Progressive back pain in elderly individuals may be caused by spine infections, metastatic cancers, or hematologic malignancies. Spine infections, such as spondylodiscitis, often result from hematogenous spread by staphylococci, streptococci, or gram-negative bacilli, whereas Clostridium species is a rare cause of spondylodiscitis. Lymphoma involving the spine can mimic infectious spondylodiscitis and lead to irreversible neurological damage. We report an elderly Thai woman with clostridial spondylodiscitis and lymphoma coexisting at the thoracic spine, highlighting the importance of a broad differential diagnosis in such cases. A 79-year-old Thai woman with osteoporosis and a previous T10 compression fracture, treated with denosumab, presented with worsening back pain radiating to both legs for five months, along with fatigue, anorexia, and a 7 kg weight loss. She developed a fever and weakness before admission. Initial treatment with ceftriaxone and cefixime temporarily alleviated her symptoms, but paralysis and sensory loss later worsened. At Siriraj Hospital, examination revealed complete paraplegia, and MRI showed spondylodiscitis and epidural abscesses at T10–T11, causing spinal cord compression. CT-guided biopsy identified gram-positive bacilli, and partial 16S rRNA sequencing showed 97.23% identity with Clostridium tarantellae. IV metronidazole was started. Additionally, tissue pathology revealed diffuse large B-cell lymphoma involving the thoracic spine. Staging CT showed extensive lymphadenopathy, but her bone marrow was unaffected. After four weeks of metronidazole, her pain improved, but neurological deficits remained. R-CHOP chemotherapy was initiated while continuing metronidazole. Unfortunately, she developed severe Acinetobacter baumannii pneumonia, which led to septic shock and respiratory failure. She died 74 days after admission. This case highlights the rare coexistence of spinal infection and lymphoma—an uncommon and challenging diagnosis in elderly patients with progressive back pain. The coexistence of infectious spondylodiscitis and spinal lymphoma is rare, posing diagnostic and therapeutic challenges that demand multimodal evaluation and prompt treatment to prevent complications and improve outcomes.
Vithitsuwannakun et al. (Thu,) studied this question.