Clinical findings of vertebral osteomyelitis: Brucella spp. versus other etiologic agents

Extended drug-resistant Salmonella typhi osteomyelitis: a case report and literature review

Background

Salmonella typhi infection commonly results in gastroenteritis, bacteremia with or without secondary seeding, or asymptomatic carrier stage. Few cases of Salmonella typhi bacteremia later result in seeding and ultimately lead to further complications including osteomyelitis and rarely vertebral osteomyelitis.

Case presentation

We are discussing a case of a 38-year-old Asian male patient, with no known comorbids. He presented with fever and backache for 4 weeks. Based on the magnetic resonance imaging (MRI) findings of the spine and positive blood cultures, a diagnosis of XDR Salmonella typhi (S. typhi) osteomyelitis (OM) was made. Patient was started on intravenous therapy as per culture report which was later modified according to treatment response.

Conclusion

S. typhi has a broad spectrum of clinical manifestations including osteomyelitis however to the best of our knowledge this is the first reported case of XDR S. typhi vertebral osteomyelitis. We describe the clinical course of the patient and review the literature regarding the treatment of S.typhi vertebral osteomyelitis with a special focus on XDR S. typhi. Treatment course and complications in view of this new resistant strain have to be reported in order to devise general guidelines for the management in such particular cases.

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults

PURPOSE

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome.

METHODS

An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology.

RESULTS

A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria.

CONCLUSIONS

This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

Vertebral osteomyelitis in adults: an update

INTRODUCTION

The incidence of vertebral osteomyelitis is increasing, attributed to an ageing population with inherent co-morbidities and improved case ascertainment.

SOURCES OF DATA

References were retrieved from the PubMed database using the terms 'vertebral osteomyelitis' and 'spondylodiscitis' between January 1, 2009 and April 30, 2014 published in English as checked in May 2014 (>1000 abstracts checked).

AREAS OF AGREEMENT

Blood cultures and whole spine imaging with magnetic resonance imaging are essential investigations. Thorough debridement is the mainstay of surgical management, although placing metalwork in active infection is becoming increasingly common.

AREAS OF CONTROVERSY

The extent of pursuing spinal biopsies to determine aetiology, antimicrobial choices and duration, monitoring the response to treatment, and surgical techniques and timing all vary widely in clinical practice with heterogeneous studies limiting comparisons. Surgery, rather than conservative approaches, is being proposed as the default management choice, because it can, in carefully selected patients, offer faster reduction in pain scores and improved quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to define the most effective technique for spinal biopsies to maximize determining aetiology. High-quality trials are required to provide an evidence base for both the medical and surgical management of vertebral osteomyelitis, including challenging medical management as the default option.