Endocrine Abstracts

A 57-year-old woman with poorly controlled type 2 diabetes (HbA1c 148 mmol/mol) presented acutely with lower back pain, in the absence of trauma. Her WHO performance status score was 2. 18 months earlier she had developed a left fifth toe ulcer, resulting in left forefoot amputation six months later which had not healed. She had also developed a neuropathic ulcer in her right hallux, complicated by osteomyelitis. Despite excellent peripheral vasculature, conservative therapy with antibiotics had failed to achieve healing. She defaulted from the diabetic foot service and concordance with antibiotic therapy was not optimal. On admission, she was septic with acute renal failure and profound metabolic acidosis. Her residual amputation wound site revealed soft tissue infection. Examination demonstrated lumbar vertebral tenderness, bilateral lower limb weakness and absent reflexes. She required inotropic support in the high dependency unit. Chest X-ray and urine cultures were negative. Blood cultures grew group β-haemolytic streptococcus. Spine MRI confirmed L3/L4 and L4/L5 discitis, with adjacent vertebral end-plate oedema. Additionally, she had a posterior epidural collection with canal compression extending from T12 to L4. She was managed conservatively with Meropenem, as neurosurgical intervention was deemed to carry significant mortality risk. Despite prolonged antibiotic therapy, she died in hospital three months later. Spondylodiscitis with epidural abscess can result from haematogenous seeding and diabetic foot disease can be the primary focus of infection. It presents clinically with back pain – fever or neurological signs can be present or absent. The most common microorganism implicated in spondylodiscitis is Staphylococcus aureus but Streptococci are also common. Here, the only likely primary focus identified clinically was her infected diabetes foot ulcer. Clinician awareness for early diagnosis and management of spondylodicsitis, following haematological seeding from diabetic foot disease, is crucial to improve clinical outcomes.