Clinical problem-solving. Beware of first impressions.

A 64-year-old Filipino man presented to a Baltimore hospital with a 4-month history of worsening midback pain, progressive leg weakness, and intermittent bladder and bowel incontinence. He had no fever or pulmonary symptoms. Magnetic resonance imaging (MRI) of the thoracic spine revealed hypointense T1-weighted and hyperintense T2-weighted bone marrow signal involving vertebral bodies T2, T3, and T4 (findings that were consistent with osteomyelitis); vertebral compression fractures; an epidural fluid collection; and spinal cord compression (Fig. 1). Multiple blood cultures were negative. Because the spine was considered unstable, he underwent T2, T3, and T4 vertebrectomy with fusion from C3 to T8. Pathological studies of the operative specimen revealed granulation and chronic inflammation. No organisms were identified with the use of routine or special stains, including an auramine– phenol stain for acid-fast bacilli. Vertebral bone and material from the fluid collection were sent for fungal, mycobacterial, and routine bacterial cultures before the initiation of treatment with antimicrobial agents.