Thoracic spondylitis from a mycotic (Streptococcus pneumoniae) aortic aneurysm: a case report

Vertebral Osteomyelitis Secondary to Pneumococcal Infection

Vertebral osteomyelitis secondary to pneumococcal infection is an uncommon condition caused by Streptococcus pneumoniae. Fever, back pain, and raised ESR are common features in the clinical setting. We report a 62-year-old female patient who presented with an unusual presentation. Later on, vertebral osteomyelitis secondary to pneumococcal infection was confirmed at T8, 9 by CT scan, MRI, and cytology. The patient was treated successfully with high-dose ceftriaxone.

Pneumococcal vertebral osteomyelitis at three teaching hospitals in Japan, 2003-2011: analysis of 14 cases and a review of the literature

BACKGROUND

Pneumococcal vertebral osteomyelitis (PVO) is a rare disease whose clinical characteristics have not been clarified. This study aimed to investigate the clinical features and outcomes of patients with PVO.

METHODS

We retrospectively evaluated all adult patients diagnosed with PVO at three teaching hospitals in Japan from January 2003 to December 2011. All cases were identified through a review of the medical records of patients with invasive pneumococcal disease (IPD).

RESULTS

Among 208 patients with IPD, we identified 14 with PVO (6.4%; 95% CI, 3.5-10%). All 14 patients (nine male, five female; median age 69 years) had acquired PVO outside the hospital and had no recent history of an invasive procedure or back injury. Five patients (36%) had diabetes mellitus, and four (29%) had heavy alcohol intake. Fever (n = 13; 93%) or back pain/neck pain (n = 12; 86%) were present in most patients. The lumbar spine was affected in nine patients (64%) but the cervical spine was the site of infection in four patients (29%). All patients except one had a positive blood culture for Streptococcus pneumoniae, and there were no distant infected sites in most patients (n = 10; 71%). Intravenous beta-lactam therapy was initiated within 1 week after the onset of symptoms in 11 patients (79%). No patients died within 30 days, but one patient died from aspiration pneumonia on day 37 after admission.

CONCLUSIONS

PVO was relatively common among adult patients with IPD, and mortality was low in this study. S. pneumoniae may be the causative pathogen of vertebral osteomyelitis, especially among community-onset cases without a history of invasive procedures or back injury.

Streptococcus pneumoniae mycotic aneurysm with contiguous vertebral discitis treated by endovascular aortic repair and antibiotics

A 61-year-old man was admitted with a history of right upper quadrant and left iliac fossa pain and raised inflammatory markers. Initial investigations, including contrast-enhanced CT scan of the abdomen and pelvis, were reported as normal. Following readmission 2 months later with thoracolumbar back pain and recurrent fevers, an MRI showed T11/12 discitis and an adjacent mycotic aneurysm of the aorta. CT angiogram confirmed an 8 cm mycotic aneurysm. A second, more distal aneurysm was found located at the left common femoral artery. The aortic aneurysm was treated by antegrade stenting. The left common femoral artery aneurysm was excised. The patient was also treated with antibiotics. He made a good recovery and was well 8 months later apart from mild residual thoracolumbar spinal pain. To date, he has been followed up for 1 year and remains asymptomatic.

Dislodged upper thoracic cage in the gastrointestinal tract: a case report and literature reviews

STUDY DESIGN

A rare case of esophageal perforation secondary to a dislodged upper thoracic cage found by the gastrointestinal endoscope is presented.

OBJECTIVE

To report an extremely rare complication of upper thoracic vertebral tuberculosis treated with corpectomy and interbody cage surgery and suggest the cause, mechanism, and outcome of the complication of esophageal perforation.

SUMMARY OF BACKGROUND DATA

Tuberculotic spondylitis often affects the anterior column of the spine and surgery is indicated in the presence of an epidural abscess, neurologic deficits secondary to compression of the spinal cord, bone destruction with instability, or failure of antituberculous therapy. Surgical treatment requires radical debridement followed by anterior stabilization. A controversy exists regarding the use of the instrumentation in the tuberculous spine.

METHODS

Retrospective case study and literature review.

RESULTS

Because of the concomitant medical problems and little deterioration of the neurologic function, our patient is managed uneventfully with conservative treatment.

CONCLUSION

To the authors' knowledge, this is an extremely rare reported complication of upper thoracic cage surgery for vertebral tuberculosis. This case demonstrates that the cage migration in the tuberculous spondylitis might have a rather benign clinical course and structural bone grafting or interbody cage insertion without supplemental instrument fixation seems to be inadequate.

Unusual femoral artery mycotic aneurysm complicated by infective spondylitis

We present a patient who experienced an aortic aneurysm and a left femoral artery mycotic aneurysm, which resulted from L4-infective spondylitis via the iliopsoas compartment. This rare complication could be underdiagnosed in the absence of a more extended field of imaging view such as is provided by computed tomography.

Anterior thoracic spine reconstruction using a titanium mesh cage and pedicled rib flap

STUDY DESIGN

A retrospective clinical study.

OBJECTIVES

To evaluate the safety and efficacy of using an integrated titanium mesh cage and pedicled rib flap for thoracic spine reconstruction in patients at high risk of pseudarthrosis.

SUMMARY OF BACKGROUND DATA

A variety of materials are available for interbody thoracic reconstruction; however, the optimal treatment of patients at high risk of pseudarthrosis remains a challenging problem. Free or pedicled bone flaps have been shown to be highly effective in terms of promoting fusion and titanium mesh cages provide excellent structural support.

METHODS

Eleven patients who underwent anterior thoracic corpectomy and spinal reconstruction using an integrated titanium mesh cage and pedicled rib flap were analyzed with a mean follow-up of 37 months (range, 25-55 months). The etiology of spinal disease was infection in 7 (64%) patients and tumor in the remaining 4 (36%) patients. Seven (64%) patients were treated with only an anterior approach while the remaining 4 (36%) patients underwent circumferential spinal reconstruction.

RESULTS

All patients demonstrated clinical and radiographic evidence of spinal fusion at the time of follow-up. All patients had stable or improved Frankel grades after surgery. There was a mean kyphosis correction of 7 degrees for both the focal and regional thoracic kyphosis. There were three significant postoperative complications: bilateral pleural effusion, gram-negative bacteremia, and transient right lower extremity weakness requiring reoperation and pedicle screw revision. Two patients died after surgery: one from aneurysmal subarachnoid hemorrhage and the other from complications of breast cancer.

CONCLUSIONS

The use of an integrated rib flap and titanium mesh cage construct appears to be a safe and effective means of providing immediate and substantial anterior column support as well as achieving arthrodesis in challenging fusion candidates.