Case 234: Neuropathic Spondyloarthropathy

History A 70-year-old woman presented to a peripheral hospital with signs and symptoms of acute chronic obstructive pulmonary disease (COPD) exacerbation. The patient also reported acute on chronic onset of thoracolumbar back pain over a period of 24 hours. She denied any history of recent trauma or intravenous drug use. She did not have any long-term indwelling catheters. The patient's medical history was also complicated by stage 4 renal failure from long-standing type II diabetes, hypertension, iron deficiency anemia, aortic stenosis, and prior bariatric surgery. The patient was not undergoing dialysis for her renal dysfunction, nor was she receiving steroids for COPD. On clinical examination, she was afebrile and tachypneic. Although she was not amenable to a full neurologic examination, she reported subjective leg weakness. There were no localizing signs or evidence of myelopathy. Perianal sensation and rectal tone were preserved. Pulmonary examination revealed wheezes and decreased basilar air entry. The patient's white blood cell count was 6.8 × 10(9)/L. Her blood chemistry was normal, aside from an elevated blood creatinine level of 158 mmol/L. Her erythrocyte sedimentation rate was elevated at 56 mm/h, and her C-reactive protein level was normal at 4.4 mg/L (41.9 nmol/L). Chest radiographs showed mild pulmonary edema with a small right pleural effusion. The patient was transferred to our facility for evaluation of findings on thoracic spine radiographs obtained at a peripheral hospital. Unenhanced thoracic spine magnetic resonance (MR) imaging was performed first and was followed by computed tomography (CT) to further delineate the findings. The patient's renal status precluded intravenous contrast material administration.