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Li L, Zhang BH, Cao JF, Zhang LJ, Guo LL. Thoracic spine infection caused by Pseudomonas fluorescens: A case report and review of literature. World J Clin Cases 2024; 12:2099-2108. [PMID: 38680271 PMCID: PMC11045498 DOI: 10.12998/wjcc.v12.i12.2099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/03/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND The clinical incidence of spinal infection is gradually increasing, and its onset is insidious, easily leading to missed diagnosis and misdiagnosis, which may lead to serious complications such as nervous system dysfunction, spinal instability and/or deformity, and cause a huge burden on society and families. Early identification of the causative agent and precision medicine will greatly reduce the suffering of patients. At present, the main pathogenic bacteria that cause spinal infection are Staphylococcus aureus, Streptococcus, Pneumococcus, Escherichia coli, and Klebsiella. There are no reports of spinal infection caused by Pseudomonas fluorescens. CASE SUMMARY We report a 32-year-old female patient with spinal infection. She presented with flank pain, initially thought to be bone metastases or bone tuberculosis, and had a family background of tumors. Her clinical features and changes in imaging and laboratory tests led to the suspicion of thoracic spine infection. Histopathology of the lesion showed inflammation, tissue culture of the lesion was negative several times, and the possible pathogen - Pseudomonas fluorescens was found after gene sequencing of the lesion. The patient recovered completely after a full course of antibiotic treatment. CONCLUSION This report increases the range of pathogens involved in spinal infections, highlights the unique advantages of gene sequencing technology in difficult-to-diagnose diseases, and validates conservative treatment with a full course of antibiotics for spinal infections without complications.
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Affiliation(s)
- Liang Li
- Department of Traditional Chinese Medicine, Zibo Central Hospital, Zibo 255000, Shandong Province, China
| | - Bao-Hua Zhang
- Department of Pathology, Zibo Central Hospital, Zibo 255000, Shandong Province, China
| | - Jin-Feng Cao
- Department of Medical Imaging, Zibo Central Hospital, Zibo 255000, Shandong Province, China
| | - Li-Jin Zhang
- Department of Traditional Chinese Medicine, Zibo Central Hospital, Zibo 255000, Shandong Province, China
| | - Ling-Ling Guo
- Department of Traditional Chinese Medicine, Zibo Central Hospital, Zibo 255000, Shandong Province, China
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Laur O, Schonberger A, Gunio D, Minkowitz S, Salama G, Burke CJ, Bartolotta RJ. Imaging assessment of spine infection. Skeletal Radiol 2024:10.1007/s00256-023-04558-3. [PMID: 38228784 DOI: 10.1007/s00256-023-04558-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/04/2023] [Accepted: 12/21/2023] [Indexed: 01/18/2024]
Abstract
This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).
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Affiliation(s)
- Olga Laur
- Department of Radiology, Division of Musculoskeletal Radiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Alison Schonberger
- Department of Radiology, Division of Musculoskeletal Radiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Drew Gunio
- Department of Radiology, Division of Musculoskeletal Radiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Shlomo Minkowitz
- Department of Radiology, Division of Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Gayle Salama
- Department of Radiology, Division of Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Christopher J Burke
- Department of Radiology, Division of Musculoskeletal Imaging, New York University School of Medicine, Center for Biomedical Imaging, 660 First Ave, New York, NY, 10016, USA
| | - Roger J Bartolotta
- Department of Radiology, Division of Musculoskeletal Radiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
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Veljanoski D, Tonna I, Barlas R, Abdel-Fattah AR, Almoosawy SA, Bhatt P. Spinal infections in the north-east of Scotland: a retrospective analysis. Ann R Coll Surg Engl 2023; 105:428-433. [PMID: 35904356 PMCID: PMC10149230 DOI: 10.1308/rcsann.2022.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Spinal infection (SI) is uncommon and patients present with varied clinical features. In this review, the presentation, investigation, treatment and outcome of patients with SI in the north-east of Scotland were assessed. METHODS Electronic medical records of adult patients with SI hospitalised at a health board in the north-east of Scotland between 2014 and 2018 were analysed retrospectively. Collected variables included demographics, presenting clinical features, risk factors, comorbidities, admission blood results, microbiological investigations, imaging, treatment and outcomes. RESULTS Seventy-two patients were included. Mean age (±sd) was 63.3 years (±14.5). The lumbar spine was the most commonly involved region (51.4%). Back pain (84.7%), altered mobility (33.3%) and fever (29.2%) were the most frequent presenting features. Thoracic spine involvement (p = 0.041), urinary symptoms (p = 0.033), cauda equina syndrome (CES) (p = 0.027) and limb weakness (p = 0.026) were associated with poorer outcome. A better outcome was associated with back pain at presentation (p = 0.03) and underlying malignancy (p = 0.045). Diabetes (15.3%), recent falls (15.3%) and immunosuppression (12.5%) were common. A likely causative organism was found in 54 patients (75.0%) and Staphylococcus aureus was isolated in 41.7% of patients. Penicillins were used in 56.3% of patients and 20.8% underwent surgery. Outcomes were full recovery (38.2%), residual symptoms or neurological deficits (50.0%), paraplegia (4.4%) and death (7.4%). CONCLUSIONS Poorer outcomes occurred in patients with thoracic disease, limb weakness, urinary symptoms or CES, whereas better outcomes were associated with the presence of back pain on presentation and malignancy. This analysis highlights the diagnostic and therapeutic challenges of SI, alerting clinicians to key factors associated with prognosis.
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Ortiz AO, Levitt A, Shah LM, Parsons MS, Agarwal V, Baldwin K, Bhattacharyya S, Boulter DJ, Burns J, Fink KR, Hunt CH, Hutchins TA, Kao LS, Khan MA, Lo BM, Moritani T, Reitman C, Repplinger MD, Shah VN, Singh S, Timpone VM, Corey AS. ACR Appropriateness Criteria® Suspected Spine Infection. J Am Coll Radiol 2021; 18:S488-S501. [PMID: 34794603 DOI: 10.1016/j.jacr.2021.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 10/19/2022]
Abstract
Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- A Orlando Ortiz
- Chairman, Department of Radiology, Jacobi Medical Center, Bronx, New York.
| | - Alex Levitt
- Research Author, Jacobi Medical Center, Bronx, New York
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Vikas Agarwal
- Vice-Chair of Education, Chief, Neuroradiology, and Director, Spine Intervention, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, American Academy of Orthopaedic Surgeons
| | - Shamik Bhattacharyya
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, American Academy of Neurology
| | - Daniel J Boulter
- Clinical Director, MRI, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Judah Burns
- Program Director, Diagnostic Radiology Residency Program, Montefiore Medical Center, Bronx, New York
| | | | | | - Troy A Hutchins
- Chief Value Officer, Department of Radiology, University of Utah Health, Salt Lake City, Utah
| | - Lillian S Kao
- Chief, Division of Acute Care Surgery, The University of Texas Health Science Center at Houston, Houston, Texas; and American Association for the Surgery of Trauma
| | - Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; Board Member, American Academy of Emergency Medicine; and American College of Emergency Physicians
| | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina; and Board of Directors, North American Spine Society
| | - Michael D Repplinger
- University of Wisconsin, Madison, Wisconsin; President, Dane County Medical Society; Councillor, American College of Emergency Physicians; and Society for Academic Emergency Medicine
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California; and Executive Committee, American Society of Spine Radiology
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; Secretary, SHM, Indiana Chapter; Secretary, SGIM, Midwest Region; and American College of Physicians
| | - Vincent M Timpone
- Co-Director, Neuroradiology Spine Intervention Service, Department of Radiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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Trub SA, Bush WW, Paek M, Cuff DE. Use of C-reactive protein concentration in evaluation of diskospondylitis in dogs. J Vet Intern Med 2020; 35:209-216. [PMID: 33319417 PMCID: PMC7848344 DOI: 10.1111/jvim.15981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background C‐reactive protein (CRP) is a positive acute phase protein that increases in many inflammatory conditions of dogs. Serum CRP concentration has important diagnostic and prognostic utility in humans with vertebral osteomyelitis. Hypothesis/objectives To determine if a correlation exists between serum CRP concentration and clinical and magnetic resonance imaging (MRI) findings in dogs with diskospondylitis, and if CRP predicts prognosis. Animals Eighteen client‐owned dogs with MRI diagnosis of diskospondylitis. Methods Retrospective study evaluating signalment, clinical signs, neurologic examination findings, white blood cell count, neutrophil count, serum globulin concentration, serum CRP concentration, radiographic findings, MRI findings, bacterial culture results, and outcome in dogs with diskospondylitis. Results Serum CRP concentration was significantly more sensitive than were fever and leukocytosis for predicting the presence of diskospondylitis. Serum CRP concentration was more sensitive than neutrophilia and hyperglobulinemia. No difference in serum CRP concentration was found between dogs with single or multiple lesions, nor between dogs with or without empyema, muscular involvement or spinal cord compression. No association was found between serum CRP concentration and positive bacterial culture. Conclusions and Clinical Importance C‐reactive protein is a sensitive, but nonspecific biomarker for diskospondylitis which may prove useful as an adjunctive diagnostic test in patients with suspicious clinical signs and may help predict prognosis.
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Affiliation(s)
- Sarah A Trub
- Bush Veterinary Neurology Service, Leesburg, Virginia, USA.,Synergy Veterinary Imaging Partners, Columbia, Maryland, USA.,Bush Veterinary Neurology Service, Rockville, Maryland, USA
| | - William W Bush
- Bush Veterinary Neurology Service, Leesburg, Virginia, USA.,Synergy Veterinary Imaging Partners, Columbia, Maryland, USA.,Bush Veterinary Neurology Service, Rockville, Maryland, USA
| | - Matthew Paek
- Bush Veterinary Neurology Service, Leesburg, Virginia, USA.,Synergy Veterinary Imaging Partners, Columbia, Maryland, USA.,Bush Veterinary Neurology Service, Rockville, Maryland, USA
| | - Daniel E Cuff
- Bush Veterinary Neurology Service, Leesburg, Virginia, USA.,Synergy Veterinary Imaging Partners, Columbia, Maryland, USA.,Bush Veterinary Neurology Service, Rockville, Maryland, USA
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Isolated septic facet joints: an underdiagnosed distinct clinical entity. Skeletal Radiol 2020; 49:1295-1303. [PMID: 32248446 DOI: 10.1007/s00256-020-03434-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We review a series of isolated septic facet joints (ISFJ) that present as a distinct clinical entity compared with spondylodiscitis. We aim to raise awareness that septic facet joints are not a rare entity in the era of modern imaging. METHODS We reviewed 353 patients with confirmed spine infections from 2008 to 2017. Of the 353 cases, there were 152 septic facet joints based on MR imaging. Sixty-two presented as ISFJ without evidence of spondylodiscitis and were reviewed. RESULTS Patients were predominantly male 38/62 (61%). The mean age was 56.7 years. Onset of back pain was more acute compared with spondylodiscitis and usually unilateral. The distribution was as follows: 6 cervical, 12 thoracic, and 44 lumbar facets. The majority of ISFJ, 53/62 (85%), were associated with an epidural abscess (EDA) 53/62. The cervical and thoracic EDA required surgical decompression more frequently than lumbar; 100%, 75%, and 53% respectively. Pathogen was identified in 59/62 (95%) cases. Most cases were associated with bacteremia 50/62 (81%). Seven ISFJ were introduced iatrogenically. All iatrogenic ISFJ required surgical decompression. CONCLUSION Septic facet joints are not rare, but frequently overlooked as the origin of an epidural abscess. The majority of cases are hematogenously seeded and associated with bacteremia. Surgical decompression is frequently required secondary to the high incidence of associated epidural abscess. Iatrogenic septic facet joints are rare but associated with significant morbidity. From a clinical standpoint, it is helpful to delineate the origin of EDA as either secondary to spondylodiscitis or SFJ.
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Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J Nucl Med Mol Imaging 2019; 46:2464-2487. [PMID: 31399800 DOI: 10.1007/s00259-019-04393-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/04/2019] [Indexed: 12/19/2022]
Abstract
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.
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Landi A, Di Bartolomeo A, Marotta N, Iaiani G, Domenicucci M, Chiara M, Salvati M, Delfini R. Multidisciplinary management of spontaneous spinal infections: is there a correlation between timing, type of treatment and outcome? J Neurosurg Sci 2016; 63:379-387. [PMID: 27879951 DOI: 10.23736/s0390-5616.16.03779-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Spontaneous spinal infections (SSIs) represent a rare and serious pathological entity. We tried to study a correlation between type of treatment, timing of treatment and clinical outcome through a multivariate analysis of an observational cohort study with the aim to define what is the optimal clinico-therapeutic management. METHODS We performed a retrospective observational cohort study on all consecutive patients observed in our Institute in a period of 13 years; from 2001 to 2014 we enrolled 50 consecutive patients with symptomatic spontaneous spinal infections (no previous surgery or recent infection in other site), confirmed with diagnostic imaging. The inclusion parameters were: diagnostic imaging, signs and symptoms positive for SSI, no history of recent infection or surgery. Of each parameter analyzed, we calculated mean and standard deviation and when necessary correlation (ρ), covariance (σ) and relation coefficient between type of treatment, timing of treatment and clinical outcome. RESULTS Our results suggest that an increase of one day from the onset of symptoms and the start of therapy leads to an increase in the Oswestry Disability Index Scale both at 6 months than at 1 year, with a statistical relevance, so our experience shows a statistically significant correlation and a positive co-variance between timing and outcome at 6 months and 1 year. CONCLUSIONS SSI are rare, very difficult to diagnose and represent a significant clinical problem. If not properly managed, they may lead to significant impact in the quality of life. The most relevant problem is not the treatment, conservative or surgical, but early diagnosis, so a careful physical, laboratory and imaging examination is fundamental, with an important help provided by isolation of the pathogen and histology. In our experience early diagnosis has a fundamental role. In the light of this, current treatment protocols may require a prompt and multidisciplinary management including infectivologists, neuroradiologists and spine surgeons.
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Affiliation(s)
- Alessandro Landi
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy -
| | - Alessandro Di Bartolomeo
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Nicola Marotta
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Giancarlo Iaiani
- Department of Infectious and Tropical Disease, Sapienza University, Rome, Italy
| | - Maurizio Domenicucci
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Massimo Chiara
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Maurizio Salvati
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Roberto Delfini
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
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Epidemiologic and Demographic Attributes of Primary Spondylodiscitis in a Middle Eastern Population Sample. World Neurosurg 2016; 95:31-39. [DOI: 10.1016/j.wneu.2016.07.088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/22/2016] [Accepted: 07/23/2016] [Indexed: 12/17/2022]
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