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Wessell NM, Krieg B, Damioli L, Kleck CJ. Atypical Mycobacterial Infections of the Spine: Evaluation and Management. Orthopedics 2024; 47:e61-e66. [PMID: 38285551 DOI: 10.3928/01477447-20240122-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Atypical mycobacterial infections of the spine can be difficult to treat and represent a subset of the vertebral osteomyelitis and diskitis spectrum often requiring early and aggressive surgical intervention. The purpose of this review is to improve the understanding of and approach to disease management from the perspective of the spine surgeon. MATERIALS AND METHODS Debridement or excision of the affected levels may be necessary to decrease mycobacterial loads and restore biomechanics. A close relationship with the patient's internal medicine and infectious disease specialists should be maintained to ensure disease eradication or remission. Long-term suppressive antibiotic therapy may be required for infection control. RESULTS AND CONCLUSION Atypical mycobacterial spine infections are rare, complex, and difficult to eradicate. Our institution proposes a collaborative effort among the spine surgeon, infectious disease specialists, and internal medicine specialists to best approach the work-up, diagnosis, and treatment of these infections. [Orthopedics. 2024;47(2):e61-e66.].
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Husain FF, Nakamae T, Kamei N, Omori K, Maruyama T, Nakao K, Adachi N. Vertebral osteomyelitis due to Mycobacterium abscessus subsp. massiliense with paravertebral abscess: A case report and review. J Infect Chemother 2023:S1341-321X(23)00134-4. [PMID: 37244350 DOI: 10.1016/j.jiac.2023.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
The incidence of vertebral osteomyelitis (VO) caused by non-tuberculosis mycobacteria (NTM) without immunocompetence is extremely rare. Herein, we reported on a case of VO caused by NTM. A 38-year-old man was admitted to our hospital with persisting low back and leg pain which had lasted for a year. Before coming to our hospital, the patient was treated with antibiotics and iliopsoas muscle drainage. The biopsy confirmed the presence of a NTM, Mycobacterium abscessus subsp. massiliense. Several tests were conducted which showed the infection had progressively increased, such as vertebral endplate destruction on plain radiography, computed tomography scan, and epidural and paraspinal muscle abscesses on magnetic resonance imaging. The patient underwent radical debridement, anterior intervertebral fusion with bone graft, and posterior instrumentation with antibiotic administration. A year later, the patient's low back and leg pain was relieved without any analgetic. VO due to NTM is rare but can be treated with multimodal therapy.
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Affiliation(s)
- Fadlyansyah F Husain
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Department of Orthopaedic and Traumatology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Toshio Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshiaki Maruyama
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuto Nakao
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Omori K, Kitagawa H, Tadera K, Naka Y, Sakamoto S, Kamei N, Nomura T, Shigemoto N, Hattori N, Ohge H. Vertebral osteomyelitis caused by Mycobacteroides abscessus subsp. abscessus resulting in spinal cord injury due to vertebral body fractures. J Infect Chemother 2021; 28:290-294. [PMID: 34593323 DOI: 10.1016/j.jiac.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
Nontuberculous mycobacteria (NTM) rarely cause vertebral osteomyelitis; however, the clinical characteristics of vertebral osteomyelitis caused by NTM are poorly understood due to its rarity. A 74-year-old man with lung cancer was treated with prednisolone for immune checkpoint inhibitor-associated immune-related adverse events. He had been experiencing mild back pain without febrile episodes for five months, and was admitted to the hospital for worsening back pain and progressive paraplegia. Magnetic resonance imaging showed spinal cord compression at T4-5 due to fractures of the T5 and T7 vertebral bodies. The culture of a sample of pus from the T7 vertebral body obtained at the time of spinal fusion surgery yielded the Mycobacteroides abscessus (M. abscessus) complex. The patient was diagnosed with vertebral osteomyelitis caused by M. abscessus complex and treated with clarithromycin, amikacin, and imipenem; clarithromycin was later replaced by sitafloxacin because of inducible macrolide resistance. However, his neurologic deficits were irreversible, and he died due to a deteriorating general condition. The strain was identified up to subspecies level as M. abscessus subsp. abscessus by hsp65 and rpoB sequencing and nucleic acid chromatography. Although vertebral osteomyelitis due to NTM is rare, delayed diagnosis can lead to serious complications or poor outcomes. A prolonged clinical course, less frequent fever, vertebral destruction or spinal deformity, neurological deficits, or immunosuppressed conditions might be suggestive of NTM vertebral osteomyelitis.
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Affiliation(s)
- Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Hiroki Kitagawa
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kayoko Tadera
- Section of Clinical Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuhiko Naka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshihito Nomura
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Norifumi Shigemoto
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Translational Research Center, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
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Zhang H, Guo Q, Wang Y, Guo C, Tang M. The efficiency of the posterior-only approach using shaped titanium mesh cage for the surgical treatment of spine tuberculosis in children: A preliminary study. J Orthop Surg (Hong Kong) 2019; 26:2309499018806684. [PMID: 30352547 DOI: 10.1177/2309499018806684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The study aimed to evaluate the efficiency of the posterior-only approach using shaped titanium mesh cage for surgical treatment of spinal tuberculosis (TB) in children. METHODS Between January 2011 and July 2013, 22 children with a single motion spinal segment involved, including 10 with thoracic, 4 with thoracolumbar, and 8 with lumbar, were enrolled in the study. The patients were treated by the posterior-only approach using the shaped titanium mesh cages. Their medical records and radiographs were retrospectively analyzed. RESULTS The mean operating time was 163 min (ranging from 120 min to 200 min). Blood loss was 210-550 ml with an average of 300 ml. The mean follow-up period was 41.1 months. At the final follow-up, all patients showed a solid bony fusion without the infection recurrence. The average bone fusion time was 6.2 months. The average correction of the local segment kyphosis angle was 6.9° (from 9.2° preoperative to 2.3° postoperative). Minimal loss in correction angle was noted in these patients at the final follow-up (only 1.5°). Changes in erythrocyte sedimentation rate, local segment kyphosis angle, and neurological status demonstrated a significant clinical improvement in all children at their last follow-up. CONCLUSION Children with spinal TB of a single motion spinal segment involved can be successfully treated by the posterior-only approach using shaped titanium mesh cage. It is a minimally invasive, safe, and effective surgical procedure.
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Affiliation(s)
- Hongqi Zhang
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qiang Guo
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yunjia Wang
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chaofeng Guo
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mingxing Tang
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Zhang H, Guo Q, Liu S, Guo C, Gao Q, Tang M. Comparison of mid-term outcomes of posterior or postero-anterior approach using different bone grafting in children with lumbar tuberculosis. Medicine (Baltimore) 2019; 98:e14760. [PMID: 30855476 PMCID: PMC6417493 DOI: 10.1097/md.0000000000014760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The anterior and middle columns instead of the posterior column of spine are usually destroyed by tuberculosis which could aggravate the kyphosis accompanying the growth imbalance of spine in children. The surgical method needs to be selected cautiously for effective treatment. To our knowledge, few studies have evaluated mid-term outcomes of 2 surgeries (posterior-only approach and combined posterior and anterior approaches) with allograft or shaped titanium mesh cages for the treatment of lumbar tuberculosis in children. The study aims to compare the surgical mid-term outcomes of the posterior-only approach and the combined approaches using different bone grafting for the treatment of pediatric lumbar tuberculosis.Between January 2007 and June 2013 at our spine center, 51 consecutive pediatric lumbar tuberculosis with an average age of 7.3 ± 3.93 years treated with combined posterior and anterior approaches (PA, 22 cases) or posterior-only approach (PO, 29 cases) were enrolled. Two types of interbody bone graft were applied in this study: fresh-frozen tricortical iliac-bone allograft (AG, 21 cases) and shaped titanium mesh cages (TM, 30 cases). All medical records and radiographs were retrospectively reviewed. The Japanese Orthopaedic Association (JOA) is applied to evaluate the neurological function. The average visual analogue (VAS) and Oswestry Disability Index (ODI) were used to evaluate the quality of life.The average follow-up was 6.7 ± 1.9 years. The mean operation time, average blood loss, complication rate, and lengths of hospital stay of PO were less than those of the PA. The postoperative VAS (1 day after surgery) of PA was significantly higher than that of PO. The ODI, VAS and JOA scores at the final follow-up had been improved significantly compared with preoperative scores. The ODI, VAS and JOA scores at the final follow-up were similar between PA and PO as well as between AG and TM. There was no statistically significant difference about the fusion times between PO and PA groups. The final follow-up kyphosis correction rate and the correction loss at the final follow-up between the PO and PA groups showed no statistically significant difference. However, the final follow-up correction rate of the AG group was lower than that of TM group. The correction loss of the AG group was higher than that of TM group.The posterior only approach in experienced hands provides satisfying treatment for the children lumbar tuberculosis with less invasive, much safer, and more effective compared with combined posterior and anterior approach. The shaped titanium mesh cages are noted to be a valuable tool in surgical decision making.
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Gray ME, Liu PW, Wispelwey B. Mycobacterium Avium complex vertebral osteomyelitis in the absence of HIV infection: a case report and review. BMC Infect Dis 2018; 18:235. [PMID: 29788907 PMCID: PMC5964668 DOI: 10.1186/s12879-018-3143-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 05/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mycobacterium Avium Complex (MAC) is an established microbiologic cause of pulmonary disease, lymphadenitis, and disseminated disease in cases of advanced immune suppression. However, MAC manifesting as vertebral osteomyelitis is less common, and is particularly rare in the absence of Acquired Immunodeficiency Syndrome (AIDS). Prompt diagnosis of MAC vertebral osteomyelitis is challenging, but necessary to prevent serious morbidity or mortality. CASE PRESENTATION We report a case of MAC osteomyelitis of the lumbar spine in a 70-year-old woman on extended duration corticosteroid therapy for systemic lupus erythematosus who presented with progressive back pain. Upon presentation, imaging revealed osteomyelitis of the lumbar spine with associated paraspinal abscess. Cultures from the surgical evacuation of the paraspinal abscess yielded no pathogen growth and she was therefore treated with empiric antibacterial therapy. Two weeks after her initial hospital discharge she represented with severe back pain and radiologic evidence of progressive disease in her lumbar spine. Two additional vertebral biopsies were required during her first 2 weeks of admission. MAC eventually grew from culture 14 days after collection. She was treated with ethambutol and rifampin and her symptoms resolved in 2 weeks, though therapy was continued for 12 months. CONCLUSIONS MAC is an unusual cause of vertebral osteomyelitis in patients with AIDS, but is exceedingly rare in those without severe immune compromise. Despite its rarity, it must be considered in cases of vertebral osteomyelitis that do not respond to empiric antibiotic therapy. Multiple biopsies may be necessary to obtain a diagnosis and avoid destructive infectious complications of an untreated infection.
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Affiliation(s)
- Megan E Gray
- Division of Infectious Diseases and International Health, University of Virginia Health System, P.O. Box 801379, Charlottesville, VA, 22908-1361, USA.
| | - Peter W Liu
- Department of Infectious Diseases, University of Pennsylvania Health System
- , 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Brian Wispelwey
- Division of Infectious Diseases and International Health, University of Virginia Health System, P.O. Box 801379, Charlottesville, VA, 22908-1361, USA
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Kim CJ, Kim UJ, Kim HB, Park SW, Oh MD, Park KH, Kim NJ. Vertebral osteomyelitis caused by non-tuberculous mycobacteria: Predisposing conditions and clinical characteristics of six cases and a review of 63 cases in the literature. Infect Dis (Lond) 2016; 48:509-16. [PMID: 27002256 DOI: 10.3109/23744235.2016.1158418] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Several case series have reported on clinical and radiographic characteristics of patients with vertebral osteomyelitis (VO) caused by non-tuberculous mycobacteria (NTM). However, only a few patients were included, and systematic reviews are still lacking. The aim of this study was to update and summarise the pre-disposing conditions, clinical and radiographic characteristics of such cases due to NTM. Methods In this study, a systematic review was conducted of the English-language literature from 1961-2014 to investigate the pre-disposing conditions and characteristics of cases of VO due to NTM. Also, six additional cases diagnosed in the study hospitals were described; these cases are included in an analysis of a total of 69 cases of NTM VO. Results The most common species, regardless of the presence of HIV co-infection, was M. avium Complex followed by M. xenopi. Ten cases with HIV infection had a median CD4 lymphocyte count of 320/mm(3) (range = 41-465/mm(3)) at the time of diagnosis of NTM VO. The VO in the cases with HIV infections occurred at an earlier age and more often involved the thoracic spine than in the cases without HIV infection. Pre-disposing trauma or surgery was reported in 14.5% (10/69) of the cases. A variety of immunosuppressive diseases were observed in 49.3% of the patients, including the 10 with HIV infections and corticosteroids were used in 27.5% of the cases. Surgery was performed in 67.6% and improvement was reported in 80.6%. Conclusion NTM should be considered in immunocompromised patients with indolent VO without confirmation of tuberculosis.
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Affiliation(s)
- Chung-Jong Kim
- a Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Uh-Jin Kim
- b Department of Infectious Diseases , Chonnam National University Medical School , Gwang-ju , Republic of Korea
| | - Hong Bin Kim
- a Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Sang Won Park
- a Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Myoung-Don Oh
- a Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Kyung-Hwa Park
- b Department of Infectious Diseases , Chonnam National University Medical School , Gwang-ju , Republic of Korea
| | - Nam Joong Kim
- a Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Republic of Korea
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Bi S, Hu FS, Yu HY, Xu KJ, Zheng BW, Ji ZK, Li JJ, Deng M, Hu HY, Sheng JF. Nontuberculous mycobacterial osteomyelitis. Infect Dis (Lond) 2015; 47:673-85. [PMID: 25915177 PMCID: PMC4714132 DOI: 10.3109/23744235.2015.1040445] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 03/29/2015] [Indexed: 11/15/2022] Open
Abstract
Osteomyelitis caused by nontuberculous mycobacteria (NTM) can have severe consequences and a poor prognosis. Physicians therefore need to be alert to this condition, especially in immunocompromised patients. Although the pathogenesis of NTM osteomyelitis is still unclear, studies in immunodeficient individuals have revealed close relationships between NTM osteomyelitis and defects associated with the interleukin-12-interferon-γ-tumor necrosis factor-α axis, as well as human immunodeficiency virus infection, various immunosuppressive conditions, and diabetes mellitus. Culture and species identification from tissue biopsies or surgical debridement tissue play crucial roles in diagnosing NTM osteomyelitis. Suitable imaging examinations are also important. Adequate surgical debridement and the choice of appropriate, combined antibiotics for long-term anti-mycobacterial chemotherapy, based on in vitro drug susceptibility tests, are the main therapies for these bone infections. Bacillus Calmette-Guerin vaccination might have limited prophylactic value. The use of multiple drugs and long duration of treatment mean that the therapeutic process needs to be monitored closely to detect potential side effects. Adequate duration of anti-mycobacterial chemotherapy together with regular monitoring with blood and imaging tests are key factors determining the recovery outcome in patients with NTM osteomyelitis.
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Affiliation(s)
- Sheng Bi
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Fei-Shu Hu
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hai-Ying Yu
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Kai-Jin Xu
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Bei-Wen Zheng
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhong-Kang Ji
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jun-Jie Li
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Mei Deng
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hai-Yang Hu
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Ji-Fang Sheng
- From the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University, Hangzhou, China
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