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Severe back pain in a hemodialysis patient

Article  in  QJM: monthly journal of the Association of Physicians · May 2009

DOI: 10.1093/qjmed/hcp046 · Source: PubMed

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Pi-Jung Hsiao
Kaohsiung Medical University
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Q J Med 2009; 102:811–812
doi:10.1093/qjmed/hcp046 Advance Access Publication 21 April 2009

Clinical picture

Severe back pain in a hemodialysis patient

A 68-year-old woman was admitted because of

severe lower back pain for 2 months. She had dia-
betes nephropathy in uremic state and began regular
hemodialysis for 2 years. Her blood pressure was
130/70 mmHg, body temperature 378C, pulse rate
70 beats/min and respiratory rate 18 breaths/min.
On examination, tenderness of L-spine without any
neurological deficient was noted. Laboratory data
showed white blood cell counts 13 100/ml with a
left shift, and C-reactive protein 19.9 mg/dl. Non-
contrast CT of L-spine demonstrated destruction of

Downloaded from qjmed.oxfordjournals.org by guest on October 13, 2011

L4 vertebral body and calcifications (arrowhead)
over left paravertebral region. Magnetic resonance
image (MRI) of the L-spine revealed compression
fracture of L4 vertebral body with enhancement
over entire L4 and posterior third of L3 vertebral
bodies on T1-weighted image after gadolinium con-
trast injection. Abscess with peripheral enhance-
ment in the ventral epidural space (arrow) and left
paravertebral region (asterisk) from L3 to L5 level
were also found, but the endplates and interverte-
bral disks were relatively spared. The diagnosis of large bony defect. The absence of high signal inten-
infective spondylitis with tuberculosis (TB), cold sity on T2-weighted images generally helps to elim-
abscess was suspected. Blood culture was sterile. inate the diagnosis of an infectious progress on
Sputum culture and acid fast bacilli all showed MRI.2 Calcifications of chronic paravertebral
negative. She underwent decompressive laminect-
abscesses may be helpful to distinguish TB spondy-
omy with complete debridement of infected tissue.
litis from bacterial spondylitis. TB spondylitis should
Histopathology of the specimen revealed chronic
be suspected in end-stage renal disease patients with
granulomatous inflammation with necrosis and
back pain and/or neuromuscular complaints and
giant cell formation of the bone tissue. TB polymer-
delay treatment of TB in dialysis patients may
ase chain reaction of the specimen was also posi-
cause significant morbidity.3
tive. She received anti-TB drug therapy and the
Photograph and text from: P.-J. Hsiao, L.-K. Diang
symptom of back pain got improvement.
and S.-H. Lin, Division of Nephrology, Department
Mycobacterium tuberculosis was isolated in
of Medicine, Tri-Service General Hospital, National
spite of multiple localizations but TB spondylitis
Defense Medical Center, Taipei, Taiwan, R.O.C;
was often delay diagnosis. The incidence of extra-
C.-W. Wang, Department of Radiology, Tri-Service
pulmonary TB in dialysis patients is more common
General Hospital, National Defense Medical Center,
than in the general population and it frequently
Taipei, Taiwan, R.O.C.
poses both diagnostic and therapeutic challenges.1
email: shihhualin@yahoo.com
Imaging features in infectious process encompass a
range of abnormalities from superficial erosion to Conflict of interest: None declared.

! The Author 2009. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
 812 Clinical picture

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References
1. Malik GH, Al-Harbi AS, Al-Mohaya S, Al-Khawajah H,
Kechrid M, Al Hassan AO, et al. Eleven years of experience
with dialysis associated tuberculosis. Clin Nephrol 2002;
58:356–62.
2. Theodorou DJ, Theodorou SJ, Resnick D. Imaging in dialysis
spondyloarthropathy. Semin Dial 2002; 15:290–6.
3. Gadallah MF, el-Shahawy MA, Campese VM. Tuberculosis
of the spine (Pott’s disease) in patients with end-stage renal
disease. Am J Nephrol 1994; 14:55–9.

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