Jen Aaron,  Iskander Paul,  Ghahremani Shahnaz

Final Pr. ID: Poster #: CR-079

Case Report:
A 14 year-old previously healthy male presented to the emergency department with weakness, fever, diarrhea, lateral right eye deviation and transient vision loss, following a week of headaches and dizziness. The symptoms began following a recent camping trip to Yosemite National Park with friends, where distant contact with squirrels and several bug bites were noted. The initial physical examination revealed additional photophobia, limited neck flexion secondary to pain, and a raised, non-tender soft tissue mass over the anterior right shin. Soon after admission, the patient developed pain in the right hip and left leg and significant lower extremity weakness. A chest X-ray demonstrated left lower lobe consolidation, a left upper lobe lung nodule, and a right upper lobe lung nodule. MRI showed multifocal osteomyelitis and multiple intraosseous, intramuscular and soft tissue abscesses. Contrast-enhanced CT angiogram demonstrated septic emboli, scarring, and atelectasis within the left lower lung with a small hydropneumothorax. Lucent lesions were also noticed in the T3-T6 vertebral bodies with increased prominence of the paravertebral soft tissue.

A lumbar puncture was found consistent with bacterial meningitis. A blood culture, CSF culture, and culture of abscess fluid from the right hip were all found to be PCR positive for Yersinia pestis, and the patient was placed on a treatment regimen of ciprofloxacin, gentamicin, and tetracycline.

Discussion:
Plague, colloquial known as the Black Death, is a zoonosis caused by the gram-negative bacterium Yersinia pestis and endemic to the Western United States and developing countries. In the modern day, plague is typically found in infected rodents and spread to humans through fleas. Three forms of plague are reported in humans: bubonic, septicemic, and pneumonic. Our patient’s presented primary septicemic plague complicated by secondary pneumonia, meningitis, and osteomyelitis. Notably, Yersinia osteomyelitis has been reported only once in the historical literature, and was likely underappreciated before the advent of MRI. This case presentation will highlight the unique imaging manifestations of the patient’s disseminated disease. Read More

Authors:  Jen Aaron , Iskander Paul , Ghahremani Shahnaz

Keywords:  plague, osteomyelitis, pneumonia, meningitis, sepsis