#2 Distinguish Streptococcus milleri (S. milleri) from other viridans streptococci by its tendency for suppurative infections. #3 Recognize S. milleri as a rare but known cause of vertebral osteomyelitis. CASE INFORMATION: A 61 year old male was found to have fractures of C5 and C6 with associated left sided radiculopathy after falling down stairs. The patient had no chronic medical conditions except for recurrent tonsillitis and tonsilloliths. The patient was admitted to an outside hospital and found to have a WBC of 13,300 Â 10 9 /L and a WESR of 67 mm/hr. Surgery was performed to stabilize the fracture and revealed cervical osteomyelitis with associated phlegmon and epidural abscess. The patient underwent debridement and internal fixation. Five of six cultures grew only pan-sensitive S. milleri. With ampicillin, the patient's WBC had normalized and WESR had improved. However, he experienced two internal fixation rod failures and developed a mediastinal abscess with associated cutaneous fistula. He was then transferred to our hospital. Tissue cultures from the neck and mediastinal abscess grew several organisms, and as such, antibiotic coverage had to be broadened. The patient required three additional spine stabilizing operations before a satisfactory result was achieved. He had a number of complications including drug induced neutropenia, thrombocytopenia, rash, and atrial fibrillation. At the time of this writing, the patient has made a nearly full recovery. He has a WBC of 4,300 Â 10 9 /L and WESR of 0 mm/hr. He has been maintained on gatifloxacin and minocycline while he has metal hardware in the previously infected region. DISCUSSION: Streptococcus milleri represents several biologically diverse, yet clinically homogenous, types of viridans streptococci. They are characterized by their tendency for suppurative infections. They can be found in abscesses of the mouth, brain, and liver as well as empyemas. Several cases of vertebral osteomyelitis have been previously reported. Of the two cases of cervical osteomyelitis, one involved an intradiscal steroid injection and the other had known severe periodontal disease. The patient in this case had known palatine tonsillar disease which may very well have led to his cervical spine osteomyelitis.