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Abstract
In the setting of both globalization and increasing use of immunosuppressive therapy, infectious myelopathies are an important cause of morbidity worldwide. Clinical spinal cord syndromes related to infection are varied, including transverse myelitis, acute flaccid paralysis related to anterior horn cell involvement, spinal cord compression, chronic spastic paraparesis, and myeloradiculitis. Causative pathogens include viruses, parasites, pyogenic and atypical bacteria, and fungi. The epidemiology, clinical characteristics, diagnosis, and treatment of selected organisms will be discussed in this article.
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Affiliation(s)
- Pria Anand
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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2
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Winn A, Martin A, Castellon I, Sanchez A, Lavi ES, Munera F, Nunez D. Spine MRI: A Review of Commonly Encountered Emergent Conditions. Top Magn Reson Imaging 2021; 29:291-320. [PMID: 33264271 DOI: 10.1097/rmr.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.
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Affiliation(s)
- Aaron Winn
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Adam Martin
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Ivan Castellon
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Allen Sanchez
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | | | - Felipe Munera
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Diego Nunez
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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3
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Salaffi F, Ceccarelli L, Carotti M, Di Carlo M, Polonara G, Facchini G, Golfieri R, Giovagnoni A. Differentiation between infectious spondylodiscitis versus inflammatory or degenerative spinal changes: How can magnetic resonance imaging help the clinician? Radiol Med 2021; 126:843-859. [PMID: 33797727 PMCID: PMC8154816 DOI: 10.1007/s11547-021-01347-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/14/2021] [Indexed: 12/19/2022]
Abstract
Spondylodiscitis is a complex disease whose diagnosis and management are still challenging. The differentiation between infectious and non-infectious aetiology is mandatory to avoid delays in the treatment of life-threatening infectious conditions. Imaging methods, in particular magnetic resonance imaging (MRI), play a key role in differential diagnosis. MRI provides detailed anatomical information, especially regarding the epidural space and spinal cord, and may allow differential diagnosis by assessing the characteristics of certain infectious and inflammatory/degenerative lesions. In this article, we provide an overview of the radiological characteristics and differentiating features of non-infectious inflammatory spinal disorders and infectious spondylodiscitis, focussing on MRI results and presenting relevant clinical and pathological features that help early diagnosis.
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Affiliation(s)
- Fausto Salaffi
- Clinica Reumatologica, Ospedale "Carlo Urbani", Dipartimento Di Scienze Cliniche E Molecolari, Università Politecnica Delle Marche, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy
| | - Luca Ceccarelli
- Unità di Radiologia, Dipartimento di Medicina Specialistica, Diagnostica E Sperimentale, Ospedale Sant'Orsola, Università Di Bologna, Via Albertoni 15, 40138, Bologna, Italy.,Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italia
| | - Marina Carotti
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
| | - Marco Di Carlo
- Clinica Reumatologica, Ospedale "Carlo Urbani", Dipartimento Di Scienze Cliniche E Molecolari, Università Politecnica Delle Marche, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy.
| | - Gabriele Polonara
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
| | - Giancarlo Facchini
- Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italia
| | - Rita Golfieri
- Unità di Radiologia, Dipartimento di Medicina Specialistica, Diagnostica E Sperimentale, Ospedale Sant'Orsola, Università Di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Andrea Giovagnoni
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
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Majmundar N, Patel PD, Dodson V, Tran A, Goldstein I, Assina R. Parasitic infections of the spine: case series and review of the literature. Neurosurg Focus 2020; 46:E12. [PMID: 30611161 DOI: 10.3171/2018.10.focus18472] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVEAlthough parasitic infections are endemic to parts of the developing world and are more common in areas with developing economies and poor sanitary conditions, rare cases may occur in developed regions of the world.METHODSArticles eligible for the authors' literature review were initially searched using PubMed with the phrases "parasitic infections" and "spine." After the authors developed a list of parasites associated with spinal cord infections from the initial search, they expanded it to include individual diagnoses, using search terms including "neurocysticercosis," "schistosomiasis," "echinococcosis," and "toxoplasmosis."RESULTSTwo recent cases of parasitic spinal infections from the authors' institution are included.CONCLUSIONSKey findings on imaging modalities, laboratory studies suggestive of parasitic infection, and most importantly a thorough patient history are required to correctly diagnose parasitic spinal infections.
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Abstract
Infectious diseases are an important cause of spinal cord dysfunction. Infectious myelopathies are of growing concern given increasing global travel and migration and expanding prevention and treatment with vaccinations, antibiotics, and antiretrovirals. Clinicians must recognize these pathologies because outcomes can dramatically improve with prompt diagnosis and management. We provide a complete review of the most frequent infectious agents that can affect the spinal cord. For each pathogen we describe epidemiology, pathophysiology, anatomic location, characteristic clinical syndromes, diagnostic approach, treatment, and prognosis. The review includes spinal imaging from selected cases.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology, Brown University, Rhode Island Hospital, 222 Richmond Street, Providence, RI 02903, USA
| | - Tracey A Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242, USA.
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Mohole J, Ho AL, Sussman ES, Pendharkar AV, Lee M. Focal Intramedullary Spinal Cord Lesion in Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome: Toxoplasmosis Versus Lymphoma. World Neurosurg 2019; 127:227-231. [PMID: 30981796 DOI: 10.1016/j.wneu.2019.04.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurologic complications are common in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Although both the central nervous system (CNS) and the peripheral nervous system can be affected, 80% of patients with HIV/AIDS have CNS involvement during the course of their illness. The brain is the primary site of HIV/AIDS-associated CNS complications. Spinal cord involvement is rare, particularly focal intramedullary spinal cord lesions without any associated cerebral lesions. Among various opportunistic infections and malignancies, toxoplasmosis and CNS lymphoma are the most common causes of focal neurologic disease in patients with HIV/AIDS. Distinguishing between toxoplasmosis and CNS lymphoma is challenging, as the diseases have similar clinical presentations. CASE DESCRIPTION In a woman with newly diagnosed HIV infection, myelopathy manifested as an isolated, single intramedullary spinal cord lesion. CONCLUSIONS Common methods to distinguish the diagnoses of toxoplasmosis and CNS lymphoma are addressed. There should be a high index of suspicion for toxoplasmosis in patients with HIV/AIDS presenting with a focal intramedullary spinal cord lesion.
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Affiliation(s)
- Jyodi Mohole
- Department of Neurosurgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Marco Lee
- Department of Neurosurgery, Santa Clara Valley Medical Center, San Jose, California, USA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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7
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Abstract
Spinal infection is rare. Clinical suspicion is important in patients with nonmechanical neck and/or back pain to make the proper diagnosis in early disease. Before planning surgery, a thorough evaluation of the spinal stability, alignment, and deformity is necessary. Timing of surgery, side of approach, appropriate surgical technique, and spinal instruments used are crucial. Biomechanical preservation of the spinal column during and after the infection is a significant issue. Postoperative spine infection is another entity of which spinal surgeons should be aware of. Proper septic conditions with meticulous planning of surgery are essential for successful spine surgery and better outcome.
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Affiliation(s)
- Derya Burcu Hazer
- Department of Neurosurgery, Mugla Sitki Kocman University School of Medicine, Orhaniye Mahallesi, Haluk Ozsoy Caddesi, Mugla 48000, Turkey
| | - Selim Ayhan
- Malatya State Hospital, Department of Neurosurgery, Firat Mahallesi, Hastane Caddesi, Malatya 44330, Turkey
| | - Selcuk Palaoglu
- Department of Neurosurgery, Hacettepe University School of Medicine, Sihhiye, Altindag, Ankara 06100, Turkey.
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Agrawal SR, Singh V, Ingale S, Jain AP. Toxoplasmosis of spinal cord in acquired immunodeficiency syndrome patient presenting as paraparesis: a rare entity. J Glob Infect Dis 2014; 6:178-81. [PMID: 25538456 PMCID: PMC4265833 DOI: 10.4103/0974-777x.145248] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Although brain has been the most common site for toxoplasma infection in acquired immunodeficiency syndrome patients, involvement of spinal cord by toxoplasma has been rarely found. Spinal cord toxoplasmosis can present as acute onset weakness in both lower limbs associated with sensory and bladder dysfunction. A presumptive diagnosis can be made in patients with CD4 count <100/mm(3) based on a positive serum Toxoplasma gondii IgG antibodies, no recent prophylaxis against toxoplasmosis, intramedullary ring enhancing lesion in spinal cord supported by similar lesions in brain parenchyma. Institutions of antitoxoplasma treatment in such patients result in prompt clinical response and therefore avoiding the need of unnecessary invasive diagnostic tests. Here, we report a case of toxoplasmic myelitis in immunocompromised patient presenting as myelopathy who showed significant clinical improvement after starting antitoxoplasma treatment. Hence toxoplasmic myelitis should be considered in toxoplasma seropositive immunocompromised patients presenting as myelopathy and imaging studies showing ring enhancing intramedullary lesion.
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Affiliation(s)
- Sachin R Agrawal
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Vinita Singh
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Sheetal Ingale
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Ajeet Prasad Jain
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
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Rodríguez C, Martínez E, Bolívar G, Sánchez S, Carrascal E. Toxoplasmosis of the spinal cord in an immunocompromised patient: case report and review of the literature. Colomb Med (Cali) 2013; 44:232-5. [PMID: 24892240 PMCID: PMC4001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 03/15/2012] [Accepted: 08/16/2013] [Indexed: 11/16/2022] Open
Abstract
We, herein, describe an HIV-positive patient with toxoplasmosis of the spinal cord. We also carried out a comprehensive literature review of this topic, with emphasis on the diagnostic tools and therapeutic approach.
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Affiliation(s)
- Carolina Rodríguez
- Universidad del Valle. Hospital Universitario del Valle. Department of Internal Medicine. Cali, Colombia.
| | - Ernesto Martínez
- Universidad del Valle and Universidad Libre. Hospital Universitario del Valle, Department of Internal Medicine. Cali, Colombia.
| | | | - Sandra Sánchez
- Universidad del Valle. Hospital Universitariodel Valle, Department of Pathology. Cali, Colombia
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Ganiem AR, Dian S, Indriati A, Chaidir L, Wisaksana R, Sturm P, Melchers W, van der Ven A, Parwati I, van Crevel R. Cerebral toxoplasmosis mimicking subacute meningitis in HIV-infected patients; a cohort study from Indonesia. PLoS Negl Trop Dis 2013; 7:e1994. [PMID: 23326616 PMCID: PMC3542116 DOI: 10.1371/journal.pntd.0001994] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/16/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND HIV-associated subacute meningitis is mostly caused by tuberculosis or cryptococcosis, but often no etiology can be established. In the absence of CT or MRI of the brain, toxoplasmosis is generally not considered as part of the differential diagnosis. METHODOLOGY/PRINCIPAL FINDINGS We performed cerebrospinal fluid real time PCR and serological testing for Toxoplasma gondii in archived samples from a well-characterized cohort of 64 HIV-infected patients presenting with subacute meningitis in a referral hospital in Indonesia. Neuroradiology was only available for 6 patients. At time of presentation, patients mostly had newly diagnosed and advanced HIV infection (median CD4 count 22 cells/mL), with only 17.2% taking ART, and 9.4% PJP-prophylaxis. CSF PCR for T. Gondii was positive in 21 patients (32.8%). Circulating toxoplasma IgG was present in 77.2% of patients tested, including all in whom the PCR of CSF was positive for T. Gondii. Clinically, in the absence of neuroradiology, toxoplasmosis was difficult to distinguish from tuberculosis or cryptococcal meningitis, although CSF abnormalities were less pronounced. Mortality among patients with a positive CSF T. Gondii PCR was 81%, 2.16-fold higher (95% CI 1.04-4.47) compared to those with a negative PCR. CONCLUSIONS/SIGNIFICANCE Toxoplasmosis should be considered in HIV-infected patients with clinically suspected subacute meningitis in settings where neuroradiology is not available.
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Affiliation(s)
- A. Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Sofiati Dian
- Department of Neurology, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Agnes Indriati
- Department of Clinical Pathology, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Lidya Chaidir
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rudi Wisaksana
- Department of Internal Medicine, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Patrick Sturm
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Willem Melchers
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Andre van der Ven
- Department of Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ida Parwati
- Department of Clinical Pathology, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- * E-mail:
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Burrowes D, Boyer K, Swisher CN, Noble AG, Sautter M, Heydemann P, Rabiah P, Lee D, McLeod R. Spinal Cord Lesions in Congenital Toxoplasmosis Demonstrated with Neuroimaging, Including Their Successful Treatment in an Adult. ACTA ACUST UNITED AC 2012; 3. [PMID: 23487348 DOI: 10.4303/jnp/235533] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging studies for persons in the National Collaborative Chicago-Based Congenital Toxoplasmosis Study (NCCCTS) with symptoms and signs referable to the spinal cord were reviewed. Three infants had symptomatic spinal cord lesions, another infant a Chiari malformation, and another infant a symptomatic peri-spinal cord lipoma. One patient had an unusual history of prolonged spinal cord symptoms presenting in middle age. Neuroimaging was used to establish her diagnosis and response to treatment. This 43 year-old woman with congenital toxoplasmosis developed progressive leg spasticity, weakness, numbness, difficulty walking, and decreased visual acuity and color vision without documented re-activation of her chorioretinal disease. At 52 years of age, spinal cord lesions in locations correlating with her symptoms and optic atrophy were diagnosed with 3 Tesla MRI scan. Treatment with pyrimethamine and sulfadiazine decreased her neurologic symptoms, improved her neurologic examination, and resolved her enhancing spinal cord lesions seen on MRI.
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