Endocrine Abstracts

Emphysematous osteomyelitis (EO) is a rare, potentially fatal infection caused by gas forming organisms. It is characterized by the presence of intraosseous gas. Diabetes is a predisposing condition. SGLT2 inhibitors increase the risk of urinary infection and Diabetic Ketoacidosis (DKA). A 78-year-old man presented with a one-week history of flu-like symptoms and lower back pain. He had a history of type 2 diabetes, and had been started on an SGLT 2 inhibitor. He was found to be in DKA, with raised inflammatory markers. Klebsiella pneumoniae was isolated in blood and urine cultures. Imaging was performed to investigate the lower back pain. Computed Tomography showed extensive pockets of air on the L4 and L5 vertebral bodies, with extension into the iliopsoas muscles bilaterally and the anterior epidural space. Magnetic resonance imaging showed an epidural abscess along the posterior body of L5. Findings were consistent with EO and an iliopsoas abscess. Urosepsis with lymphovascular drainage to the lumbar region is considered the likely route of transmission. Klebsiella Pneumoniae is not commonly associated with osteomyelitis. However, a literature review of EO identified Klebsiella Pneumoniae as the causative agent in 20% of all reported cases in the literature. Diabetes was a predisposing factor in 34% of cases. In recent years, hypervirulent strains of K pneumonia have been identified, causing invasive infections including liver abscesses and necrotizing fasciitis. Diabetes is reported to predispose to this syndrome. Though it is not clear the degree to which the SGLT2 inhibitor contributed to the development or course of this infection, the case emphasizes the importance of considering the increased risk of urinary infections when prescribing SGLT2 inhibitors to patients with diabetes, given their predisposition to aggressive infections. It also highlights the role for cross sectional imaging in patients with diabetes and klebsiella bloodstream infection.