Brucellar spondylitis presenting as right hypochondrial pain.

A 24 year old Yugoslavian woman, who had lived in Britain for 18 months, presented with right loin pain, dysuria, and frequency of micturition of two months' duration. After collection of a urine sample co-trimoxazole tablets were prescribed. No bacterial growth was obtained from the urine culture. Six days later she was admitted to a surgical ward with intense right hypochondrial pain of a colicky nature with radiation to the right shoulder tip and associated symptoms of nausea, vomiting, weakness, and rigors. She had been well previously and reported no unusual dietary habits or contact with livestock. On examination she had a fever of 37.8CC and a tachycardia of 88/min. There was slight pallor but no lymphadenopathy. Abdominal findings were of an undistended soft abdomen with tenderness in the right upper quadrant but no features suggesting peritoneal irritation. The liver edge was just palpable. Rectal and pelvic examinations were normal. There were no abnormalities of the spine apart from minimal tenderness in the lower thoracic region. No abnormal neurological findings were detected. Serial blood counts, biochemical studies, urine and blood cultures, and x ray examinations of the chest and abdomen were performed. The only abnormal findings were consistently raised erythrocyte sedimentation rates (always greater than 75 mm in the first hour) and increased serum aspartate transaminase activity of 55 IU/l on one occasion. The Mantoux test was weakly positive. In keeping with the presumptive diagnosis of acute cholecystitis intravenous ampicillin 500 mg six hourly was given, but the abdominal pain and low grade fever persisted. Abdominal ultrasound, oral cholecystography, intravenous urography, and computed tomography of the right upper quadrant failed to show any abnormality. In the search for intra-abdominal sepsis a radioactive gallium scan showed increased uptake of isotope in the lower thoracic spine. X ray films and tomograms of the area showed a paravertebral shadow around the bodies of the seventh to the tenth thoracic vertebrae with destruction of the inferior part of the body of the eighth and