A 62-year-old man presented with progressive lower back pain for six months’ duration. He noticed significant weight loss, occasional sweats, and subjective fevers. No significant neurological symptoms or any other significant complaints. Patient lives mainly in Texas, but goes to Mexico during winter time for a couple of months. He denied tobacco abuse, intravenous drug use, incarceration or animal exposure. He denied important raw dairy products consumption, except for eating possible unpasteurized cheese a year ago; once in Cuba and once in Mexico, both small amount. Physical examination was unremarkable except for mild lumbar vertebral tenderness. Labs showed ESR of 64 mm/h and CRP of 4.4 mg /dl with normal WBC. MRI of the lumbar spine showed infective lumbar spondylitis at L1-L2 and L4-L5 with extensive bilateral psoas abscesses. Blood and abscess aspirate cultures were obtained, and the patient was started on anti-tuberculosis medications given the classic MRI features, which were suspicious for tuberculosis. Nevertheless, abscess aspirate grew later Brucella melitensis. Anti-tuberculosis medications were stopped, and the patient was started on Gentamycin and Doxycycline. The patient did not have any significant improvement despite two weeks of therapy. Abscesses were drained, and Gentamycin was changed to Rifampin. The patient had significant improvement after that, and both Doxycycline and Rifampin were continued for four months after abscesses drainage.
Discussion:
Back pain is a common complaint encountered by internists. The differential diagnosis is broad. Brucellosis is one of the most common zoonotic diseases worldwide. However, In the United States, human brucellosis is rare. Brucellae are transmitted to humans by direct contact with infected animals or consumption of unpasteurized dairy products. Brucellosis may present as a subclinical illness, an acute disease with general manifestations or as a localized disease. Osteoarticular involvement is one of the most common complications; this may present as arthritis, sacroiliitis or spondylitis. This case describes a patient with progressive back pain who was found to have lumbar spondylitis and bilateral psoas abscesses with features typical for tuberculous spondylitis. However, the culture grew Brucella melitensis. Back pain is a common reason for ED visits, a high index of suspicion is needed to identify any unusual symptoms or signs that warrant further investigations.
Conclusions:
Back pain is a common reason for ED visits. Providers should investigate any back pain associated with other significant, “red flags,” symptoms or signs