Charcot Spine and Infection: A Diagnostic Challenge in a Diabetic Patient

Case Diagnosis: Charcot spine secondary to Diabetes, associated with Discitis and Osteomyelitis.

Case Description or Program Description: A 55-year-old female with type 1 diabetes mellitus, Charcot arthropathy of the foot, bilateral blindness, hypertension, and lumbar stenosis was admitted for lower back pain following transforaminal lumbar intervertebral surgery complicated by postoperative encephalopathy. She presented with severe back pain and was found to have a fracture and severe stenosis at L3-L4. The cause of the fracture was unclear. Physical examination revealed dull, non-radiating axial low back pain with occasional sharp pain on ambulation, improved with activity but worsened by immobility.

Setting: Mount Sinai Hospital Acute Inpatient Rehabilitation.

Assessment/Results: Computed tomography of the lumbar spine revealed progressive vertebral destruction with endplate irregularities and cortical erosions at L3-L4, raising concern for infection versus neuropathic arthropathy. Magnetic resonance imaging showed bone marrow edema, L3-L4 disc space enhancement, and inflammatory changes in adjacent vertebral bodies, suggesting discitis and osteomyelitis. However, no epidural abscess or paraspinal involvement was seen. Bone biopsy and cultures were negative, and leukocytosis trended down with acyclovir treatment. The patient was started on antibiotics, with glucose levels closely managed.

Discussion (relevance): The prevalence of Charcot Spine ranges from 0.8%-8% in diabetic patients. The condition often presents with vertebral destruction, disc space narrowing, and subchondral sclerosis, resembling infection. However, imaging showed absence of abscesses and restricted diffusion, rule out infection. Given its rarity, misdiagnosis is common, leading to unnecessary antibiotic use or delays in appropriate surgical stabilization. In uncertain cases, bone biopsy is essential for confirmation. Early recognition and multidisciplinary collaboration, including neurosurgery, infectious disease, and rehabilitation, are critical for guiding treatment and optimizing recovery.

Conclusions: Charcot spine can be associated with discitis or osteomyelitis both as a differential diagnosis and as a complication. Accurate diagnosis often requires a combination of clinical diagnosis, imaging and sometimes biopsy to differentiate between these conditions.