[Diagnostic image (222). A boy with backache and loss of neurological function]

A 14-year-old boy from Ghana presented with low lumbar pain and loss of neurological function of the legs, due to spinal tuberculosis.

Multifocal discitis caused by Staphylococcus warneri

Staphylococcus warneri is a coagulase-negative staphylococcus that is a normal inhabitant of the skin but occasionally causes septicemia and endocarditis. We report a case of multifocal discitis caused by S. warneri in an immunocompetent patient. Only three cases of spinal S. warneri infections have been reported in the literature. They illustrate the atypical clinical presentation, with chronic pain of increasing severity in the thoracic or lumbar spine instead of the abrupt onset that characterizes S. aureus discitis. In our patient, despite the multifocal distribution of the lesions, heretofore unreported, clinical presentation suggested common low back pain. This presentation may be ascribable to the unique bacteriological characteristics of S. warneri. The case reported here illustrates the diagnostic challenges sometime raised by discitis due to coagulase-negative staphylococci.

Epidural abscess and discitis complicating instrumented posterior lumbar interbody fusion: a case report

STUDY DESIGN

A case of epidural abscess and discitis following instrumented PLIF using a single carbon fiber interbody cage is presented.

OBJECTIVE

To describe a previously unreported complication of epidural abscess and discitis following posterior lumbar interbody fusion using a single carbon fiber cage.

SUMMARY OF BACKGROUND DATA

Various complications have been reported with PLIF. These include graft migration, pseudarthrosis, implant subsidence, epidural hemorrhage, incidental durotomy, arachnoiditis, transient or permanent neurologic deficits, persistence of pain, and wound infections. There are no reported cases of epidural abscess or refractory discitis associated with PLIF.

METHODS

A 35-year-old infantryman on active duty with chronic low back pain and single-level lumbar disc degeneration underwent instrumented PLIF after reporting no improvement with 3 years of extension-based physical therapy and nonsteroidal pain medications. His back pain was reported improved at 6 weeks after surgery. At 12 weeks after surgery, he presented to the emergency department with intense back pain and fevers. Laboratory data were remarkable for elevated erythrocyte sedimentation rate (118) and C-reactive protein (38). Initial imaging studies, including a lumbar MRI, did not demonstrate any abnormalities. The patient continued to spike fevers, and a repeat lumbar MRI 1 week later clearly demonstrated the presence of an epidural abscess at the level of the PLIF surgery. The patient was treated with surgical debridement and epidural abscess drainage. The interbody cage was left in place. Surgical cultures identified Staphylococcus aureus as the pathogen, and the patient was placed on intravenous vancomycin. During the ensuing 3 weeks, his clinical symptoms worsened and his radiographs demonstrated lucency in the region of his interbody cage. Repeat debridement was performed, and his interbody cage and pedicle screw instrumentation were removed 4 months after initial surgery.

RESULTS

The disc space infection resolved following removal of the implants. Radiographs at 6 months after instrumentation removal demonstrated solid bilateral posterolateral arthrodesis. The patient returned to active duty 1 year after his initial surgery, reporting that his back pain was reduced compared with his preoperative level.

CONCLUSIONS

There is a paucity of literature on epidural abscess and discitis as complications associated with PLIF. In this case, the infection persisted despite surgical debridement and intravenous antibiotics. The patient ultimately required removal of the interbody implant and posterior instrumentation. The patient developed solid posterolateral arthrodesis despite the presence of deep infection, which led to early implant removal 4 months after the initial surgery. This case underscores the potential importance of concomitant posterolateral fusion, particularly following wide laminectomy and facetectomy required for PLIF.

Bacterial spondylodiscitis in the patients with hemodialysis

STUDY DESIGN

Retrospective clinical and laboratory data analyses were performed on hemodialysis (HD) patients with bacterial spondylodiscitis.

OBJECTIVES

The purpose of this study was to investigate clinical characteristics and related problems for the diagnosis and treatment of spondylodiscitis in patients on maintenance HD. Possible factors for the development of spondylodiscitis were also discussed.

SUMMARY OF BACKGROUND DATA

Although bacterial spondylodiscitis is one of most serious complications that can occur in HD patients, few reports are seen describing its clinical course and treatment in HD patients.

METHODS

A total of 9 HD patients were diagnosed as having bacterial spondylodiscitis at our institute. The onset of infection, characteristics of clinical symptoms, and clinical course were reviewed retrospectively.

RESULTS

Latent form occurrence was most frequent, and only 1 in 9 cases presented high-grade fever at the beginning of treatment. Many complications were encountered both in conservatively treated and operated cases. Three patients were operated on, 1 of whom died 2 days after operation. Two of six patients in the conservatively treated group also died during the treatment period.

CONCLUSIONS

The presence of bacterial spondylodiscitis must be considered when treating back pain of HD patients even when they are afebrile. Careful observation of general status in addition to local conditions is essential. Indication of operation should be considered carefully because of the poor general status and bone quality of HD patients. MRI, in addition to plain radiographs, was necessary to differentiate destructive spondylarthropathy from bacterial spondylodiscitis.

Vertebral osteomyelitis caused by non-tuberculous mycobacteria

Vertebral osteomyelitis caused by non-tuberculous mycobacteria is a rare disease, with only 31 cases and one nosocomial outbreak reported in the literature (MedLine review between 1965 and December 2003). The clinical features are often indistinguishable from those of pyogenic osteomyelitis. Early diagnosis of such infections is a major challenge because of the slow growth of these microorganisms. No consensus guidelines for the treatment of these infections exist. Prolonged anti-mycobacterial therapy in combination with surgical debridement is recommended.

[Osteomyelitis of the spine]

Spinal infections are rare, occurring most often in elderly patients with urinary tract infections or diabetes. With the increasing number of patients with immune suppression, and also the increasing number of immigrants in the population, spinal infections are seen more frequently, especially in young adults. Typically spinal infections are monomicrobial, Staphylococcus aureus being the most common organism. Hematogenous spread of bacteria through the arterial paravertebral collateral vessels into the subchondral bone marrow of the vertebral bodies is the most common source of infection. Clinical presentation is often nonspecific. Important diagnostic measurements are laboratory studies, radiological evaluation including MR image scans, and CT-guided percutaneous biopsy of the lesion for microbiological studies. The management of spinal infections consists of antimicrobial therapy over 6-8 weeks. Surgical intervention is indicated in neurologically compromised patients for spinal instability and abscesses.

Diagnosis and treatment of Candida vertebral osteomyelitis: Clinical experience with a short course therapy of amphotericin B lipid complex

BACKGROUND

Musculoskeletal candidiasis occurs in some patients with candidemia resulting from organ infection, IV drug use, or indwelling central venous catheters. Diagnosis is often difficult because of vague symptomatology and a frequent afebrile course.

CASE DESCRIPTION

Three patients with Candida vertebral osteomyelitis are presented. All followed the use of indwelling central venous access catheters and antimicrobial therapy between 6 months and 3 years earlier. In 2, fungemia with the same Candida spp. preceded the spondylodiskitis. These 3 patients bring to nearly 75 the number of reported individuals with what was once quite rare. Although IV amphotericin B doxycholate and fluconazole have usually been effective therapy over prolonged periods of time, we used liposomal amphotericin B to treat 2 of our 3 patients. Both received 5 mg/kg daily for 18-42 days that resulted in total disappearance of signs and symptoms.

CONCLUSION

This relatively brief duration of therapy reduces treatment time and is cost-effective.

Intramedullary blastomycosis in a child: case report

OBJECTIVE

To report a case of spinal intramedullary blastomycosis causing myelopathy.

CLINICAL PRESENTATION

An otherwise healthy 13-year-old patient was diagnosed with respiratory North American blastomycosis. She subsequently received a five-month course of itraconazole with presumed resolution of the infection. The patient presented again at 14 years of age with a lumbar myelopathy. Magnetic resonance imaging revealed an intramedullary lesion of 1 cm diameter at the level of T12-L1.

INTERVENTION

A T12-L1 laminectomy was performed with a gross total resection of the lesion. Pathological examination and microbiological culture of the specimen was consistent with blastomycosis. Postoperatively, the patient was placed on a five week course of amphotericin B. The patient showed substantial improvement in neurological function.

CONCLUSION

Blastomycosis can present as an isolated intramedullary lesion causing compromised function. It should be considered in the differential diagnosis of a patient with a myelopathy and previously recognized blastomycosis. The prognosis is good with surgical resection.

Group B streptococcal spondylodiscitis in adults: 2 case reports

Streptococcus agalactiae, or group B streptococcus (GBS), has been traditionally considered an infrequent etiologic agent of disease in adults except for urinary tract infection in pregnant women. Attention has recently been drawn to other adult infections caused by GBS such as skin and soft tissue infections, bacteriemias, pneumonia, meningitis, endocarditis, peritonitis, and bone and joint infections. We present two adult patients with GBS spondylodiscitis and review 30 cases of GBS spinal infection previously reported in the literature. This series clearly illustrates that GBS has recently been recognized as an emerging cause of vertebral infections in adults, particularly in those with chronic underlying diseases, although it can also affect immunocompetent patients without debilitating conditions. Although uncommon, GBS should be considered in the differential diagnosis of infective spondylodiscitis in nonpregnant adults, whatever the patient's immunological status.

One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis

There are few articles in the literature concerning anterior instrumentation in the surgical management of spinal tuberculosis in the exudative stage. So we report here 23 cases of active thoracolumbar spinal tuberculosis treated by one-stage anterior interbody autografting and instrumentation to verify the importance of early reconstruction of spinal stability and to evaluate the results of one-stage interbody autografting and anterior instrumentation in the surgical management of the exudative stage of throracolumbar spinal tuberculosis. Twenty-three patients, including two children (9 and 15 years old, respectively) and 21 adults with thoracolumbar spinal tuberculosis were treated surgically. T9 to L4 spinal segments were affected, and MRI/CT showed evident collapse of the vertebrae because of tuberculous destruction and paravertebral abscess. Neurological deficits were found in 15 patients. Before surgery, patients received standard anti-tuberculosis chemotherapy for 2 to 3 weeks. Under general endotracheal anaesthesia, the patients were placed in right recumbent positions, and a transthoracic, lateral extracavitary or extrapleural approach was chosen according to the tuberculosis lesion segment. After exposure, the tuberculous lesion region, including the collapsed vertebrae and in-between intervertebral disc, was almost completely resected in order to release the segmental spinal cord. Then, autologous iliac, rib or fibular graft was harvested to complete interbody fusion, and an anterior titanium-alloy plate-screw system was used to reconstruct the stability of the affected segments. Anti-tuberculosis chemotherapy was continued for at least 9 months, and the patients were supported with thoracolumbosacral orthosis for 6 months after surgery. All patients were followed up for an average of 2 years. All 23 cases were healed without chronic sinus formation or any recurrence of tuberculosis during the follow-up period. Spinal fusion occurred at a mean of 3.8 months after surgery. Of all patients with neurological deficits, 14 patients showed obvious improvement; only one patient with Frankel C lesion remained unchanged, but none of the patients got worse. During the follow-up period, a mean of 18 degrees of kyphosis correction was achieved after surgery in the adult group. Moderate progressive kyphosis because of this procedure fusion occurred postoperatively in a 9-year-old child after 2 1/2 years; another 15-year-old child did not demonstrate this phenomenon. Except for the early loosening of one screw in two cases (which did not affect the reconstruction of spinal stability), no other complications associated with this procedure were found during follow-up. Early reconstruction of spinal stability plays an important role in the surgical management of spinal tuberculosis. One-stage anterior interbody autografting and instrumentation in the surgical management of the exudative stage of spinal tuberculosis show more advantages in selected patients, but supplementary posterior fusion should be considered to prevent postoperative kyphosis when this procedure is performed in children.

Diagnostic value of 99mTc-HMDP bone scan in atypical osseous tuberculosis mimicking multiple secondary metastases

STUDY DESIGN

A case of atypical osseous tuberculosis (TB) mimicking multiple secondary metastases on radiologic and nuclear imaging is presented.

OBJECTIVES

To emphasize the contribution of nuclear bone scanning for the assessment of osseous tuberculosis in typical and atypical presentations.

SUMMARY AND BACKGROUND DATA

Skeletal locations of TB mostly involve the dorsolumbar spine and diagnosis is often delayed. The presence of multiple TB sites can mimic secondary metastases and biopsy remains the mainstay for final diagnosis.

METHODS

Clinical symptoms, lab tests, and imaging data are presented. Possible diagnoses are discussed. A review of imaging characteristics in cases of typical and atypical presentations of osseous TB is proposed.

RESULTS

A dorsal spine spondylitis was first diagnosed on a 56-year-old patient presenting neurologic deficit of the left arm. Fine needle aspiration identified bacterial infection but was negative for Mycobacterium tuberculosis. Whole-body bone scan allowed the identification of an asymptomatic sacroiliac lesion, which was accessible to biopsy and gave a final diagnosis.

CONCLUSION

Nuclear bone scanning should be kept in mind when assessing spinal pain in patients at high risk of TB infection or reactivation.

Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12-48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.

Pathomimie révélée par une arthrite septique interapophysaire postérieure polymicrobienne : diagnostic par biopsie percutanée

Septic arthritis of a lumbar facet joint is rare with few reports in the literature. Clinically, septic arthritis of a lumbar facet joint can mimic spondylodiscitis. Imaging is usually required for diagnosis. Bacteriological diagnosis is needed to optimize treatment with antibiotics. Most of the previously reported cases were due to staphylococcus aureus. We report one case due to rare bacteria which lead to a diagnosis of factitious disorder. Precise bacteriological diagnosis was obtained by CT-guided percutaneous biopsy.

Skeletal tuberculosis mimicking seronegative spondyloarthropathy

Skeletal tuberculosis (TB) is still a common problem in developing countries. It is a postprimary manifestation of TB and appears usually with fever, pain, tenderness, and limitation of motion at the involved site. We present a patient with a clinical course very suggestive of seronegative spondyloarthropathy and who had partially responded to sulphasalazine (SSZ) and nonsteroidal anti-inflammatory drugs (NSAID) but proved later to be a TB case.

One case of gram-negative anaerobic spondylodiscitis with Prevotella intermedia

We report the case of a 45-year-old woman with spondylodiscitis at L1/L2, communicating with paravertebral, intravertebral and bilateral psoas abscesses. Percutaneous computed tomography (CT)-guided abscess drainage and an intravenous antibiotic therapy with Imipenem were performed. After removing the drainage at 2 weeks, the patient was discharged at 4 weeks with normalized blood parameters, normal temperature, and without need for analgesics. The underlying bacterium in the case was a very rare gram-negative anaerobic bacterium: Prevotella intermedia.

Infective discitis with Neisseria sicca/subflava in a previously healthy adult

STUDY DESIGN

A case report of Neisseria sicca/subflava discitis in a healthy elderly female.

OBJECTIVE

To report a rare case, which is usually seen exclusively in children.

SETTING

Stoke on Trent, England.

METHOD

Case report, a 65-year-old female with a 6 month history of back and bilateral leg pain. X-rays showed collapse of L4/5 disc. No neurological deficit. Magnetic resonance imaging supported the clinical suspicion of discitis. Percutaneous biopsy followed 2 weeks later by open biopsy with bilateral root decompression was performed. Culture of L4/5 disc tissue produced Neisseria sicca/subflava. The patient was treated with a 4-week course of intravenous amoxycillin. Follow-up at 3 months confirmed clinical resolution of original symptoms.

CONCLUSION

Any organism cultured from biopsy needs to be interpreted within the context of the clinical case. If clinical suspicion is high, further weight must be added to the finding of unusual or environmental organisms and culture of a repeat aspirate or biopsy may clarify the significance.

[Spondylodiscitis. Analysis of 25 cases]

BACKGROUND

Spondylodiscitis is a rare but prolonged inflammation of two adjacent vertebral bodies and the disk in between.

AIM

To report the clinical features of a series of patients with spondylodiscitis.

MATERIAL AND METHODS

A retrospective analysis of medical records of patients with spondylitis, identified between 1989 and 2002.

RESULTS

A total of 25 cases were identified, 15 female, aged 49.8 years as a mean. Their mean evolution before admission was 4.3 months. Main complaints were back or radicular pain. Mild anemia was present in most patients. Mean erythrocyte sedimentation rate and C reactive protein values were 66 mm/h and 60 mg/L, respectively. Forty four percent of patients had neurological complications. Vertebral computed tomography and scintigraphic studies were done in 72% of patients, but magnetic resonance imaging was done only in 4 (16%). In 18 patients, a tissue sample for pathological and microbiological analysis, was obtained by imaging guiding or surgically. Tuberculosis, diagnosed on pathology, was the leading cause of spondylitis in nine cases (36%), followed by Staphylococcus aureus infection in five (20%). Other agents found were E coli and group D Streptococcus (one each). Age, symptoms, evolution time and different laboratory parameters did not differ between patients with tuberculosis and patients with other causes. A microbiological cause was not established in 36% of cases. Most patients evolved satisfactorily and recovered from neurological complications (88%). One patient with tuberculosis did not improve after prolonged treatment and 2 patients infected with S aureus died (8%).

CONCLUSIONS

Spondylodiscitis is associated to a diversity of microbial agents and in most cases has a favorable prognosis.

Psoas abscess: the spine as a primary source of infection

STUDY DESIGN

Case report, literature review, discussion.

OBJECTIVES

To emphasize the role of the spine as primary source of infection for psoas abscess.

SUMMARY OF BACKGROUND DATA

Spine-associated psoas abscesses increase with more frequent invasive procedures of the spine and recurring tuberculosis in industrialized countries. Diagnosis is often delayed by misinterpretation as arthritis, joint infection, or urologic or abdominal disorders.

METHODS

We present six cases of psoas abscesses associated with spinal infections that were treated in our hospital from January to December 2001. Diagnostic and treatment concepts are discussed.

RESULTS

Our data emphasize the importance of the spine as primary source of infection and suggest an increase in the incidence of secondary psoas abscess. Treatment includes open surgical drainage and antibiotic therapy. In patients with high operative risk and uniloculated abscess, a CT-guided percutaneous abscess drainage can be sufficient. It is essential to combine abscess drainage with causative treatment of the primary infectious focus. Related to the spine, this includes treatment of spondylodiscitis or implant infection after spinal surgery. Usually, several operations are necessary to eradicate bone and soft-tissue infection and restore spinal stability. Continuous antibiotic therapy over a period of 2-3 weeks after normalization of infectious parameters is recommended.

CONCLUSION

The spine as primary source of infection for secondary psoas abscess should always be included in differential diagnosis. Because the prognosis of psoas abscess can be improved by early diagnosis and prompt onset of therapy, it needs to be considered in patients with infection and back or hip pain or history of spinal surgery.

[Eikenella corrodens-induced spondylitis. Detection with 16s-RNA polymerase chain reaction]

Isolation of the relevant organism in patients with spondylitis even after an open biopsy is successful only in 75-90%. The rare case of an Eikenella corrodens-induced spondylitis is presented, which could only be identified using 16S ribosomal DNA polymerase chain reaction following unsuccessful microbiological cultivation. Eikenella corrodens is a facultative anaerobic gram-negative organism, which is mostly found in the oropharynx of healthy patients.

Three-year outcome in a patient with Staphylococcus lugdunensis discitis

The few reported cases of bone and joint infection by Staphylococcus lugdunensis indicate that the clinical manifestations are severe, the diagnosis elusive, and the treatment difficult. We report a case of lumbar discitis caused by Staphylococcus lugdunensis in a 67-year-old man receiving chemotherapy for stage III IgA lambda multiple myeloma. Treatment was with ofloxacin and pristinamycin for 1 year. Although he started to improve only 5 months after treatment initiation, the outcome was favorable. Follow-up at the time of this writing is 3 years.

Management of nontuberculous infectious discitis. treatments used in 110 patients admitted to 12 teaching hospitals in France

The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 +/- 13.7 years (range, 17-86 years). Mean time from symptom onset to diagnosis was 39.6 +/- 39.8 days (range, 24 h-240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 +/- 14.1 days (range, 4-78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 +/- 17.6 days (range, 4-124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 +/- 43.6 day (range, 20-278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.

Pneumococcal vertebral osteomyelitis: a unique case with atypical clinical course

STUDY DESIGN

A case report.

OBJECTIVES

To report and discuss a case of pneumococcal vertebral osteomyelitis with meningitis in a previously healthy 51-year-old immunocompetent woman who presented with acute onset lower back pain.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, pneumococcal vertebral osteomyelitis with meningitis in an immunocompetent person with no other predisposing factor has not been reported previously.

METHODS

The patient was diagnosed to have pneumococcal meningitis 10 days after the onset of acute and severe lower back pain. Significant improvement of clinical symptoms from meningitis was achieved with appropriate antimicrobial treatment. Lumbar CT and MRI scans were performed on persistence of fever and lower back pain. Loss of height and peridiscal inflammation at L3-L4 and epidural and bilateral psoas abscesses were detected.

RESULTS

Diagnosis of pneumococcal vertebral osteomyelitis was established after evaluation of the material obtained from CT-guided aspiration of the psoas abscess and biopsy of the L3 body. With appropriate antimicrobial treatment, the patient's complaints resolved completely.

CONCLUSION

To the authors' knowledge, this is the first reported case of pneumococcal vertebral osteomyelitis with meningitis.

[Isolated purulent arthritis of lumbar facet joint]

We present the case of a 51-year-old woman suffering from septic arthritis of a lumbar facet joint, which was probably caused by an infected central venous catheter. Increased uptake on the bone scintigraphy was an early finding. Magnetic resonance imaging (MRI) of the spine contributed to the diagnosis by showing lesions of the facet joint and involvement of the surrounding soft tissues. Percutaneous needle aspiration guided by computed tomography established a bacteriological diagnosis. The positive response to antibiotic therapy was confirmed by MRI.

A definite case of spondylodiscitis caused by Streptococcus equisimilis

To shed light on the role of Streptococcus equisimilis (SE) in the pathogenesis of intervertebral disc infection, we report here a case of lumbar spondylodiscitis in a 37-year-old male caused by SE, with identification of this strain by cultures from L4-L5 lumbar disc biopsy. Intravenous therapy with penicillin and gentamycin combined with immobilization resulted in a rapid and complete recovery. The patient did not have underlying disease and showed no obvious history of exposure to animals. We conclude that SE may be responsible for both septic arthritis and spondylodiscitis.

Bacteroides fragilis vertebral osteomyelitis secondary to anal dilatation

STUDY DESIGN

A case report of anaerobic vertebral osteomyelitis after anal dilatation.

OBJECTIVES

To present a patient with monomicrobial anaerobic vertebral osteomyelitis secondary to a previously undescribed source of infection.

SUMMARY OF BACKGROUND DATA

A 17-year-old boy presented with low back pain 3 months after anal dilatation.

METHODS

Physical examination, technetium-99m bone scan, plain radiograph, CT, and MRI studies of the lumbar spine were used to clinically diagnose lumbar osteomyelitis. Culture material from the involved disc was positive for Bacteroides fragilis.

RESULTS

The patient recovered after 8 weeks of treatment with oral metronidazole.

CONCLUSIONS

Bacteroides fragilis hematogenous osteomyelitis is a rare entity. This is the first reported case of such disease after anal dilatation.

Hematogenous pyogenic facet joint infection

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections.

SUMMARY OF BACKGROUND DATA

There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases.

METHODS

This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment.

RESULTS

A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37).

CONCLUSIONS

Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.

Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis

STUDY DESIGN

A case report.

OBJECTIVES

To report and discuss a case of contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis, so that investigators and practitioners may avoid the diagnostic and therapeutic pitfalls associated with pyogenic vertebral spondylitis and aortic disease.

SUMMARY OF BACKGROUND DATA

Pyogenic vertebral spondylitis is a rare disorder that may have serious consequences, including death, if it is not diagnosed promptly and treated effectively. The association of pyogenic vertebral spondylitis with infection of the aorta is a rare but potentially fatal condition that requires prompt diagnosis and aggressive surgical and medical therapy. To our knowledge, this is the first report of a contained rupture of the aneurysm of common iliac artery case associated with pyogenic vertebral spondylitis resulting from an infection with Bacteroides fragilis,although Salmonellae infections are commonly associated with vertebral osteomyelitis and lesions of the contiguous aorta.

METHODS

A 60-year-old man with chronic lower back pain began to experience a severe pain and had increased difficulty in walking. An MRI scan showed an increased signal in the L4-L5 disc space and an abscess extending into the spinal canal. The presumptive diagnosis was infective spondylitis. While performing a CT-guided needle biopsy, an unexpected contained rupture of the aneurysm of common iliac artery was discovered.

RESULTS

A wide resection of all infected tissue, including the right common iliac artery and bony lesions, was performed in combination with antimicrobial therapy. A cryopreserved aortic allograft was used to reconstruct the artery, and an iliac strut graft was used to fill the debrided vertebral cavity. The patient's postoperative recovery was uneventful.

CONCLUSION

The coexistence of pyogenic vertebral spondylitis and lesions of the aorta is rare, but may be lethal if not diagnosed promptly and treated effectively. Even if a patient's condition is stable and the hematocrit is normal, it is important to consider the possibility of a contained rupture of a mycotic abdominal aneurysm in all patients with vertebral osteomyelitis who have acute episodes of unusual severe back pain. CT is sometimes more beneficial than MRI in the identification and characterization of contained rupture of aneurysms.

Candida albicans spinal epidural abscess secondary to prosthetic valve endocarditis

A 56-year-old woman, with underlying rheumatic heart disease status post mitral valve replacement, presented with fever, low back pain radiating to right leg, and congestive heart failure. Magnetic resonance imaging detected an L5-S1 spinal epidural abscess. A vegetation on prosthetic mitral valve was found by transesophageal echocardiography. Cultures of epidural aspirate, surgical specimen, and blood all grew Candida albicans. She received surgical drainage of the spinal epidural abscess and i.v. amphotericin B 1 mg/kg/day for eight weeks. Clinical symptoms improved gradually and she was discharged without neurologic sequelae. She remained well and continued to lead an active life two years after discharge.

Vertebral infections caused by Haemophilus aphrophilus: case report and review

OBJECTIVE

To review in detail clinical presentation, bacteriologic findings, associated conditions and treatment of Haemophilus aphrophilus vertebral osteomyelitis and to compare them to a case we report herein.

METHODS

A Medline (National Library of Medicine) search of the literature was performed by using the key words H. aphrophilus, spondylodiscitis, discitis, and vertebral osteomyelitis. The references of the case reports were examined for additional cases, especially those cited in older articles that had not been entered onto the bibliographic database.

RESULTS

A case report of spondylodiscitis due to H. aphrophilus in a 35-year-old patient with a history of dental abscess 7 months before admission is presented. The patient responded well to treatment with ceftriaxone and ciprofloxacin. To date, only 14 cases of H. aphrophilus vertebral osteomyelitis have been reported. They are usually reported in middle-aged patients, usually male. Most recent cases have been treated with fluoroquinolones. Duration of treatment usually ranges from 1 to 3 months.

CONCLUSIONS

H. aphrophilus is an uncommon cause of vertebral osteomyelitis. Patients are regularly cured by antibiotic therapy, provided that a tissue biopsy is performed in order to isolate the causative bacterium.

Fungal discitis due to Aspergillus terreus in a patient with acute lymphoblastic leukemia

We report a case of Aspergillus terreus discitis which developed in a patient with acute lymphoblastic leukemia following induction chemotherapy. A. terreus was isolated from sputum, one month earlier, but the physician did not consider it significant at the time. Magnetic resonance imaging study showed the involvement of L3-4, L4-5 and L5-S1 intervertebral discs. Etiology was established by means of histology and culturing a surgical specimen of disc materials. Our patient survived after a surgical debridement and amphotericin B administration with a total dose of 2.0 g. Discitis caused by Aspergillus terreus is a very rare event. A. terreus is one of the invasive Aspergillus species. The pathogenetic mechanism is discussed and the literature is reviewed.

Septic arthritis of a lumbar facet joint caused by Staphylococcus aureus

STUDY DESIGN

Case report of a 35-year-old woman with septic arthritis of a lumbar facet joint.

OBJECTIVES

To report a rare case of severe low back pain and the specific differential diagnostic problems.

SUMMARY OF BACKGROUND DATA

Differential diagnosis between spondylodiscitis and facet joint septic arthritis on a clinical basis is very difficult. The lesions of the joint appear on a plain film only approximately 1.5 months after onset of the symptoms. Although the radionuclide bone scan is sensitive and shows a more laterally and vertically localized uptake than in spondylodiscitis, this technique is not very specific. Computed tomography scan and magnetic resonance imaging are the most reliable investigations even at the very early stages of the disease. Confirmation of the diagnosis has to be obtained by blood cultures or, in exceptional cases, by direct puncture of the joint. Appropriate antibiotic treatment is in most cases sufficient to heal this lesion.

METHODS

The etiology, clinical presentation, technical examinations, and treatment are reviewed.

RESULTS

Computed tomography scan and magnetic resonance imaging complemented by positive blood cultures led to the very early diagnosis of septic arthritis of the lumbar facet joint in this relatively young patient.

CONCLUSIONS

With our case report we confirm the very small number of data reported in the literature, indicating that infections of the facet joint can be detected at a very early stage using magnetic resonance imaging and computed tomography scan.

Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study

BACKGROUND

Intervertebral disk tissue is resistant to hematogenous infection because of its avascularity. However, spondylodiskitis is being diagnosed with increasing frequency because of advancement in magnetic resonance imaging technology. There is a dearth of information regarding the bacteriology, histomorphologic features, and radiopathologic correlation of spondylodiskitis.

DESIGN

The study population consisted of 20 patients diagnosed as having spondylodiskitis by magnetic resonance imaging with and without gadolinium 67 enhancement and bone scans with technetium Tc 99m or gallium citrate Ga 67. Twenty-seven biopsy and debridement specimens were obtained from these patients. The specimens were cultured for microorganisms and also processed for histopathologic testing. Tissue sections were examined with hematoxylin-eosin and stains for infectious agents (Gomori's methenamine-silver, Gram, and Ziehl-Neelsen stains).

RESULTS

Where intervertebral disk tissue was present (23 of 27 cases), the morphologic changes included vascularization (with or without granulation tissue), myxoid degeneration, and necrosis. Chronic osteomyelitis was present in all 27 specimens and was associated with acute osteomyelitis in 7 cases (25%). Twenty-one of 27 cases had positive culture results (mostly pyogenic bacteria), but special stains revealed microorganisms in sections of the disk in only 4 cases (3 cases with gram-positive cocci and 1 with yeast consistent with Blastomyces). Florid acute inflammation was present in all the 4 cases.

CONCLUSION

Histopathologic features of acute spondylodiskitis include vascular proliferation, myxoid degeneration, and necrosis of the disk tissue with adjacent chronic osteomyelitis. Acute inflammation is variable and when florid is usually associated with identifiable organisms on histologic examination. At biopsy, tissue should be submitted for culture, since culture has a high sensitivity and specificity for detecting the etiologic organism.

Beware of short-course therapy for Staphylococcus aureus bacteremia without a removable cause

Staphylococcus aureus bacteremia has long been known to cause significant morbidity and mortality. The optimal treatment of this disease has evolved over the years. Recently, criteria have been established for the use of shorter courses of antibiotic therapy in certain patients, most notably those with an easily removed source of the bacteremia. We present the case of a 55-year-old man with S aureus bacteremia unrelated to an intravascular device. He was treated with "short-course" antibiotic therapy, and lumbar diskitis and an epidural abscess developed.

Surgical treatment of aspergillus spondylodiscitis

Four cases of aspergillus spondylodiscitis were treated with operative debridement and fusion. In this rarely encountered mycotic infection of the spine in immunocompromised patients rapid destruction of the intervertebral disc and vertebral bodies can occur. In advanced cases antimycotic drug therapy is thought to be ineffective and a forcing indication for surgery exists when the destruction is progressive and spinal cord compression is imminent or manifest. Spinal instrumentation can be of help in maintaining or restoring spinal stability and maintaining spinal alignment. In our four patients the aspergillus spondylodiscitis was successfully eradicated and fusion achieved. In two of three patients with a neurologic deficit, this deficit disappeared. Two patients died within 6 months after the operative treatment, due to complications related to the underlying illness. One patient was left with a subtotal paraplegia.

Multidrug-resistant tuberculosis spondylitis

We report a case of multidrug-resistant spinal tuberculosis complicated by epiduritis and paraspinal abscess in a 68-year-old black woman. Multidrug-resistant tuberculous spondylitis is still rare in Belgium. Two others cases were reported from 1992 to 1997. The optimal therapy is not standardized and the mandatory duration of treatment is not known. Clinical presentation, radiological findings, and treatment are presented. The need for prompt diagnosis and optimal therapy is emphasized.

MR imaging of spinal infections

In the appropriate clinical situation, MR imaging is a powerful tool in the diagnosis of spinal infection. Imaging of spinal infections requires the use of a combination of T1-weighted and T2-weighted or STIR sequences. Contrast enhancement is useful and helps to define paraspinal and epidural disease. Knowledge of potential pitfalls with MR imaging and of normal marrow conversion is required. With these points in mind, MR imaging will be beneficial in the care of patients with spinal infections.

Fungal spinal osteomyelitis in the immunocompromised patient: MR findings in three cases

The MR imaging findings of fungal spinal osteomyelitis in three recipients of organ transplants showed hypointensity of the vertebral bodies on T1-weighted sequences in all cases. Signal changes and enhancement extended into the posterior elements in two cases. Multiple-level disease was present in two cases (with a total of five intervertebral disks involved in three cases). All cases lacked hyperintensity within the disks on T2-weighted images. In addition, the intranuclear cleft was preserved in four of five affected disks at initial MR imaging. MR features in Candida and Aspergillus spondylitis that are distinct from pyogenic osteomyelitis include absence of disk hyperintensity and preservation of the intranuclear cleft on T2-weighted images. Prompt recognition of these findings may avoid delay in establishing a diagnosis and instituting treatment of opportunistic osteomyelitis in the immunocompromised patient.