Spontaneous emphysematous osteomyelitis of spine detected by computed tomography: Report of two cases

Extensive Emphysematous Osteomyelitis Attributed to Escherichia coli Infection: Radiological Insights and Detailed Case Report of a Rare Entity

Emphysematous osteomyelitis (EO) is a rare and severe bone infection characterized by the presence of gas within the bone and surrounding soft tissues, commonly caused by gas-forming bacteria. We present a case of an elderly patient with extensive EO due to Escherichia coli infection. The patient exhibited systemic signs of infection and severe localized pain. Radiological assessments, including computed tomography and magnetic resonance imaging, demonstrated significant gas accumulation within the bone and adjacent tissues, confirming the diagnosis. Despite intensive antibiotic treatment and surgical intervention, the patient's condition initially worsened, highlighting the high morbidity and mortality associated with this infection. However, through prompt action and targeted intervention, a positive outcome was ultimately achieved. This case emphasizes the critical need for early diagnosis and aggressive management of EO to improve patient outcomes.

Emphysematous Osteomyelitis Involving the Spine, a Case of a Rare Form of Osteomyelitis

Gas-forming bacteria like Staphylococcus aureus (SA), along with the worrisome infections it causes, can lead to a fairly overlooked but lethal complication, called emphysematous osteomyelitis (EO). It is a condition characterized by the infection of bones complicated by the presence of gas-forming organisms. Here, we present a 50-year-old woman with insulin-dependent type 2 diabetes, who presented with cough, high-grade fevers, rigors, chills, and back pain from the last seven days. Laboratory tests revealed elevated inflammatory markers and a hyperosmolar hyperglycemic state. Sputum smear and blood cultures both reported the presence of SA. The presence of air foci in the third lumbar spine vertebra (L3) and the surrounding soft tissue was confirmed by computed tomography (CT). The posterior elements were spared, and the vertebral height and intervertebral disc were preserved. The extent of the damage done to the bone was analyzed by magnetic resonance imaging (MRI). The findings showed transverse relaxation time (T2) and short tau inversion recovery (STIR) sequences, consistent with the diagnosis of EO. She was put on strict glucose monitoring and a combination of intravenous antibiotics for three weeks followed by two weeks of oral therapy. Her symptoms improved with conservative management and reported no recurrence of any symptom of such type ever since.

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: Report of two cases and review of literature

Emphysematous osteomyelitis is a rare condition characterized by the presence of intraosseous gas. A prompt diagnosis is required for this disease to expedite management as it is a potentially fatal condition. Many comorbidities, such as malignancy, diabetes mellitus, alcohol abuse, Crohn's disease, and other etiologies causing immunosuppression, predispose to this condition. The causative organisms are generally anaerobes or members of Enterobacteriaceae family; however, the infection can be mono or polymicrobial. We report two cases affected with emphysematous osteomyelitis due to varied underlying comorbidities. The purpose of this study is to (a) emphasize the importance of computed tomography in diagnosing emphysematous osteomyelitis and (b) to highlight an unusual location of this rare pathology.

Atypical infectious spondylitis with reduced bone marrow enhancement: "black vertebra sign"

BACKGROUND

A few patients suspected of having infectious spondylitis exhibited a reduced enhancement pattern on postcontrast T1-weighted (T1W) magnetic resonance imaging (MRI).

PURPOSE

To investigate the characteristics of infectious spondylitis patients who exhibited reduced vertebral enhancement.

MATERIAL AND METHODS

From January 2010 to November 2017, 456 patients with findings suspicious for infectious spondylitis on 706 postcontrast T1W imaging were retrospectively evaluated. When an affected vertebra exhibited markedly reduced enhancement compared to normal bone marrow (BM), the vertebra was termed a "black vertebra." MRI and computed tomography (CT) imaging findings within two-week intervals and the patients' clinical characteristics were reviewed.

RESULTS

Ten patients (5 men, 5 women; mean age 66.4 years) whose MRI scans revealed the black vertebra sign were included. Among the 10 patients with black vertebrae, six patients exhibited signal voids in or around the affected vertebral bodies on T2-weighted (T2W) images. Eight patients showed air bubbles on CT images, suggestive of emphysematous infection. However, the typical image findings of infectious spondylitis were uncommon, namely, low BM signal intensity (SI) on T1W images (n=1) and intradiscal fluid-equivalent SI on T2W images (n=5) at an early stage. On follow-up MRI (average interval 7.2 weeks from initial MRI), available for five patients, marked progression of infection was evidenced by increased numbers of affected segments (n=3), low T1 SIs of the affected vertebrae (n=5), and increased contrast enhancement (n=3). Five patients underwent surgery to treat infections not controlled by antibiotics.

CONCLUSION

A black vertebra sign on postcontrast T1W imaging seems to reflect an early emphysematous infection.

Gas forming infection of the spine: a systematic and narrative review

PURPOSE

Gas forming infection (GFI) of the spine is a rapidly progressive and potentially life-threatening infection. It can be a consequence of aetiologies such as Emphysematous Osteomyelitis (EOM), Necrotizing Fasciitis (NF), and Gas-containing Spinal Epidural Abscess (Gas-containing SEA). This review aims to summarize the characteristics of these subtypes of GFI, describing their aetiology, diagnosis, management, and prognosis.

METHODS

PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on gas forming infections of the spine or a known subtype. Cases of post-operative and iatrogenic spinal infection were excluded.

RESULTS

The literature review revealed 35 studies reporting on 28 cases of EOM, three cases of NF involving the spine and seven cases of Gas-containing SEA. Thirty studies reporting on 32 cases of GFI were available for data analysis. The mean age of the patients was 60.9 years and a concomitant diagnosis of diabetes mellitus was reported in 57.5% of patients infected. Fever and back pain were the most common presenting symptoms. The lumbar spine was the most commonly affected spinal segment. Mortality from EOM, NF and Gas-containing SEA were 34.8, 100 and 28.5%, respectively.

DISCUSSION

Gas forming infection of the spine is a rare condition with an extremely poor prognosis, requiring early and aggressive surgical treatment. A multi-disciplinary approach is necessary for management. Nonetheless, even in cases of early recognition and optimal management, multisystem failure may still occur, and mortality rates remain high due to the aggressive nature of this infection.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Extensive multifocal emphysematous osteomyelitis: fatal outcome in a patient with psychiatric history

Emphysematous osteomyelitis is a rare entity with potentially devastating consequences, even after prompt and aggressive intervention. It is characterized by intraosseous gas and may be complicated by adjacent abscess formation. There are a handful of previously reported cases of emphysematous osteomyelitis, but none to the degree as reported here. Specifically, we report an extremely rare case of extensive multifocal emphysematous osteomyelitis involving both the axial and appendicular skeleton in a 20-year-old woman.

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.

Emphysematous Osteomyelitis of the Spine: A Case Report and Literature Review

Emphysematous osteomyelitis is a rare but potentially fatal infection. It is caused by gas-forming organisms and is characterized by the presence of intraosseous gas. A 75-year-old woman with untreated diabetes mellitus presented with difficulty in moving and anorexia. Laboratory studies revealed inflammation, a urinary infection, and diabetic ketoacidosis. Klebsiella pneumoniae was detected in both urine and blood cultures. Computed tomography and magnetic resonance imaging revealed emphysematous lesions in the paravertebral soft tissue, spinal canal, and iliopsoas muscle, with intraosseous gas at L1 and L2. These findings led to a diagnosis of emphysematous osteomyelitis. We herein review 35 reported cases of emphysematous osteomyelitis including our case.

Sacral Emphysematous Osteomyelitis Caused by Escherichia coli after Arthroscopy of the Knee

Emphysematous osteomyelitis is a rare but serious condition which is often associated with a fatal outcome. The typical appearances of emphysematous osteomyelitis are clusters of small gas bubbles within the medullary cavity. We report a case of a 62-year-old male who presented with emphysematous osteomyelitis due to hematogenous spread of Escherichia coli from the knee after arthroscopy.