Introduction:
Spinal epidural abscess (SEA) is uncommon but increasing in frequency. It presents along a spectrum and may not be considered, especially if encountered early in its course, unless a high index of suspicion is maintained.

Case Presentation:
A 42-year-old man presented to the ED with pain in both upper quadrants of his abdomen for 2 days that was worse on the left side. The pain radiated to his back and was worsened by eating which also caused nausea and abdominal distention. There was no recent history of fever. He had a history of chronic back pain and had been hospitalized three months prior with sepsis. Past medical history was remarkable for dyslipidemia, hypertension, type 2 diabetes and obstructive sleep apnea. Physical exam was remarkable for being afebrile with a resting tachycardia of 117, obesity, abdominal tenderness in both upper quadrants, worse on the left and extending into the left flank. His back was mildly tender to palpation but was at baseline and there were no neurologic deficits. Investigation revealed a CRP of 6 and a CT abdomen with IV and oral contrast showed no intra-abdominal pathology but findings in the thoracic spine concerning for discitis and osteomyelitis. An MRI of the thoracic spine revealed discitis and osteomyelitis of T8-T9 with a posterior phlegmon and evidence of infectious enhancement in the posterior epidural space at this level.

Final Diagnosis:
Osteomyelitis of thoracic vertebra with developing spinal epidural abscess

Management:
IV Vancomycin was begun and he was transferred to a facility with neurosurgical capabilities. He did well with treatment and had a full recovery.