You’re working at a teaching hospital ED in Houston one evening when one of your residents presents a case of back pain. The patient is a 57-year-old African-American female with a history of Hepatitis C diagnosed in 2000, questionable cirrhosis, macrocytic anemia, GERD, and chronic back pain for five years. Apparently the patient has close follow-up with her PCP and has suffered back problems for some time, and treatment with Flexeril and Darvocet was no longer relieving her pain. She started seeing a pain specialist one month ago and had received epidural nerve block injections to the lumbar spine every two weeks. The patient had her third and last epidural injection eight days prior to her presentation to the ED. Today she comes in complaining of worsening back pain that is sharp in nature, throbbing, 10/10 in severity with radiation down her legs intermittently. The patient also complained of progressively worsening leg weakness to the point that she could no longer ambulate, and numbness and tingling of her left lower extremity. Her right leg also felt weaker than usual and she had shooting pains going down her leg occasionally. Associated symptoms included a temperature of 100.6°F the night before, night sweats for one week duration, difficulty walking, constipation, and decreased appetite. She also reported difficulty lying on her back due to pain and tenderness over her low back when lying supine.
Her medications include only Nexium for GERD, Lasix 20mg po daily as needed for leg edema, Flexeril and Darvocet prn for back pain. Past surgical history was significant for hysterectomy in 1973 for uterine fibroids and a right knee arthroscopy in 1989. The patient lives in Houston with her husband, was retired, and denied any tobacco, alcohol, or illicit drug use. She had no travel history, no pets, nor any sick contacts.
When you see the patient, she is in moderate distress and appears unable to find a comfortable position to lie on the stretcher even after receiving a dose of IV Morphine. Her pulse is 90, she is afebrile (T=98.7° F), blood pressure 144/72, breathing comfortable at 14 breaths per minute and O2 sats of 99% on room air. Cardiac exam is normal with no murmurs noted. Abdominal exam reveals moderate ascites with shifting dullness, no tenderness on palpation, bowel sounds present, no rebound, no guarding, no hepatosplenomegaly. Her extremities have 1+ pitting edema to her knees bilaterally, no clubbing or cyanosis is noted, and pedal pulses are 2+ equal and symmetric bilaterally. Her neurologic exam reveals patellar tendon and ankle reflex of 3+ in the right lower extremity 2+ in the left lower extremity. Strength is 3/5 in the right lower extremity and 4/5 in the left lower extremity. Straight leg lift of left leg causes shooting back pain down to great toe. Sensation including sharp vs. dull, proprioception, and hot vs. cold are intact in upper and lower extremities bilaterally. Examination of her back shows no erythema, no lesions, nor fluctuance, but her lower lumbar spine (L4-L5) and upper sacral region is tender to light palpation. Rectal exam shows no masses or lesions and normal sphincter tone.
The patient’s labs are unremarkable except for WBC=11.8 K/uL with 72%neutrophils and 14% monocytes, Platelet count=87K/uL, with hemoglobin=11.7 g/dL, hematocrit=34.5%, and MCV=123fL. Pt’s HIV is negative. Sedimentation rate=6 mm/Hr.
In the setting of fevers, back pain, and progressive leg weakness, the patient underwent an MRI for further evaluation for an epidural abscess. Neurosurgery was consulted while awaiting the MRI. Two sets of blood cultures were drawn, and the patient was given one dose of Vancomycin 1 gram IV, Metronidazole 500mg IV and Ceftazidine 2 grams IV empirically.
The patient’s MRI images appear. What do you see? What do you do next?