脓胸并发椎体骨髓炎影像学表现一例

Vertebral Osteomyelitis Associated with VRE Empyema Following Stabilization of Unexplained Compression Fracture Kaley Tash, HMS3 Gillian Lieberman, MD Clinical Presentation • 45yoF c h/o alcoholism, cirrhosis, hepatic encephalopathy, pancreatitis, diabetes mellitus, gastroesophageal reflux, recently admitted to outside hospital for EtOH detoxification. • Returned from rehab with new acute back pain, bilateral leg spasms. No reported history of recent trauma. • Transferred to BIDMC following chest CT. Coronal +C (+Contrast) CT from OSH. BIDMC PACS Flattened T4 Vertebral Body on CT Hospital Day 0 T4 vertebral body Axial C+ CT from OSH. DDx of mass includes abscess, hematoma, neoplasm. Bone fragments and mass impinge on spinal canal. BIDMC PACS T4 Soft Tissue Mass + Cord Compression on CT Soft tissue mass Bone fragments Hospital Day 0 Evidence of cirrhosis, prior trauma on CT BIDMC PACS Ascites Chronic L non-united posterior 10th rib fracture Hospital Day 0 Axial C+ CT from OSH. Pursued further imaging at BIDMC to guide likely surgical management. MR uninterpretable due to motion, so CT repeated. •Destruction of T4 vert. body •Cord compression from soft tissue mass + bone fragments •Kyphosis •Normal mineralization, vertebral height, disc spaces •. BIDMC PACS Kyphotic Deformity and Cord Compression on CT Hospital Day 1 Bone Fragments Sagittal C- CT. What destroyedT4? • DDx: osteomyelitis, neoplasm, occult trauma (e.g., seizure*) • Blood cultures positive for Corynebacterium in 1 of 4 bottles, suggestive of possible osteomyelitis. • Lack of diffuse spine disease and no recent trauma history raised strong suspicion for osteomyelitis, including Pott’s disease. •*Aboukasm AG and Smith BJ. 1997 Upright chest PA and Lateral. Note that spine deformity is not clearly seen. Note that CXR is not sensitive for vertebral compression fracture or osteomyelitis. BIDMC PACS Little Pathology on Pre-op Chest X-Ray Hospital Day 15 Anesthesia unable to ventilate pt in prone position with safe pressures, likely due to ascites pushing against diaphragms. Surgery rescheduled using anterior approach. Intra-op PA CXR, supine portable. BIDMC PACS R Pneumothorax and Lung Collapse on Intra-Op CXR Hospital Day 19 Post-Op Day 0 R pneumothorax Pathology Result from T4 Fragments • Giant cell reaction consistent with infection or fracture. Infection likely given no known history of recent trauma. • No evidence of neoplastic process. • Negative gram stain, acid fast stain, KOH stain. • Despite withdrawal of antibiotics to increase culture yield, bacterial + mycobacterial + fungal cultures were negative. ƒR pleural fluid marginating mediastinum ƒDecreased R lung volume BIDMC PACS Hospital Day 19 Post-Op Day 0 R Pleural Effusion and Pneumothorax on Post-Operative CXR R pleural fluid Ptx Supine AP Portable CXR. BIDMC PACS Correction of Kyphotic Deformity, Bone Fragments on CT Hospital Day 19 Post-Op Day 0 BIDMC PACS Hospital Day 1 Bone Fragments New Hardware Sagittal C- CT. Increase T2 intensity of cord at T3-T5. Post-op changes vs. ongoing impingement. Improved neuro exam. Sagittal MRI, T2-weighted. BIDMC PACS Post-Op Edema of Cord on MRI Hospital Day 21 Post-Op Day 2 Patient experienced hypoxia while recovering from procedure and still required supplemental oxygen at post- operative day 10. Team ordered CXR. ƒElevated R hemidiaphragm ƒRML/RLL collapse ƒR apical lateral ptx ƒPersistent R pleural effusion despite chest tubes. Small L effusion. BIDMC PACS Hospital Day 29 Post-Op Day 10 Non-Resolution of R Pleural Effusion on CXR Ptx Elevated hemidiaphragm Effusion Supine AP Portable CXR. Surgical team performed bedside pleurodesis with doxycycline x 2, then ordered CXR to evaluate results. Official read: “Entire right hemithorax is now filled with fluid.” Differental includes R lung collapse. Mediastinal scarring prevents shift so difficult to differentiate fluid from collapse. Team ordered CT. BIDMC PACS Hospital Day 31 Post-Op Day 12 R Lung Whiteout Following Pleurodesis on CXR Supine AP Portable CXR. Coronal C- CT: Occluded R mainstem. Total R lung collapse. Loculated R effusion. BIDMC PACS R Lung Collapse and Occluded R Mainstem on CT Hospital Day 31 Post-Op Day 12 Collapsed R Lung Occluded Mainstem Flexible Bronchoscopy Report “A flexible bronchoscope was inserted into the trachea. There was copious purulent secretions both in the distal trachea and completely occluding the right main stem. These were therapeutically aspirated.” –David Berkowitz, MD Secretions spilled into left mainstem bronchus, pt became hypoxic and bradycardic, required emergency intubation and pressors. Pt transferred to MICU. Intubated post- bronchoscopy. R lung inflation improved with clinical improvement in oxygen requirement. BIDMC PACS Hospital Day 32 Post-Op Day 13 Improved R Lung Inflation After Bronchoscopy on CXR Continued effusion Improved R lung inflation Supine AP Portable CXR. Hospital Day 32-60 • Developed hepatorenal syndrome, HD started • Bleeding from chest tubes, required repeated transfusions (43 PRBCs), FFP, cryo, DDAVP • Chest tubes placed on waterseal with goal of tamponade, self-extubated 5/16 • Delirium, BC grew VRE x 2 sets, started linezolid • Stabilized, transferred to general medicine floor • Fevers to 100.4 on 6/3-6/7 • LE numbness/weakness worse on 6/7 Axial CT with Contrast. Large R loculated R pleural effusion with heterogenous density, small pockets of gas. Split pleura sign is concerning for empyema .* *Kraus GJ. 2007. BIDMC PACS Pleural Effusion Communicating with Perispinal Fluid Collection CT Hospital Day 60 Post-Op Day 41 Perispinal collection Pleural Collection Sagittal C- CT. Destructive process involving T3 with bony fragments impinging on spinal canal. BIDMC PACS T3 Destruction on CT Hospital Day 60 Post-Op Day 41 Fragmentation of T3 Bone fragments in spinal canal Post-Op Day 0 Post-Op Day 45 Fever, ↑LE weakness BIDMC PACS BIDMC PACS Progression of Kyphotic Deformity on CT Sagittal C- CT. T3 Fragments in Spinal Canal. BIDMC PACSBIDMC PACS Hospital Day 64 Post-Op Day 45 Hardware Loosening. T3 Destruction Compromising Surgical Repair on CT Axial C- CT. Ultrasound. Fluid grew vancomycin-resistant Enterococcus. Pt already got course of linezolid for VRE bacteremia. Now started on daptomycin for likely T3 osteomyelitis with pleural+spinal empyema. BIDMC PACS Hospital Day 66 Post-Op Day 47 Drainage of R Pleural Collection on Ultrasound Needle Loculated Collection Outcome • Pt deemed not a surgical candidate given severe medical issues, including hepatorenal syndrome. • Did not meet criteria for liver transplant. • Discharged to rehab on dialysis with plan to continue daptomycin suppression. • Expired in Hospice three months after discharge. • No known autopsy. Pleural Effusion Can Delay Recognition of Thoracic Vertebral Osteomyelitis • Bass, et al., 1998 describe 5 cases of vertebral osteomyelitis with pleural effusion. • None had evidence of osteomyelitis on CXR. • Effusion culture = bone culture where both known (2/5). • In 4/5, management directed at effusion, and dx of osteomyelitis delayed up to 6 wks. • Delay contributed to neurologic complication in 2/5. Conclusions • Pleural effusion in our pt was initially expected post-op, but infected effusion became contiguous with likely spinal empyema and T3 osteomyelitis. • Pleural effusion can be the presenting sign of osteomyelitis and can delay its recognition, as pulmonary issues tend to become the focus of care (Bass, et al, 1998). • If pt has back pain in the setting of unexplained pleural effusion, investigate the spine! References • Aboukasm AG and Smith BJ. 1997. Nocturnal vertebral compression fracture. A presenting feature of unrecognized epileptic seizures. Arch Fam Med 6(2):185-7. • Bass SN, Ailani RK, Shekar R, Gerblich AA. 1998. Pyogenic vertebral osteomyelitis presenting as exudative pleural effusion: A series of five cases. Chest 114(2):642-7. • Kraus GJ. 2007. The split pleura sign. Radiology 243(1):297-8. Acknowledgements • James Knutson, MD • Gillian Leiberman • Maria Levantakis Vertebral Osteomyelitis Associated with VRE Empyema Following Stabilization of Unexplained Compression Fracture Clinical Presentation Flattened T4 Vertebral Body on CT T4 Soft Tissue Mass + Cord Compression on CT Slide Number 5 Slide Number 6 Slide Number 7 What destroyedT4? Slide Number 9 Slide Number 10 Slide Number 11 Pathology Result from T4 Fragments Slide Number 13 Slide Number 14 Slide Number 15 Slide Number 16 Slide Number 17 Slide Number 18 Slide Number 19 Slide Number 20 Flexible Bronchoscopy Report Slide Number 22 Hospital Day 32-60 Slide Number 24 Slide Number 25 Slide Number 26 Slide Number 27 Slide Number 28 Outcome Pleural Effusion Can Delay Recognition of Thoracic Vertebral Osteomyelitis Conclusions References Acknowledgements