Rapidly Fatal Emphysematous Osteomyelitis with Multiple Septic Emboli and Liver Abscess Caused by Klebsiella pneumoniae

"Beyond the Bladder: Exploring the Intricacies of Emphysematous Cystitis and Its Surprising Associations"

Emphysematous cystitis is defined by the presence of air within the bladder wall or lumen in imaging studies with increased incidence in elderly women and diabetics. It is a result of gas-forming organisms like Klebsiella and E. coli but can be caused by fungi such as Candida and Aspergillus as well with a wide spectrum of clinical presentations. In this article, we present a case of a 77-year-old female with diabetes mellitus who presented to the hospital with a chief complaint of left lower quadrant abdominal pain. Abdominal imaging revealed emphysematous cystitis, paraspinal abscess, and air in the thoracic and lumbar vertebrae. Laboratory results showed leukocytosis, lactic acidosis, and urinalysis significant for urinary tract infection but no positive urine or blood cultures. The patient was admitted to the intensive care unit for septic shock and was treated with mechanical ventilation, vasopressor support, and prompt antimicrobial therapy following which the requirement of vasopressors ceased on the third day of admission. The decision was then made by the family to pursue hospice care, following which mechanical ventilation was discontinued and the patient transferred to inpatient hospice. With this case report, we aim to add to the existing literature regarding the spread of intra-abdominal infections and go over a brief review of the currently available literature. From our review, we would like to conclude that the presence of pneumoracchis, especially in the setting of an intra-abdominal infection, is a poor prognostic marker, and timely diagnosis and treatment of potential causes are required to reduce mortality.

Emphysematous osteomyelitis of the spine: a case report and case based review of the literature

BACKGROUND/OBJECTIVE

Emphysematous osteomyelitis (EO) of the spine is an uncommon type of osteomyelitis characterized by intraosseous gas-formation in the vertebrae. The objective of this report is to present a rare case of spine EO in a patient with emphysematous cystitis. A case-based review of the literature on spinal EO was also performed as an update to the relevant literature of this rare infection.

CASE DESCRIPTION/METHODS

A 55-year-old female with diabetes mellitus and peripheral vascular disease (PVD) presented to our institution with recurrent falls, fatigue, and low back pain. Computed tomography (CT) and magnetic resonance imaging (MRI) scans confirmed emphysematous cystitis and EO at L4. Given the diffuse involvement, surgical intervention was deferred for IV antibiotic therapy. A case-based review was also conducted by searching the SCOPUS and PubMed databases for the following terms: "emphysematous osteomyelitis", "gas", and "spine". Only publications in English were included in this review.

KEY CONTENT/FINDINGS

Urine/blood cultures identified Klebsiella pneumoniae. After initial improvement with six weeks of broad-spectrum antibiotics, the patient re-presented with recurrent fevers and fatigue. Despite maximal medical therapy, the patient expired 2 months later due to multi-organ system failure. Including the present report, only 29 cases of spine EO have been described in the literature. Patients almost consistently presented with fever, elevated inflammatory markers, and localized pain. Most cases of spinal EO (89.7%) were monomicrobial. Escherichia coli (37.9%) and Klebsiella pneumoniae (27.6%) were the most causative organisms identified. Medical treatment universally consisted of broad-spectrum IV antibiotics prior to tailoring. Debridement and decompression, with or without fusion, were the main operative procedures performed for spine EO. Outcomes following spinal EO are varied with a 44.4% mortality rate.

CONCLUSIONS

We present a case of EO of the spine and concomitant emphysematous cystitis with Klebsiella pneumoniae and a case-based review of the literature. Appropriate work up for this rare infection should include inflammatory markers, cultures, and CT/MRI imaging. Treatment consists of IV antibiotics with anaerobic and gram-negative coverage. However, treatment guidelines and operative indications for spinal emphysematous osteomyelitis remain unclear.

Emphysematous osteomyelitis of the clavicle: a pleural process?

Emphysematous osteomyelitis (EO) is a rare infection associated with intraosseous gas. EO is an often fatal disease with an estimated 34% mortality. We present a case of a 63-year-old man with sternoclavicular EO with pleural involvement and significant subcutaneous emphysema diagnosed by CT. Extension of intraosseous gas into the pleural cavity is an extremely interesting presentation that has not been previously reported. The patient underwent a multidisciplinary treatment approach with surgical debridement and an extended antibiotic course. Intraoperative cultures of the pectoralis muscle and bone biopsy grew pan-sensitive Escherichia coli Prompt recognition and treatment are paramount to avoid a potentially fatal outcome. A review of the literature of the previous 46 cases of EO is presented for associated risk factors, the role of surgical management and antibiotic therapy.

Strongyloides Hyperinfection Associated with Enterococcus faecalis Bacteremia, Meningitis, Ventriculitis and Gas-Forming Spondylodiscitis: A Case Report

An elderly Singaporean male with no travel history was hospitalized for fever and altered mental status. Blood cultures grew Enterococcus faecalis, and given a preceding history of steroid use and peripheral eosinophilia, Strongyloides hyperinfection was suspected. Stool specimens were positive for Strongyloides stercoralis larvae over four days, and larvae were also isolated in an early morning nasogastric aspirate specimen prior to initiation of ivermectin. A cerebrospinal fluid examination was consistent with partially treated bacterial meningitis and ventriculitis was demonstrated on neuroimaging. In view of a persistent fever, a further imaging evaluation was performed, which demonstrated bilateral pneumonia as well as the unusual finding of gas-forming emphysematous spondylodiscitis and left psoas abscesses. Despite the early suspicion of Strongyloides hyperinfection, commencement of appropriate antibiotics and anti-helminthics, microbiological clearance of bacteremia as well as clearance of S. stercoralis from the stool, the patient still succumbed to infection and passed away 11 days after admission.