An 80-year old man presented with low back pain, fever, and night sweats. An MRI of the spine revealed spondylodiskitis of the L2-3 disk and adjacent vertebrae.
An 80-year-old man was admitted to our hospital with low-grade fever of 2 weeks duration, fatigue, back pain, and malodorous night sweats. The patient’s past history was positive for chronic low back pain. He was a farmer and he reported regular consumption of unpasteurized milk. On physical examination the patient’s temperature was 37.80 C; blood pressure 120/80 mmHg; respiratory rate 16/min; and pulse rate 84 beats/min. Tenderness was present over the lower lumbar spine, but no neurological abnormality was noted. Straight-leg raising to an angle of 60 degrees provoked hamstring pain on both sides. A complete blood cell count was normal. Erythrocyte sedimentation rate was 90 mm/1st h and C-reactive protein was 45 mg/L. Blood biochemistry was normal, except for a mild elevation in the liver function tests. Plain radiographs of the lumbar spine showed spondylolisthesis and mild degenerative changes (Figure 4). Magnetic resonance imaging of the lumbar spine revealed spondylodiskitis involving the L2-3 disk and the adjacent L2 and L3 vertebrae (Figures 1 and 2). Following gadolinium application enhancement of the bone marrow of the involved vertebral bodies and in the epidural space was seen(Figure 3).
The most common causes of infectious spondylitis are Staphylococcus aureus and Mycobacterium tuberculosis. In our case serology for Brucella was positive, with an antibody titer of 1:3560, and subsequent blood cultures yielded Brucella melitensis. Brucellosis is a zoonosis endemic in the Mediterranean basin. The disease is transmitted to humans either through direct contact with infected animals or through ingestion of contaminated dairy products. Although brucellosis is characterized by osteoarticular manifestations, spondylodiskitis is rather infrequent. In two series of 593 and 285 patients with brucellosis, spondylitis was present in 58 (9.7 %) and 35 (12.3%) patients respectively [1,2]. The sites of spinal involvement are the lumbar, thoracic, and cervical regions, in decreasing order of frequency. Brucella enters the vertebral body through the nutrient arteries to the subchondral region, causing early radiographic changes, which are osteoporosis followed by subchondral osteolysis. The ensuing invasion of the disk results in narrowing of the intervertebral space and contamination of the opposite vertebra. Eventually, break out of the bone occurs, resulting in the formation of a paravertebral abscess. In our case the patient's history of low back pain should be underlined because brucellar spondylitis is associated with preexisting vertebral disease, which predisposes to bacterial localization [3]. Plain radiographs of the spine are not very helpful because they have a low sensitivity during the first weeks of the disease [4]; moreover, radiographic findings are similar to those of degenerative disease [5]. On the contrary, the typical MRI findings are usually present within 1 month after the onset of symptoms [2]. Therefore, when brucellar spondylodiskitis is suspected, MR imaging should be performed as early as possible.
Brucellar spondylodiskitis
Based on the provided MRI and X-ray images, the following observations can be made:
1. At the lumbar vertebra L2-3 and the corresponding intervertebral disc, a noticeable abnormal signal is observed, involving the adjacent vertebral endplates.
2. On MRI, varying degrees of osseous destruction and bone marrow edema signals are visible at the vertebral margins. The intervertebral disc shows abnormal signals, presenting high signal intensity on T2-weighted images and low signal intensity on T1-weighted images.
3. There is swelling in the paravertebral soft tissue, suggesting possible inflammatory infiltration or a small-scale abscess formation.
4. X-ray plain films are less sensitive to early lesions, but in some slices, a slightly narrowed lumbar intervertebral space and signs of bony destruction at the vertebral edges can be seen.
Based on the patient’s clinical presentation (low back pain, fever, night sweats) and the imaging findings indicating infectious changes in the vertebrae and intervertebral discs, potential diagnoses include:
1. Bacterial spinal infection (including pyogenic spondylitis caused by common organisms such as Staphylococcus aureus): Frequently seen in elderly patients with compromised immunity or poor local blood supply, potentially exhibiting similar imaging features.
2. Tuberculous spondylitis (Pott’s disease): This infection commonly involves the vertebral bodies and intervertebral discs, manifesting as bony destruction and paravertebral abscess. If there is a known history of tuberculosis exposure, it should be highly suspected.
3. Brucella spondylitis: If the patient has a notable history of exposure (e.g., contact with infected animals or consumption of inadequately sterilized dairy products) along with corresponding positive serological tests, this condition should be strongly considered. Imaging findings can be similar to other infectious spondylitides; however, diagnosis can be confirmed with laboratory investigations.
Considering the patient’s age, symptoms (low back pain, fever, night sweats), laboratory findings (Brucella antibody titer 1:3560, positive blood culture), and the aforementioned MRI and X-ray observations, the most likely diagnosis is
Brucella spondylitis (Brucella spinal infection).
In this case, serological analysis and microbiological culture have identified Brucella as the pathogen, confirming the etiological diagnosis.
1. Pharmacotherapy:
• Under the guidance of an infectious disease specialist or relevant specialist, initiate combination antibiotic therapy targeting Brucella (e.g., doxycycline combined with rifampin) for several weeks to months.
• Closely monitor liver and kidney function as well as complete blood counts to ensure patient tolerance.
2. Supportive and Symptomatic Treatment:
• During the acute phase, moderate bed rest may be advised to reduce stress on the affected area, with pain management as necessary based on the patient’s discomfort.
• If there is a significant paravertebral abscess or spinal cord compression, surgical intervention may be considered when necessary.
3. Rehabilitation and Exercise Prescription:
Once the acute infection is controlled and symptoms have subsided, a gradual rehabilitation program can be initiated. Recommended steps include:
• Early Phase (after infection control): Perform mild isometric exercises for the lumbar and back muscles, along with bedside limb activities (e.g., ankle pumps, gentle joint movements), 2–3 times a day, 5–10 minutes each session.
• Intermediate Phase (functional recovery stage): Increase core muscle strengthening exercises (e.g., modified bridge exercises, supine leg raises) and low-intensity walking. Conduct these 3–4 times a week, 15–20 minutes per session, gradually increasing intensity as tolerated.
• Late Phase (strengthening and return to daily activities): Once there is no significant pain or functional limitation, moderate-intensity aerobic exercises (such as walking on level ground or using an elliptical) and lumbar/back muscle training can begin. Follow the FITT-VP principles (frequency, intensity, time, type, progression, and individualization) 3–5 times a week, 20–30 minutes each session.
• Throughout the program, pay attention to the patient’s bone health (especially important in elderly patients who may have osteoporosis). Avoid excessive bending, twisting, and load-bearing movements, and regularly assess bone density and cardiopulmonary function to ensure safe progression.
This report is intended for reference only and does not replace an in-person consultation or professional medical opinion. For an accurate diagnosis and treatment plan tailored to individual conditions, please consult a clinical specialist.
Brucellar spondylodiskitis
