Blastomycosis with pathologic fracture T9
Findings:
Sagittal multiplanar CT bone reconstructions demonstrate poorly defined lysis central aspect of the T9 vertebral body associated with mild to moderate vertebral body height loss, compatible with a pathologic fracture. Sagittal T-1 and T2 weighted images, some with fat saturation, demonstrate abnormal marrow replacement of T9 with plaquelike ventral paravertebral signal abnormality. Selected axial noncontrast CT chest images demonstrate nodular extensive consolidation of the left upper lobe marginating the major fissure, associated with air bronchograms. Selected axial MRI and CT images again demonstrate the lytic process of T9 with asymmetric right paravertebral extent. On follow-up MRI six weeks later, T1 sagittal fat saturated post contrast and axial T-1 post contrast images demonstrate progressive height loss of T9 with progressive predominantly right paravertebral enhancement, with no significant extent into the epidural space.
Differential Diagnosis:
Metastasis, Plasmacytoma, Osteomyelitis, recent trauma with fracture
Discussion:
The presence of marrow replacement with pathologic fracture and a lung mass should raise the possibility of metastatic lung cancer, but this would be unusual in a 26 yo nonsmoker. The lung consolidation with air bronchograms and fissure margination is atypical for neoplastic disease unless it is bronchoalveolar carcinoma (very rare in 26 yo), and should raise the possibility of an infectious process. BAL demonstrated fungal forms which were confirmed to represent blastomycosis and were not felt to be a contaminant. There were no AFB seen. Note that in this case the adjacent disc spaces are spared, which is not seen with bacterial spondylitis due to a predilection for the disc first, but may be seen with tuberculous or fungal osteomyelitis. Additional discussion of discitis/osteomyelitis is found below:
This case was prepared with the assistance of Joshua Hall, UC undergraduate
-vertebral osteomyelitis
-discitis osteomyelitis epidural phlegmon
-cervical discitis/osteomyelitis
-septic facet disease
-thoracic epidural abscess