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Images in Neurology |

Emphysematous Osteomyelitis

Olivia McDonnell, MBBCh1; Ziyad Khaleel, MBChB1
[+] Author Affiliations
1Neurological Intervention and Imaging Service (WA), Sir Charles Gairdner Hospital, Nedlands, Perth, West Australia
JAMA Neurol. 2014;71(4):512. doi:10.1001/jamaneurol.2013.90.
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A 60-year-old man was admitted to the hospital with a 1-day history of confusion, generalized abdominal tenderness, and pyrexia. He had bilateral hip flexor weakness with a power grade of 4 of 5. His C-reactive protein level was elevated at 35 mg/L (reference range, <5 mg/L) (to convert to nanomoles per liter, multiply by 9.524). The findings on chest radiography and head computed tomography were unremarkable. Computed tomography of the abdomen was performed and revealed locules of air within the L5 vertebral body and the epidural space extending from T9 to S1. Additional small gas locules were present in the retroperitoneum, right psoas muscle, and erector spinae. There was associated inflammatory change in the retroperitoneal fat (Figure 1). Magnetic resonance imaging of the spine confirmed L5 emphysematous osteomyelitis and an extensive gas-containing epidural abscess. The L5 vertebral body was poorly enhancing because of multiple small locules of intravertebral air. Small locules of air were seen tracking along the psoas muscles, and a shallow ventral gas-containing epidural collection contributed to mild canal narrowing that extended from the T9 to the S1 levels. There was abnormal enhancement in the psoas, dorsal paravertebral, and right iliacus muscles (Figure 2). Blood cultures revealed Klebsiella infection. The patient improved clinically with ciprofloxacin and cefazolin administered intravenously for 6 weeks and orally for 2 weeks.

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Figure 1.
Computed tomogram of the lumbar spine

Sagittal (A) and axial (B) images illustrate multiple small, low-density foci of gas within the L5 vertebral body (black arrowhead), a shallow ventral epidural collection (white arrowhead), and the prevertebral space and retroperitoneum (yellow arrowhead).

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Figure 2.
Magnetic resonance image of the lumbar spine

Sagittal T1 images before (A) and after (B) contrast administration demonstrate multiple low-signal foci of gas within a poorly enhancing vertebral body (white arrowhead) and a peripherally enhancing shallow ventral epidural collection (black arrowhead).

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