16 June 2022: Articles
Mistake in diagnosis, Diagnostic / therapeutic accidents, Management of emergency care, Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathologyGeorgios S. Papaetis12ABDEFG*, Theodosios A. Petridis3ABF, Stylianos A. Karvounaris4ABF, Theodora Demetriou5ABF, Savvas Lykoudis3ABDEF
Am J Case Rep 2022; 23:e936179
BACKGROUND: Pyogenic spondylitis comprises several clinical entities, including native vertebral osteomyelitis, septic discitis, pyogenic spondylodiscitis, and epidural abscess. The lumbar spine is most often infected, followed by the thoracic and cervical areas. It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route). Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death.
CASE REPORT: We describe a 63-year-old man with no significant past medical history who presented with fever and an altered level of consciousness. Significant thoracic spine pain was also reported during the last 3 months. The final diagnosis was vertebral spondylodiscitis, contiguous spinal epidural abscess, and sepsis due to Bacteroides fragilis bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for 12 weeks. The primary focus of the infection was not clarified, despite all the investigations that were performed.
CONCLUSIONS: Spondylodiscitis, spinal epidural abscess, and sepsis as complications of Bacteroides fragilis bacteremia are rare in a patient without any previously known predisposing conditions and without an obvious primary focus. Early diagnosis and proper treatment of anaerobic spondylodiscitis, especially if epidural abscess and sepsis are present, are of great importance to reduce mortality and avoid long-term complications.
Keywords: Bacteria, Anaerobic, case reports, Epidural Abscess, Sepsis, Bacteremia, Bacteroides fragilis, Discitis, Humans, Lumbar Vertebrae, Male, Middle Aged
Pyogenic spondylitis includes a wide range of clinical entities, such as native vertebral osteomyelitis (NVO), septic discitis, pyogenic spondylodiscitis, and epidural abscess . It is an infrequent and serious cause of back pain. The lumbar spine is most often infected (50–60% of cases), followed by the thoracic (T) areas (approximately 30% of cases) and cervical areas (about 10%). It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route) [1,2]. In patients aged 50 years or older, NVO is the most common form of hematogenous osteomyelitis . Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death. In patients who experience spinal epidural abscess, the best clinical outcomes have been achieved after probe surgical intervention, abscess drainage, and appropriate antibiotic therapy [1–3].
A 63-year-old man presented to our clinic with fever and an altered level of consciousness. His past medical history was insignificant. His wife reported that he experienced pain in the mid-back region and fever that spiked up to 38°C for the previous 3 months. The pain was constant and became worse at night. During the last month before his presentation, the pain became stronger and radiated to his chest. He was treated with several courses of non-steroidal anti-inflammatory drugs and muscle relaxants from his general practitioner. He was also treated with cefuroxime and azithromycin for a presumed respiratory infection. Ten days before his presentation, he was hospitalized for a presumed urine infection. His urine analysis showed 8 to 10 white blood cells (WBC) per high-power field, while urine cultures were negative. Blood cultures were not obtained during that hospitalization. He was treated with piperacillin/tazobactam for 7 days and was advised to receive levofloxacin for another 2 weeks. He was receiving levofloxacin at the time of his presentation to our hospital. He did not report any other symptoms (such as abdominal pain, cough, or dyspnea). He had never smoked and had not been prescribed any other medications in the past. His past mental health was excellent. He did not report any recent trauma or gastrointestinal procedures.
His physical examination showed that he experienced all 3 quick SOFA criteria for sepsis: (i) altered mentation (Glasgow Coma Scale score of 12); (ii) respiration rate of 25 breaths/min; and (iii) systolic blood pressure of 100 mm Hg . His full SOFA score was 4. His body temperature was 38.5°C, and his heart rate 115 beats/min. Palpation and percussion of his back showed severe point tenderness over his mid-T spine. His neurological examination was normal. The rest of the clinical examination was not remarkable. Results of his laboratory investigations showed mild anemia (hemoglobulin: 10.3 g/dL) and WBC of 16 170/mm3 (neutrophils: 92%). The erythrocyte sedimentation rate was 95 mm/h, and the C-reactive protein level was 16.8 mg/dL. All other laboratory values were within the reference range, except for renal function markers: serum urea and creatinine levels were 72 mg/dL and 2.6 mg/dL, respectively. Urine analysis showed mild microscopic hematuria. The urine culture was negative.
His electrocardiogram showed sinus tachycardia, while the transesophageal echocardiogram did not show any vegetations. The chest radiography and the abdominal ultrasound did not show any abnormal findings. Magnetic resonance imaging (MRI) of the T spine suggested septic spondylodiscitis at the T6–T7 level, with associated osteomyelitis at the T6 and T7 vertebra, as well as a mass-like lesion in the anterior epidural space measuring 4×2.2×1 mm, representing an epidural abscess (Figure 1A, 1B). Two sets of blood cultures for bacteria (aerobic and anaerobic) and fungi were obtained during the first day of his hospitalization. No other blood cultures were obtained during his hospitalization and the follow-up period. Serological studies showed that (i) antibodies for HIV, HCV,
The patient was hemodynamically stabilized. Meropenem 1 g intravenously (i.v.) every 8 h and teicoplanin 12 mg/kg i.v. daily were initially administered. He was operated on by the orthopedic and spine surgery team of our hospital 24 h after his admission. A 1-stage operation with a standard posterior mid-line approach over the spinous processes, with the patient in the prone position, was done in the T region. A wide decompression with laminectomy, foraminotomy, and facetectomy were performed. Debridement of the spinal canal and abscess drainage were also achieved. Two perioperative samples of the epidural abscess were examined. Routine bacterial, fungal, and acid bacilli cultures of all samples that were investigated did not show any possible pathogens. The polymerase chain reaction for the detection of
The patient gradually improved and regained his normal state of consciousness and mobility. All renal function markers eventually normalized. He was then discharged and continued ertapenem 1g i.v. daily and metronidazole 500 mg orally every 8 h, completing, in total, a 12-week course. After 6 weeks of treatment, infection markers declined to normal levels. No recurrence was found in the MRI scan that was performed 1 year after diagnosis (Figure 2). A colonoscopy that was performed before the patient left the hospital showed multiple diverticula in the left and right colon (Figure 3). A 1.5-cm polyp was also found and was completely excised (Figure 4). The histo-logical examination revealed a tubulovillous adenomatous polyp with high-grade dysplasia.
NVO usually involves 1 or more adjacent vertebral bodies, owing to their rich cellular marrow and ample blood supply. The corresponding intervertebral disk, which has no blood supply, can also be affected together or independently [1–3]. Moreover, epidural infections have increased dramatically with the increased use of vascular access, spinal instrumentation, and injection drugs, and these infections can have insidious presentation and variable progression and can promote neurologic decline [5,6]. The most common pathogens are
Anaerobic infections cause approximately 3% of all axial skeleton infections [1–3]. They are most common in patients with direct inoculation due to penetrating spinal trauma and in the diabetic population . They are mainly caused by
A significant number of these patients experience polymicrobial anaerobic bacteremia;
Even though the primary focus of the infection was not clarified, a few hypotheses could be made. The patient was diagnosed with diverticular disease before his discharge from the hospital. Although he did not report any symptoms of diverticulitis, several cases of asymptomatic diverticulitis have been reported, and some of them were associated with serious complications . Moreover, retrospective studies and several case reports have shown possible associations between bacteremia from certain intestinal microbes, including
Spondylodiscitis, spinal epidural abscess, and sepsis as complications of
FiguresFigures 1.. (A, B) MRI of the thoracic spine showed septic spondylodiscitis in the T6–T7 level with associated osteomyelitis in the T6 and T7 vertebra, as well as a mass like lesion in the anterior epidural space representing an epidural abscess. MRI – magnetic resonance imaging; T – thoracic. Figure 2.. Magnetic resonance imaging scan that was performed 1 year after the time of diagnosis. Figure 3.. Multiple diverticula were found, both in the left and right colon, during colonoscopy. Figure 4.. A 1.5-cm tubulovillous adenomatous polyp was also found and was completely excised.
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