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09-JULY-2009  NAEEMEH MUSTAFA AHMAD  59 YEARS  DISCITIS OF l3-4 WITH WIDE-SPREAD EPIDURAL AND PARAVERTEBRAL ABSCESS.

Please! wait for 3-5 min till the video start to load. It depends upon the internet connection.

Anamnesis:

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The patient was admitted to Shmaisani hospital 30-June-2009 with clinical picture of agonizing LBP with inability to set or stand for several days. She is a known insulin dependent diabetes mellitus and arterial hypertension and Charcot joints for more than 15 years.  The relatives claim that she has sleep apnea attacks and was admitted several time for pulmonary problems.

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The patient was hallucinating with rapid breath pattern and failing vital signs. MRI lumbar spine performed the same day showing an extruded mass from L3-4 with upward migration.

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The patient was admitted late in the night and the next morning showed rapid deterioration, for what she was sent to the ICU. sPO2 was around 70-75%, but her condition was not convincing to put her in artificial ventilation. Cardiac consultation was unremarkable and a suggestion for PE was considered but all studies with spiral CT-scan ruled out the presence of gross changes. The patient has an old changes of the lungs with pulmonary restrictive disease. The patient was treated for septic shock and when the result of CXS was that of staphylococcus aureus MRSA sensitive only to vancomycin, Targocid was added to Teinam. After 4 days to patient started to show some improvement of her vital signs and she was transferred from the ICU 06-July-2009.

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The Clexane was reduced and tapered to prepare her for surgery.

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The patient was sent 09-July-2009 to the operating room. Using image-intensifier the level of L3-4 was identified and during the approach a pussy material start to come out through the soft tissues.

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Flavotomy of L3-4 was performed during what a huge amount of puss was coming out and the dura was white in color. The disc space of L3-4 was full of pus and the pus was coming from the paravertebral region under pressure. The pus and debris were sent for histological and CXS and for acid fast bacilli. For more than 2 hours meticulous cleaning and washing with saline was performed. The disc space which usually contain 1-2 ml volume was accepting 60-70 ml of saline and the pus was retuning from all the surround. Gentamicine was applied during wash. ReadyVac drain No 12 was inserted to the disc cavity  . Routine closure of the wound.

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Smooth postoperative recovery. The patient was sent to the ICU with acceptable vital signs and improvement of her neurological picture.


Comments

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In my 30 years experience it is the first case that discitis could lead to septic shock as the first clinical manifestations during admission.

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During her presence no fever  and no nuchal rigidity were observed.

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Tbc could be the cause, but there were no any changes in the bony elements  and tuberculosis cannot cause such catastrophic phenomena as septic shock with septicemia. It is mostly a pyogenic discitis with fulminant course.


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