirmed by the presence of innumerable micronodules on CT chest (Figure 2).
MRI of the brain with contrast did not show any evidence of hydrocephalus, space-occupying lesions, or basilar meningitis. A lumbar puncture was done, and the results are given in Table 1.
MRI of the lumbar spine showed L4-L5 osteomyelitis and postsurgical changes (Figure 3).
MRI of the cervical and thoracic spine was negative for any structural lesions. Due to the lack of cord compression symptoms and no evidence of compression of the thecal sac of the lumbar cistern, leading to severe stenosis, the risk of reoperating was deemed to be higher than any benefit. The decision was made between the infectious disease team and neurosurgery team to treat the patient medically and not have any further neurosurgical intervention. The patient was treated for disseminated TB from the graft infection with rifampin, isoniazid, pyrazinamide, and ethambutol. Ethambutol was switched to levofloxacin. Patient's mentation and headache improved gradually. Patient was discharged with plan for 12 weeks of total antituberculosis TB therapy. At 3-month follow-up, patient was noted to be doing well, and her symptoms, including back pain, headache, photophobia, encephalopathy, and weakness, had completely resolved. A repeat MRI of the lumbar spine with and without contrast did not show any further osteomyelitis.