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.
McDonnell O, Khaleel Z. Emphysematous Osteomyelitis. JAMA Neurol. 2014;71(4):512. doi:10.1001/jamaneurol.2013.90