Salmonella osteomyelitis of the thoracic spine: an unusual presentation

A Systematic Review of the Diagnosis and Treatment of Non-Typhoid Salmonella Spondylodiscitis in Immunocompetent Children

The aim of this systematic review is to distinguish the clinical features of immunocompetent children with non-typhoid Salmonella spondylodiscitis and summarize the diagnosis, diagnostic tools, and treatment methods to guide clinicians. The review was conducted according to the preferred PRISMA guidelines. We conducted a literature search in the PubMed, Embase, and Cochrane Library databases. Article screening, data extraction, and study evaluation were performed by two independent reviewers. A total of 20 articles, published between 1977 and 2020, were selected, which included 21 patients with average age of 12.76 years (range, 2-18) without comorbidities; in total, 19% of the patients had positive blood cultures for non-typhoid Salmonella, and 80.9% underwent either CT-guided or open biopsy, which were positive for NTS. All infections were monomicrobial, and 11 different serotypes of non-typhoid Salmonella were identified. Analyzing the reviewed cases, 52.4% of the patients presented with fever, 90.5% had localized pain, and only 19% had gastroenteritis. The most common level of discitis was the lumbar region, especially the L4/L5 level. Primarily, third-generation cephalosporin was administered, and antibiotic treatment was given for an average of 9.6 weeks. Non-typhoid Salmonella spondylodiscitis is a rare clinical entity in healthy and immunocompetent children. The identification of the responsible organism is essential to guide antibiotic therapy and define the treatment duration. A significant limiting factor in this systematic review was the lack of published research articles and case series due to the rarity of the disease.

A Rare Case of Salmonella Osteomyelitis in Immunocompetent Toddler Without Risk Factors

Salmonella infections are common, though rarely cause disseminated or severe disease in immunocompetent children. We present a case of severe salmonella osteomyelitis and epidural abscess in a patient without significant risk factors. This patient presented over the course of multiple visits with nonspecific symptoms of fever, malaise, and eventual joint pain. As symptoms progressed, the workup was broadened to find the eventual source of infection.

Salmonella enteritis spondylitis of thoracic spine: a case report and review of the literature

BACKGROUND

Spondylitis is a very common back problem in orthopedics, but is rarely caused by Salmonella enteritidis. We herein reported an uncommon case of thoracic spondylitis caused by Salmonella enteritidis.

CASE PRESENTATION

A 68-year-old man with high fever was diagnosed as salmonella septicemia initially. His condition was improved after antibacterial treatment. But the symptom of pyrexia was recurred after some days. He was then diagnosed with thoracic spondylitis caused by salmonella enteritidis. After that, he was put on strict antibiotic treatment, and underwent intervertebral lesion debridement, partial rib resection, intervertebral bone fusion and pedicle screw internal fixation. Subsequently, the patient had a significant relief in pain, temperature remained normal, and had no severe complications.

CONCLUSIONS

Special attention should be paid to systemic pain and remain cautious to the occurrence of osteomyelitis in patients with Salmonella septicemia. Moreover, the treatment time for using sensitive antibiotics should be sufficient. Surgical treatment should be considered if strict conservative treatment is failed.

Spondylodiscitis initially presenting as exudative pleural effusion: A case report and review of the literature

Pleural effusions are associated with a variety of disease states, rendering the differential diagnosis challenging. Spondylodiscitis is an uncommon disease, and its prompt diagnosis can reduce morbidity and mortality. However, an atypical manifestation of the disease, such as pleural effusion, can result in delayed diagnosis. A 76-year-old woman presented with back pain and right pleural effusion. Magnetic resonance imaging revealed paravertebral soft tissue infiltration, with enhancement of bone marrow and intervertebral disk at the T8 and T9 levels, suggesting spondylodiscitis. In patients with exudative pleural effusion, spondylodiscitis may be the cause, so careful analysis of imaging is necessary.

Multi-foci Salmonella enteritis Osteomyelitis of Thoracic Spine with Pleural Effusion and Fatal Outcome. A Unique Case Presentation and Review of the Literature

Introduction:

A case of thoracic vertebral osteomyelitis due to Salmonella enteritis (SE) in an immunocompetent patient is reported. This is the third case in the literature of SE thoracic vertebral osteomyelitis, but the first one with this multi-foci presentation and finally fatal outcome due to meningoencephalitis. Further data that makes our case unique are the absence of fever (body temperature: 37.4°C) and gastrointestinal disorders.

Case Report:

A 57-year-old male patient initially presented with thoracic pain, dyspnea, and knee pain. Examinations revealed a large pleural effusion and septic arthritis. Blood and all these sides (vertebrae, pleural fluid, and joint fluid) cultures revealed SE. The infection was successfully treated with three surgical interventions, plus antibiotic administration. First, a chest tube was inserted and at the same time, we took cultures and specimens from the infected sites. Subsequently, bone debridement and spine fusion were performed, and finally, knee fusion was held with an Illizarov device. Although 8 months later, our patient passed away due to viral meningoencephalitis and severe hydrocephalus, due to immunosuppression after Salmonella infection recurrence. Furthermore, no sign of relapse was found in the last follow-up, just 2 months ago.

Conclusion:

Physicians should be aware for this rare but potentially fatal spinal infection. Osteomyelitis of thoracic spine should be considered in the differential diagnosis of pleural effusion. More suspiciousness is needed due to the possibility of immunosuppression and relapse, even with sufficient antibiotic administration and negative inflammatory markers. Follow-up should be more frequent and accompanied with blood cultures taking.

Salmonella spondylodiscitis of the thoracic vertebrae mimicking spine tuberculosis

Extraintestinal Salmonella infection involving the thoracic spine is very rare. It commonly presents with non-specific chronic back pain and can occur with no gastrointestinal manifestation. Blood test results and imaging findings are often indistinguishable from more common chronic spine infections such as spine tuberculosis. Culture studies remain the key to establishing a definitive diagnosis and subsequently successful treatment. We report a case in which a patient presented with symptoms and signs suggestive of spine tuberculosis, yet the culture examination revealed otherwise.

Salmonella Typhi Vertebral Osteomyelitis and Epidural Abscess

Salmonella vertebral osteomyelitis is an uncommon complication of Salmonella infection. We report a case of a 57-year-old transgender male who presented with lower back pain for a period of one month following a fall. Physical examination only revealed tenderness over the lower back with no neurological deficits. MRI of the thoracic and lumbar spine revealed a spondylodiscitis at T10-T11 and T12-L1 and right posterior epidural collection at the T9-T10 level. He underwent decompression laminectomy with segmental instrumentation and fusion of T8 to L3 vertebrae. Intraoperatively, he was found to have acute-on-chronic osteomyelitis in T10 and T11, epidural abscess, and discitis in T12-L1. Tissue and wound culture grew Salmonella Typhi and with antibiotics susceptibility guidance he was treated with intravenous ceftriaxone for a period of six weeks. He recovered well with no neurological deficits.

Chest pain? An unusual presentation of vertebral osteomyelitis

We present a case of vertebral osteomyelitis presenting as chest pain. The patient initially underwent a CT chest angiogram to rule out a pulmonary embolism, which incidentally showed a soft tissue vertebral mass at T3-T4 disk space. Subsequent thoracic vertebral MRI was consistent with osteomyelitis with cord compression. Tissue culture from a CT-guided biopsy grew MRSA. The patient was successfully treated with Vancomycin. This is a rare presentation of vertebral osteomyelitis which poses an interesting diagnostic challenge.

Salmonella Osteomyelitis of the Pelvis in Healthy Adults: A Case Report

We report a case of a healthy 32-year-old patient suffering from Salmonella osteomyelitis of the pelvis. He was treated successfully with surgical debridement and third-generation cephalosporin.

Salmonella spondylodiscitis in the immunocompetent: our experience with eleven patients

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To report the clinical features, diagnostic dilemmas and management options of 11 immunologically normal patients with salmonella spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Majority of existing data on salmonella spondylodiscitis in the immunologically normal patient is from anecdotal case report.

METHODS

From 1995 to 2008, 11 patients with salmonella spondylodiscitis proven by positive culture, biopsy, and Widal test were included. One patient died, and the average follow-up of the remaining 10 patients was 36 months (12-122 months). Five (50%) patients had a documented history of typhoid fever. Intravenous antibiotics for 2 weeks and oral antibiotics for at least 10 weeks were given to all patients. Indications for surgical intervention were unrelenting pain and osseous instability. Clinical outcome was evaluated according to Macnab criteria.

RESULTS

Salmonella typhi was cultured in 4 and S. Paratyphi in 5 patients. No organism was identified in 2 patients, on whom the diagnosis was performed by a characteristic history, high Widal titers, and a positive biopsy. Widal titers were positive for all patients (Average + 1360). Five patients were managed with antibiotics only, 1 with surgical debridement and uninstrumented fusion and 4 with single-stage debridement, anterior fusion, and posterior instrumentation. Healing of disease with a good to excellent outcome was seen in all patients.

CONCLUSION

Salmonella and tuberculous spondylitis must be differentiated as they both have similar epidemiological and clinicoradiologic presentations. Prodromal gastrointestinal symptoms are usually not present. The diagnosis rests largely on the recovery of the organism by appropriate culture techniques. However, when this is not apparent the Widal test, in the setting of a suggestive history and radiograph, may be used as a diagnosis tool. Though antibiotics are the mainstay of treatment, surgical debridement with the use of instrumentation may be indicated in selected patients.

Salmonella osteomyelitis of multiple ribs and thoracic vertebra with large psoas muscle abscesses

BACKGROUND CONTEXT

Salmonella vertebral osteomyelitis is a well-known complication of sickle cell disease. However, it has been infrequently reported in immunologically normal people or diabetic patients.

PURPOSE

To report a case of Salmonella vertebral osteomyelitis in a diabetic patient with multiple rib infections, large bilateral psoas muscle abscesses, and pleural effusion.

STUDY DESIGN/SETTING

Case report.

METHODS

A case of Salmonella vertebral osteomyelitis is reported in a 42-year-old man with diabetes. The patient had multiple rib and T12 vertebral infections with pleural effusion and large bilateral psoas muscle abscesses. The adjacent discs were intact.

RESULTS

Diagnosis was made by computed tomography-guided psoas muscle abscess drainage and aspirate culture. Appropriate antibiotic treatment resulted in a favorable outcome. The patient had mild back pain with a 38 degrees residual kyphosis at his thoracolumbar junction after treatment.

CONCLUSIONS

Vertebral osteomyelitis caused by Salmonella is uncommon in diabetic patients. Salmonella can cause multiple bone infections and large abscesses of psoas muscles in patients without sickle cell disease. Correct diagnosis can be confirmed by blood, biopsy, or abscess culture. Appropriate antibiotic treatment was effective.

A case of vertebral osteomyelitis due to quinolone-resistant Salmonella paratyphi A

This is a case of a 63-year-old Asian female patient who presented to accident and emergency with a febrile illness 3 weeks after her return from the Indian subcontinent. She was given empirical treatment with ciprofloxacin. Blood cultures grew a quinolone-resistant resistant Salmonella paratyphi A so she was re-called, admitted to hospital and treated with intravenous cefotaxime. She did not have known risk factors for invasive salmonellosis. On day 8 she complained of back pain, but since her fever was settling an MRI of the spine was not performed at that point.On day 19 her fever relapsed so the MRI was done and showed images consistent with vertebral osteomyelitis at T7-T8 level. She completed 8 weeks of intravenous antibiotic therapy with good clinical response and normalisation of inflammatory markers, and was discharged on an 8 week course of oral azithromycin. On follow-up after 7 months, her back pain had settled and an MRI showed improvement.

Septic arthritis of hip in a neutropenic child caused by Salmonella typhi

A 5-year-old male child was undergoing chemotherapy for pre-B acute lymphoblastic leukemia. He developed Salmonella typhi arthritis of his left hip joint during neutropenic phase. Infection was successfully treated with intravenous antibiotics without surgical management. S. typhi is a potential cause of arthritis, especially in immunocompromised children. More than 100 other cases of Salmonella arthritis are reviewed and reveal a disease primarily of children and young adults with a favorable treatment response.

Clinical assessment and medical treatment of spine infections

Spinal infections affect the vertebral bodies, the intervertebral disks, the spinal canal, and the paravertebral soft tissues and structures. A delay in diagnosis can result in spine deformity, substantial neurologic complications, and even death. Because of this, a high level of awareness is required by physicians in order to diagnose infections of the spine promptly. Advances in medical microbiologic testing and newer imaging methods have contributed considerably to the medical treatment of these infections. Through careful followup, less invasive approaches orchestrated by a multidisciplinary team that includes a spine surgeon, an infectious diseases specialist, and a neuroradiologist may be sufficient to treat patients with these infections. Research done through multidisciplinary collaborations will further advance our knowledge for the successful treatment of spinal infections.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.