1991, The British Journal of Radiology, 64, 969-970
Case of the month Inflammatory back pain By S. A. Renowden, BSc, MRCP, FRCR and M. W. J . Hayward, FRCS, FRCR Department of Radiology, University of Wales College of Medicine, Heath Park, Cardiff (Received April 1990 and in final form August 1990)
A 57-year-old male was admitted as an emergency with a 3 day history of thirst, frequency and severe low back pain radiating to his right flank for 24 h. He was apyrexial and examination was normal. An elevated plasma glucose confirmed late onset diabetes. Urinalysis did not show any evidence of infection. He developed a temperature of 39°C 24 h later and his erythrocyte sedimentation rate (ESR) was raised at 133. Blood cultures demonstrated Gram negative (G-ve)
L
R
Figure 1. Posterior view of vascular phase of isotope bone scan.
Vol. 64, No. 766
bacilli, later confirmed as Salmonella enteritidis. Appropriate intravenous antibiotics were commenced, stool cultures, ultrasound of his renal tract, gallbladder and plain films of the lumbar spine were normal. In view of his severe back pain, a three phase bone scan was performed (Figs 1 & 2). What does it demonstrate and, given the clinical history, what is the most likely diagnosis?
L
p
Figure 2. Posterior image of bone scan of lumbar spine at 3 h.
969
Keywords: Salmonella, Aneurysm
Case of the month
survivor was reported (Meade & Moran, 1969). With improved treatment and more rapid diagnosis the prognosis has improved. Even so, 40% of patients die from rupture or sepsis prior to surgery. Salmonella accounts for 35% of mycotic aneurysms associated with G-ve septicaemia (Jarret et al, 1977). Involvement is more common in men (Mendelowitz et al, 1979) and occurs most frequently in the fourth to sixth decade. Predisposing factors include clinical sepsis, pre-existing medical illness, immuno-suppression and congenital and traumatic vascular lesions. Clinical features are usually non-specific, fever being by far the most common symptom (Mendelowitz et al, 1979). The classical triad of fever, back pain and a pulsatile abdominal mass is present only in 50% (Mendelowitz et al, 1979). Characteristically, CT demonstrates a well localized aortic dilatation, with a paucity of calcification and an encasing mass which may contain gas. There may be Figure 3. CT scan, just below the level of the renal arteries, demonstrating the aneurysm (closed straight arrows) and its neighbouring osteomyelitis and a juxta aortic retroperitoneal abscess (Wechsler et al, 1985). Angiography, neck (open curved arrows). typically demonstrates a saccular, eccentric aneurysm. (Kaufman et al, 1978). The treatment of choice for mycotic aneurysms is The vascular phase of the bone scan demonstrates abnormal vascularity just below the level of the renal bacteriocidal antibiotics and surgical resection of the arteries. The 3 h scan is normal. The most likely diag- aneurysm. No one has survived without surgery. nosis, in view of the clinical history, is a mycotic aortic Interpositional grafts are inadequate; the aorta should be ligated and vascularization to the lower limbs aneurysm, as a result of Salmonella septicaemia. A computed tomography (CT) scan (Fig. 3) demon- provided through clean tissue planes. The prognosis of mycotic aneurysms caused by strated a 6 cm right sided aortic aneurysm, with a narrow neck at the level of the renal arteries. There is Salmonella remains bleak. If diagnosis is not to be marked compression of the inferior vena cava and an delayed, with potentially fatal consequences, it must be associated soft tissue mass extending caudally adjacent suspected and aggressively investigated in the approto the psoas muscle representing either a haematoma or priate clinical setting. an abscess. A technetium labelled white cell study showed increased activity in the right upper abdomen References confirming an infective process. Angiography demon- JARRET, F., DARLING, R. C , MUNDTH, E. D. & ANSTEN, W. G., 1977. The management of infected arterial aneurysms. strated a huge aneurysm arising just below the level of Journal of Cardiovascular Surgery, 18, 361-366. the renal arteries. Embolization was considered hazar- KAUFMAN, S. L., WHITE, R. I., HARRINGTON, D. P., BARTH, dous and he underwent resection of the false aneurysm K. H. & STEGELMAN, S. S., 1978. Protean manifestations of with oversewing of the aorta and an axillo-bifemoral mycotic aneurysms. American Journal of Roentgenology, 131, graft. At surgery, the extensively friable and indurated 1019-1025. aneurysm had perforated on the right, producing a false MEADE, R. H. & MORAN, J. M., 1969. Salmonella arteritis—a preoperative diagnosis and cure of salmonella typhimurium aneurysm. Histology showed some atheromatous aortic aneurysm. New England Journal of Medicine, 281, degeneration with acute inflammation and Salmonella 310-312. enteritidis was demonstrated in the pathological MENDELOWITZ, D. S., RAMSTEDT, R., YAO, J. S. T. & BERGAN, specimen. J. J., 1979. Abdominal aortic Salmonellosis. Surgery,'85, Post-operatively he made a good recovery and con514-519. tinued oral antibiotic therapy for a further 6 weeks. PATEL, S. & JOHNSTON, K. W., 1977. Classification and Discussion
The most common clinical manifestation of Salmonella infection is gastroenteritis associated with a fever, but 7% of cases present with septicaemia or focal disease (Saphra & Winter, 1957), usually in the appendix or gallbladder. Arteritis with or without mycotic aneurysm formation is a severe but rare complication and, if not diagnosed early and treated aggressively, is associated with a high incidence of either aortic rupture or overwhelming sepsis. Before 1969, only one 970
management of mycotic aneurysms. Surgery, Gynaecology and Obstetrics, 144, 691-694. SAPHRA, I. & WINTER, J. W., 1957. Clinical manifestations of
Salmonellosis in man. New England Journal of Medicine 256, 1129-1134. WECHSLER, R. J., KURTZ, A. B., WANG, Y. & STEINER, R. M.,
1985. CT evaluation of the retroperitoneal vasculature. Critical Review in Diagnostic Imaging, 24, 237-291. WILSON, S. E., GORDON, H. E. & VAN WAGENER, P. B., 1978.
Salmonella arteritis: a precursor of aortic rupture and pseudo-aneurysm formation. Archives of Surgery, 113, 1163-1166. The British Journal of Radiology, October 1991
Case of the month Inflammatory back pain By S. A. Renowden, BSc, MRCP, FRCR and M. W. J . Hayward, FRCS, FRCR Department of Radiology, University of Wales College of Medicine, Heath Park, Cardiff (Received April 1990 and in final form August 1990)
A 57-year-old male was admitted as an emergency with a 3 day history of thirst, frequency and severe low back pain radiating to his right flank for 24 h. He was apyrexial and examination was normal. An elevated plasma glucose confirmed late onset diabetes. Urinalysis did not show any evidence of infection. He developed a temperature of 39°C 24 h later and his erythrocyte sedimentation rate (ESR) was raised at 133. Blood cultures demonstrated Gram negative (G-ve)
L
R
Figure 1. Posterior view of vascular phase of isotope bone scan.
Vol. 64, No. 766
bacilli, later confirmed as Salmonella enteritidis. Appropriate intravenous antibiotics were commenced, stool cultures, ultrasound of his renal tract, gallbladder and plain films of the lumbar spine were normal. In view of his severe back pain, a three phase bone scan was performed (Figs 1 & 2). What does it demonstrate and, given the clinical history, what is the most likely diagnosis?
L
p
Figure 2. Posterior image of bone scan of lumbar spine at 3 h.
969
Keywords: Salmonella, Aneurysm
Case of the month
survivor was reported (Meade & Moran, 1969). With improved treatment and more rapid diagnosis the prognosis has improved. Even so, 40% of patients die from rupture or sepsis prior to surgery. Salmonella accounts for 35% of mycotic aneurysms associated with G-ve septicaemia (Jarret et al, 1977). Involvement is more common in men (Mendelowitz et al, 1979) and occurs most frequently in the fourth to sixth decade. Predisposing factors include clinical sepsis, pre-existing medical illness, immuno-suppression and congenital and traumatic vascular lesions. Clinical features are usually non-specific, fever being by far the most common symptom (Mendelowitz et al, 1979). The classical triad of fever, back pain and a pulsatile abdominal mass is present only in 50% (Mendelowitz et al, 1979). Characteristically, CT demonstrates a well localized aortic dilatation, with a paucity of calcification and an encasing mass which may contain gas. There may be Figure 3. CT scan, just below the level of the renal arteries, demonstrating the aneurysm (closed straight arrows) and its neighbouring osteomyelitis and a juxta aortic retroperitoneal abscess (Wechsler et al, 1985). Angiography, neck (open curved arrows). typically demonstrates a saccular, eccentric aneurysm. (Kaufman et al, 1978). The treatment of choice for mycotic aneurysms is The vascular phase of the bone scan demonstrates abnormal vascularity just below the level of the renal bacteriocidal antibiotics and surgical resection of the arteries. The 3 h scan is normal. The most likely diag- aneurysm. No one has survived without surgery. nosis, in view of the clinical history, is a mycotic aortic Interpositional grafts are inadequate; the aorta should be ligated and vascularization to the lower limbs aneurysm, as a result of Salmonella septicaemia. A computed tomography (CT) scan (Fig. 3) demon- provided through clean tissue planes. The prognosis of mycotic aneurysms caused by strated a 6 cm right sided aortic aneurysm, with a narrow neck at the level of the renal arteries. There is Salmonella remains bleak. If diagnosis is not to be marked compression of the inferior vena cava and an delayed, with potentially fatal consequences, it must be associated soft tissue mass extending caudally adjacent suspected and aggressively investigated in the approto the psoas muscle representing either a haematoma or priate clinical setting. an abscess. A technetium labelled white cell study showed increased activity in the right upper abdomen References confirming an infective process. Angiography demon- JARRET, F., DARLING, R. C , MUNDTH, E. D. & ANSTEN, W. G., 1977. The management of infected arterial aneurysms. strated a huge aneurysm arising just below the level of Journal of Cardiovascular Surgery, 18, 361-366. the renal arteries. Embolization was considered hazar- KAUFMAN, S. L., WHITE, R. I., HARRINGTON, D. P., BARTH, dous and he underwent resection of the false aneurysm K. H. & STEGELMAN, S. S., 1978. Protean manifestations of with oversewing of the aorta and an axillo-bifemoral mycotic aneurysms. American Journal of Roentgenology, 131, graft. At surgery, the extensively friable and indurated 1019-1025. aneurysm had perforated on the right, producing a false MEADE, R. H. & MORAN, J. M., 1969. Salmonella arteritis—a preoperative diagnosis and cure of salmonella typhimurium aneurysm. Histology showed some atheromatous aortic aneurysm. New England Journal of Medicine, 281, degeneration with acute inflammation and Salmonella 310-312. enteritidis was demonstrated in the pathological MENDELOWITZ, D. S., RAMSTEDT, R., YAO, J. S. T. & BERGAN, specimen. J. J., 1979. Abdominal aortic Salmonellosis. Surgery,'85, Post-operatively he made a good recovery and con514-519. tinued oral antibiotic therapy for a further 6 weeks. PATEL, S. & JOHNSTON, K. W., 1977. Classification and Discussion
The most common clinical manifestation of Salmonella infection is gastroenteritis associated with a fever, but 7% of cases present with septicaemia or focal disease (Saphra & Winter, 1957), usually in the appendix or gallbladder. Arteritis with or without mycotic aneurysm formation is a severe but rare complication and, if not diagnosed early and treated aggressively, is associated with a high incidence of either aortic rupture or overwhelming sepsis. Before 1969, only one 970
management of mycotic aneurysms. Surgery, Gynaecology and Obstetrics, 144, 691-694. SAPHRA, I. & WINTER, J. W., 1957. Clinical manifestations of
Salmonellosis in man. New England Journal of Medicine 256, 1129-1134. WECHSLER, R. J., KURTZ, A. B., WANG, Y. & STEINER, R. M.,
1985. CT evaluation of the retroperitoneal vasculature. Critical Review in Diagnostic Imaging, 24, 237-291. WILSON, S. E., GORDON, H. E. & VAN WAGENER, P. B., 1978.
Salmonella arteritis: a precursor of aortic rupture and pseudo-aneurysm formation. Archives of Surgery, 113, 1163-1166. The British Journal of Radiology, October 1991
