A 73-year-old patient with a history of arterial hypertension and polyarthrosis presented to the emergency department with abdominal distension and pain associated with constipation and febrile fever. The symptoms had started three weeks earlier and worsened during the four days prior to admission. During this period, an upper gastrointestinal fibroendoscopy (oesophagus, stomach and duodenum) and a colonoscopy (up to the splenic angle) were performed, but no abnormalities were found.
Physical examination revealed a low-grade fever (37.6º C), a distended abdomen, diffusely painful on palpation, tympanised on percussion, with scant borborygmi but no evidence of peritonism, pulmonary auscultation with decreased ventilation in the lower half of the right hemithorax and the onset of intense pain on palpation and percussion of the last three dorsal spinous processes.
Analyses showed 8.2 x 109 leukocytes / L, haemoglobin 136 g / L, platelets 186 x 109 / L. Except for glycaemia (123 mg/dl), the following laboratory parameters were normal or negative: urea, creatinine, bilirubin, transaminases, gamma-glutamyltranspeptidase, sodium, potassium, chlorine, calcium, phosphorus, creatine phosphokinase, amylase, lactate dehydrogenase (LDH), proteinogram, immunoglobulin dosage, alpha-fetoprotein, CA 19 antigens. 9 and CA 125 antigens, as well as general urinalysis. ESR and C-reactive protein were elevated, with values of 85 mm / 1 h and 133 mg / L (normal < 5 mg / L), respectively. Mantoux intradermal reaction (10 IU RT-23) was positive, with an induration of 25 mm. Chest X-ray showed an image compatible with right lower lobe atelectasis in the context of an ipsilateral pleural effusion. There were no signs suggestive of adenopathy or alterations in the cardiopericardial silhouette. A thoracoabdominal CT scan confirmed the existence of a right pleural effusion and identified prominent degenerative changes along the dorsolumbar spine but, above all, erosions in the vertebral plates adjacent to the D10-D11 disc space. A lumbar MRI showed hyposignal on T1-weighted sequences and hypersignal on T2-weighted sequences in these vertebrae and their corresponding disc, with morphological alterations typical of infectious spondylodiscitis D10-D11. Three serial blood cultures were negative. Samples obtained by aspiration of the D10-D11 space showed gram-positive cocci chains, which were subsequently recovered and typed as penicillin-sensitive Streptococcus pneumoniae. Pleural fluid analysis showed pH: 7.55; leucocytes: 8.4 x 109/L (58% neutrophils, 26% eosinophils, 16% lymphocytes), protein: 48 g/L (ratio to serum protein: 0.65), glucose: 125 mg/dl, ADA: 25.92 IU/ml, LDH: 362 U/L (pleural LDH/serum LDH ratio: 0.8). Both auramine-rhodamine staining and Löwenstein-Jensen medium culture of pleural fluid were negative and cytology showed no evidence of neoplastic cells.

The patient was initially treated intravenously with amoxicillin + clavulanic acid (1 g / 200 mg, every 8 hours). After 21 days, she was switched to the oral route (875 / 125 mg, every 8 hours) for 6 weeks. The evolution was favourable and she was able to start walking with a dorsolumbar corset after the fourth week. One month after the end of antibiotic therapy, a control chest CT scan still showed a discrete pleural effusion, but the patient had only mild mechanical dorsalgia, her ESR had decreased to 21 mm / 1 h and her CRP was 2.4 mg/L. Outpatient follow-up continued for a further three years, during which time the evolution was favourable and a D10-D11 vertebral block was formed.