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A 6-month-old presents with intense crying, possible back pain
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A 6-month-old male presented to the ED of a local hospital with the chief complaint of progressively intense crying during diaper changes for the past few weeks.
The parents said he had begun sitting up, but now he won’t. Nothing was found on examination and he was referred back to his primary. His provider felt there may be some back pain on exam and sent the infant for an MRI (Figures 1 and 2), and he was referred for admission. There was no history of fever or injury, and the rest of his medical history was that of a normal infant. His immunizations were up-to-date for his age, and his family history was unremarkable. There were no sick contacts and his appetite was normal; taking formula only.
James H. Brien
Examination on arrival was positive for irritability on movement of his pelvis and legs. His vital signs were normal and the rest of his exam was normal for his age. Admitting lab tests included a normal complete blood count (CBC) and a C-reactive protein of 3.1.
What’s Your Diagnosis?
A. Infant botulism
B. Diskitis
C. Pott disease
D. Spinal epidural abscess
The MRI revealed not only diskitis, but also vertebral osteomyelitis of the adjacent vertebrae (L4 and 5). Diskitis is an uncommon inflammatory condition of the intervertebral disk that usually results in destruction of the disk with narrowing of the disk space. It often involves the end plates of the adjacent vertebral bodies and may continue to result in significant bone destruction (Figure 3), depending on the causative organism.
The patient’s primary care provider felt there may be some back pain on exam and sent the infant for an MRI (Figures 1 and 2).
To understand diskitis and vertebral osteomyelitis, and why diskitis occurs mostly in young children and vertebral osteomyelitis in older children and adults, one must understand the vascular supply to these structures and how they change with time. In fact, vascular supply plays a pivotal role in the evolution of any hematogenously spread infection.
When it comes to the spine in young children, the vascular supply to the vertebrae is fairly rich and supplies the disk via a network of arteries and anastomoses from the periosteum and the central vertebral body via their cartilaginous end plates. This blood supply to the disk begins to atrophy in infancy and is largely obliterated by age 7 to 10 years, resulting in an avascular disk by about age 30 years. The disk then relies on capillary beds between it and the vertebral body endplates for nutrients and removal of waste by diffusion.
Disk atrophy can occur as a consequence of vascular injury (thrombosis) from trauma, but most believe that infection is the cause of most cases of diskitis. In young children, it appears that bacteremic seeding of the end plates result in a low-grade infection that result in necrosis and/or infection of the disk. In decades past, it was felt that only bed rest was needed for these cases because most spontaneously resolved with time. However, improved imaging and culture data have added to the collective knowledge of this condition, supporting the infectious role and benefit of antimicrobial therapy.
Diskitis involves the end plates of the adjacent
vertebral bodies and may continue to result
in significant bone destruction.
When an organism is isolated, it is usually Staphylococcus aureus, with a wide array of other gram-positive and a few gram-negative bacteria making up a small minority. Most will involve the lumbar area, with pain associated with activity involving the low back, such as sitting or movement of the lower back area. Diskitis in the lower thoracic area may result in referred pain to the abdomen, flanks and chest. There may be low-grade fever and mild to moderate elevation of inflammatory markers. If an organism is not recovered to guide therapy, most experts recommend using an IV antibiotic with anti-staph activity such as clindamycin for a few weeks, then transition to oral therapy, depending on the response. It is difficult to determine which of these cases will resolve spontaneously and which will go on to severe destruction of the vertebrae.
Pott disease is essentially synonymous with Mycobacterium tuberculosis vertebral osteomyelitis of adjacent vertebral bodies. It usually involves the upper lumbar or lower thoracic vertebrae, resulting in destruction of the vertebral bodies with eventual formation of a gibbus deformity (Figure 4, courtesy of
Spinal epidural abscess (Figure 5) is often a surgical emergency, especially if there are progressive neurologic findings. It can occur as a complication of pyogenic infection of the disk or the vertebral body, trauma or hematogenous spread. It can be associated with sepsis and result in death or permanent neurologic disability. The treatment is usually surgical drainage and IV antimicrobials. Empiric therapy should be similar to that of a brain abscess; ie, against S. aureus, gram-negative rods and anaerobes. One combination might be vancomycin plus metronidazole plus ceftriaxone pending culture results, for a total of 6 to 8 weeks.
Pott disease usually involves the upper lumbar or lower thoracic vertebrae, resulting in destruction of the vertebral bodies with eventual formation of a gibbus deformity (Figure 4). Spinal epidural abscess (Figure 5) is often a surgical emergency, especially if there are progressive neurologic findings.
Infant botulism has virtually nothing in common with these other conditions. This is a neuroparalytic condition that some infants acquire by ingesting the spores of Clostridium botulinum, which germinate in the gut and produce the neurotoxin. The usual initial symptoms are constipation, poor feeding, loss of facial expression followed by descending weakness; not pain. If you have copies of this column going back to 1997, I showed a case in the December issue.
Columnist Comments
Next month, the 26th Annual Infectious Diseases in Children Symposium in New York will be held. For the first time, the meeting will be at the Waldorf Astoria Hotel — a truly historic venue. Also for the first time, the dates have been moved up by 1 week (Nov. 16-17), instead of the weekend before Thanksgiving. Lastly, and most importantly, I have attended 20 of these meetings, and I can tell you that the agenda is the most ambitious compendium of topics that I can remember; all discussed by leading experts. I count myself fortunate to be included on this program, and hope to see you there.
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Disclosure: Brien reports no relevant financial disclosures.