A Case of Confounding Back Pain

Objective: Unusual clinical courseBackground: Acute back pain is common in primary care settings (>60% lifetime prevalence). Patients can also have asso-ciated red flag signs, such as fever, spinal tenderness, and neurologic deficits, that warrant further evaluation and investigation to optimize diagnosis and treatment.Case Report: A 70-year-old man with a history of benign prostatic hyperplasia and hypertension sought care for midthoracic back pain. He had been recently admitted to the hospital for sepsis from a urinary tract infection (UTI) caused by multidrug-resistant (MDR) Escherichia coli. Initial treatment was conservative management with physical therapy, given the lack of red flag signs on physical examination and the likelihood that his pain was musculo-skeletal, resulting from immobilization during hospitalization. At follow-up, thoracic spine radiography showed no fracture or other acute abnormalities. After persistent pain, he underwent magnetic resonance imaging, which showed T7-T8 osteomyelitis and discitis with substantial paraspinal soft tissue involvement. Computed tomography-guided biopsy showed MDR E. coli, which indicated hematogenous spread from his recent UTI. Pharmacologic treatment included intravenous ertapenem for 8 weeks, with consideration for discectomy if later indicated. This case highlights the value of maintaining a broad differential diagnosis and high alert for red flag symptoms during routine office visits with a chief concern of back pain.Conclusions: A high clinical suspicion for vertebral osteomyelitis must be maintained for patients with acute back pain as-sociated with red flag signs. Detailed assessment with appropriate investigations and close follow-up is rec-ommended to support the diagnosis and to allow timely management to prevent complications.