Concomitant osteoporotic vertebral compression fracture and infectious spondylitis in a patient with herpes zoster: A case report

RATIONALE: The incidences of herpes zoster, osteoporotic vertebral compression fractures, and infectious spondylitis is increasing worldwide owing to the aging population. Given the potential for multiple comorbid conditions with overlapping clinical presentations, thorough history-taking and physical examination are essential for accurate diagnoses. However, the coexistence of herpes zoster, osteoporotic vertebral compression fractures, and infectious spondylitis in a single patient is exceedingly rare, making timely diagnosis even more challenging. PATIENT CONCERNS: A 64-year-old woman with a medical history of hypertension, asthma, and right-sided hemiplegia secondary to a previous hemorrhagic stroke presented with painful vesicular lesions in the right T10 dermatome consistent with herpes zoster. Despite antiviral and antibiotic therapy, her pain worsened, and inflammatory markers increased significantly. DIAGNOSES: Physical examination revealed midline spinal tenderness and pain, exacerbated by postural changes. Magnetic resonance imaging confirmed a collapsed L3 vertebral body consistent with Kummell's disease, along with paravertebral soft tissue changes and psoas muscle involvement, suggesting coexisting infectious spondylitis. INTERVENTIONS: Although the biopsy cultures were negative, empirical intravenous cefazolin therapy was initiated. After 2 weeks of intravenous antibiotic treatment, the C-reactive protein and procalcitonin levels normalized. Given the persistent mechanical back pain and stabilized infection, a vertebroplasty was performed. OUTCOMES: After the vertebroplasty, the patient experienced rapid pain relief without any signs of recurrent infection. Following a 5-week course of intravenous antibiotic therapy and an additional 2 months of oral administration, the patient achieved complete clinical resolution with full remission of both infectious manifestations and zoster-associated sequelae. LESSONS: This case underscores the importance of a comprehensive clinical assessment in older patients, even when a diagnosis of herpes zoster is apparent. Persistent or atypical symptoms warrant further evaluation to exclude concurrent diseases. Furthermore, vertebroplasty can be safely performed in select patients with infectious spondylitis following adequate antibiotic therapy, leading to pain reduction. A multidisciplinary, individualized approach is essential to achieve optimal outcomes in patients with complex spinal pathologies.