A 55-year-old farmer was admitted to the hospital with low back pain without neurological compromise and nodulopustular skin lesions in the thighs and forearms. The patient reported recurrent episodes of right elbow bursitis as well as right heel pain during the last 8 months.

Past medical history revealed renal transplantation for end stage glomerulonephritis 15 years prior to the admission to the hospital and therapy with immunosuppressive agents since then. During the last 3 years, the patient received methylprednisolone, 4mg per day, and azathioprine, 75mg per day. Moreover, the patient had liver cirrhosis due to chronic hepatitis C viral infection diagnosed at the time of transplantation.

Physical examination and plain radiographs of the lumbar spine showed no abnormalities. The patient was discharged from the hospital with the advice to receive a 2-week treatment with non-steroid anti-inflammatory medications and bed rest for the low back pain and amoxicillin/clavulanic acid for the skin lesions.

Four weeks later, he presented with intense low lumbar pain, numbness of the lower extremities and gait disturbance. Furthermore, there was cervical spine pain, loss of dexterity, and numbness of the hands. The patient had malaise, vertigo, and tinnitus but no fever.

Physical examination revealed a palpable gibbus at the cervical region. Neck motion was decreased. The muscle strength of both lower and upper extremities muscles was mildly decreased (4/5). Deep tendon reflexes of the upper extremities were decreased. Deep tendon reflexes of the lower extremities were normal. There was no clonus.

Imaging evaluation with plain radiographs, computed tomography and magnetic resonance imaging of the spine showed spondylodiscitis at C4-C5, C5-C6, C7-T1, and T1-T2 intervertebral discs (Fig. 1) and spondylodiscitis at L4-L5 associated an epidural mass. Cervical kyphosis was present because of osteolysis with anterior wedged deformity of the C5 vertebra. Posterior C5-C6 spondylolisthesis resulted in compression of the spinal cord at this level. Osteolytic lesions were also shown radiographically at the left elbow (olecranon and radius), the right carpal bones, the distal right fibula, the right calcaneus (Fig. 2), and the right middle and forefoot (the head of the fifth metatarsal and the proximal phalanxes of the fifth, fourth, third and second toes).

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