Unusual Case of Osteomyelitis and Discitis in a Drug User with a Background of Chronic Back Pain: Do Not Miss the Serious Etiologies

Chronic back pain is a common presenting complaint that is frequently encountered by clinicians. The challenge for clinicians is identifying the relatively few patients with a significant probability of a more serious problem that requires further evaluation. Such individuals require further evaluation for possible occult malignancy, infection, or fracture. We present a case of a 50-year-old male with a past medical history of chronic back pain and IV drug abuse who presented with acute back pain and in whom a diagnosis of vertebral osteomyelitis was missed during multiple visits to the emergency room. 1. Introduction Back pain ranks second only to upper respiratory illness as a symptomatic reason for office visits to physicians. An etiologic diagnosis is not established for most patients with back pain in whom episodes of back pain are self-limited and resolve without specific therapy. Diagnostic tests are only indicated if the test will change the management strategies and improve the outcomes. Otherwise, these tests, if performed in low-pretest probability population, will lead to unnecessary further workup or interventions. Nevertheless, physicians should be able to identify the cases of back pain in which further workup might reveal a serious pathology. 2. Case Presentation A 50-year-old male with a history of intravenous (IV) drug abuse presented to the hospital with acute onset back pain. The patient had a 10-year history of chronic back pain as well as a history of cervical radiculopathy, for which he underwent anterior cervical discectomy and fusion 6 years ago. The patient stated that his back pain had been worsening over the past 3 weeks. The patient presented to the emergency room several times in the last couple of weeks prior to admission. His back pain was presumed to be related to his previous history, and he was discharged home on opioid analgesics. On admission, the patient reported severe squeezing back pain extending from his lower to middle back. The pain was described by the patient as a 10/10 in intensity with radiation to his buttocks. The pain was not relieved by lying down and was aggravated by activity. The patient did not exhibit any lower extremity weakness, numbness, or bladder/bowel dysfunction, and he denied any fevers or night sweats. On physical examination, palpation of the spine revealed diffuse tenderness. Straight leg raising test was negative. In the ED plain X-ray of the lumbosacral spine revealed degenerative changes of the lumbosacral spine but no evidence of infection, malignancy, or fracture (see Figure 1).