Espondilodiscite em idade pediátrica ­ uma doença rara, um diagnóstico difícil / Spondylodiscitis in pediatric age ­ a rare disease, a difficult diagnosis

Introdução e objetivo: a espondilodiscite é a infeção que atinge o disco intervertebral e as vértebras contíguas e representa dois a quatro % do total das infeções osteoarticulares em idade pediátrica. O agente patogénico é identificado em cerca de metade dos casos, sendo o Staphylococcus aureus o mais frequentemente isolado. Estudos recentes demonstram que entre os seis meses e os quatro anos a Kingella kingae tem um papel etiológico importante. O objetivo da exposição deste caso clínico foi chamar atenção para esta patologia rara cujo diagnóstico é difícil e exige um elevado nível de suspeição. Descrição do caso: criança de 16 meses, sexo masculino, com antecedentes de obstipação, é trazida múltiplas vezes à Urgência Pediátrica por quadro com mais de um mês de evolução de irritabilidade persistente, dor abdominal e recusa da marcha de agravamento progressivo. Na segunda vinda à Urgência Pediátrica apresentava dorsolombalgia à palpação da coluna dorsolombar e diminuição da lordose lombar, o que motivou a realização de avaliação analítica, sumária de urina, ecografia renal e vesical e radiografia dorsolombar sem alterações. Na terceira vinda à Urgência Pediátrica foi decidido internamento e solicitada ressonância magnética nuclear dorsolombar e cintigrafia óssea que revelaram espondilodiscite em D7-D8. Parâmetros analíticos sem alterações valorizáveis, exceto discreta elevação da velocidade de sedimentação. Hemoculturas e restante estudo etiológico negativo. Iniciou terapêutica endovenosa com cefu-roxime e flucloxacilina, com melhoria progressiva das queixas álgicas. Aquando da alta, assintomático, mantendo flucloxacilina oral até completar seis semanas de tratamento. Reavaliado posteriormente, encontrando-se assintomático, com um exame físico, reavaliação analítica e radiografia dorsolombar sem alterações. Conclusões: a espondilodiscite é uma identidade de difícil diagnóstico, especialmente na criança, devido à sua raridade, clínica inespecífica, impossibilidade de as crianças verbalizarem os seus sintomas e aos sinais radiológicos tardios, requerendo um alto índice de suspeição. O intervalo médio de tempo entre o início dos sintomas e o diagnóstico é de três semanas a três meses. A ressonância magnética é o exame de escolha. As hemoculturas são, muitas vezes, negativas. O pilar do tratamento é a antibioterapia por várias semanas, mas a sua escolha e duração são controversas. O tratamento inadequado pode originar dor crônica, sequelas ortopédicas graves e complicações neurológicas devastadoras. Quando atempada e adequadamente tratada, a maioria dos casos apresenta uma evolução clínica benigna e autolimitada.

Introduction and objective: spondylodiscitis is an infection that affects the intervertebral disc and the contiguous vertebrae. It represents two to four % of all osteoarticular infections in pediatric age. The pathogen is identified in about half of the cases, with Staphylococcus aureus being the most frequently isolated. Recent studies show that between six months and four years, Kingella kingaehas an important etiological role. The purpose of the presentation of this clinical case was to draw attention to this rare pathology whose diagnosis is difficult and requires a high level of suspicion. Clinical case description: a sixteen-month-old male, with a history of constipation, is brought multiple times to the Pediatric Emergency Department for a clinical picture with more than a month of evolution of persistent irritability, abdominal pain and refusal to walk, with progressive worsening. On the second visit to the Pediatric Emergency Department, he presented dorsolombalgia on palpation of the dorsolumbar spine and decreased lumbar lordosis, which led to the performance of analytical evaluation, urinalysis, renal and bladder ultrasound and dorsolumbar radiography, all without changes. On the third visit to the Pediatric Emergency Department, hospitalization was decided and dorsolumbar nuclear magnetic resonance and bone scintigraphy were requested, revealing spondylodiscitis in D7-D8. Analytical parameters had no changes, except for a slight increase in erythrocyte sedimentation rate. Blood cultures and remaining etiological study negatives. Intravenous therapy with cefuroxime and flucloxacillin was started with progressive improvement of pain. Upon discharge he was asymptomatic and maintained oral flucloxacillin until a total of six weeks of treatment. He was subsequently reassessed and remained asymptomatic, with a physical examination, analytical evaluation and dorsolumbar radiography without changes. Conclusions: spondylodiscitis is an identity that is difficult to diagnose, especially in children, due to its rarity, unspecific clinic, inability for children to verbalize their symptoms and late radiologic signs, requiring a high index of suspicion. The average time between the onset of symptoms and the diagnosis is three weeks to three months. Magnetic resonance imaging is the exam of choice. Blood cultures are often negative. The mainstay of treatment is antibiotic therapy for several weeks, but its choice and duration are controversial. Inappropriate treatment can lead to chronic pain, severe orthopaedic sequelae and devastating neurological complications. When timely and properly treated, most cases have a benign and self-limited clinical course.

Espondilodiscitis: análisis de 19 casos internados en un hospital de tercer nivel / Spondylodiscitis: analiysis of 19 inpatients at a referral hospital in Rosario, Argentina

Introducción: la espondilitis representa un desafío diagnóstico, ya que el dolor lumbar, su principal manifestación clínica, constituyeun motivo de consulta muy frecuente en la práctica cotidiana y carece de especificidad. Por lo tanto, resulta indispensablemantener una elevada sospecha clínica. Objetivo: Analizar las características clínicas, analíticas, microbiológicas e imagenológicas,el tratamiento, la evolución y los factores pronósticos de pacientes internados por espondilodiscitis en el Hospital Provincial delCentenario, desde enero de 2011 a marzo de 2015, excluyéndose los casos postquirúrquicos. Resultados: Se analizaron 19 pacientescon una edad media 48±11 años, 63% varones. Se identificaron como comorbilidades: diabetes (37%), obesidad (16%), etilismo(21%), insuficiencia renal crónica en hemodiálisis (16%), HIV (11%), adicción EV (11%). Los gérmenes más frecuentes fueron losestafilococos (52%). Al ingreso el 94% presentó dolor, 73% fiebre y 36% foco neurológico. La media de tiempo de evolución desíntomas hasta ingreso fue 62±80 días (rango 4-360 días). La velocidad de eritrosedimentación fue elevada en todos los pacientes,y sólo 37% presentaban leucocitosis. La vancomicina fue el antibiótico más utilizado. El 37% de los pacientes presentaba infeccióndiseminada. La mortalidad fue del 26%. Los pacientes que tuvieron un tiempo de evolución al ingreso mayor a 25 días presentaronpeor evolución (colecciones, foco neurológico o muerte) (p<0,05). Conclusiones: en esta serie, la asociación de la consulta tardíacon la mala evolución destaca la importancia de considerar las pautas de alarma en centros de atención primaria para posibilitar undiagnóstico más temprano.

Introduction: Spondylodiscitis represents a diagnostic challenge since the main clinical manifestation, low back pain, is very frequent andnonspecific, and often impedes a timely diagnosis. Clinical suspicion is essential. Objective: to analyze the clinical, analytical, microbiological,and radiological features, as well as outcome and prognostics factors, in patients with spondylodiscitis admitted to the Hospital Provincialdel Centenario (Rosario, Argentina), from January 2011 to March 2015. Postsurgical cases were excluded. Results: Nineteen patients wereincluded. Mean age was 48±11 years, 63% were males. We identified the following comorbid diseases: diabetes (37%), obesity (16%),alcoholism (21%), hemodialysis-dependent chronic kidney disease (16%), HIV (11%), intravenous drug abuse (11%). The most frequentcausative organism was Staphylococcus sp. (52%). Upon admission 94% of patients presented pain, 73% fever, and 36% neurologicalinvolvement. The average time from the onset of symptoms to diagnosis was 62±80 days (range 4-360). The erythrocyte sedimentation ratewas raised in all the patients, and only 37% had leukocytosis. Vancomycin was the most frequently prescribed antibiotic. Disseminatedinfection was present in 37% of patients. The mortality rate was 26%. Patients with a time lag to diagnosis higher than 25 days had worseoutcome (suppurative collections, neurological involvement, or death) compared to those with earlier diagnosis (p <0.05). Conclusions:The association of late consultation with poor outcome in this study emphasizes the importance of educating the general population toencourage attendance to medical centers. Physicians in primary care settings must be trained to identify pain pattern, and incorporateclinical perspectives capable of recognizing a defined syndrome at first contact, in other to achieve a better outcome.Key words: Spondylodiscitis, comorbid conditions, diagnostic delay, outcome.

Discitis in infancy

An eleven-month-old male infant with diskitis was diagnosed through clinical, neurological, laboratory, and radiological evaluation. The clinical signs were: irritability, abdominal or hip pain and refusal to sit. Narrowing of the disc space was found radiographically and by magnetic resonance imaging [MRl]. Blood culture was positive for Staphylococcus aureus. Treatment consisted of intravenous antibiotics, immobilization of the spine, and bed rest. It is concluded that it is important to be aware of this condition in order to treat it as early as possible

Fungal discitis due to Aspergillus terreus in a patient with acute lymphoblastic leukemia

We report a case of Aspergillus terreus discitis which developed in a patient with acute lymphoblastic leukemia following induction chemotherapy. A. terreus was isolated from sputum, one month earlier, but the physician did not consider it significant at the time. Magnetic resonance imaging study showed the involvement of L3-4, L4-5 and L5-S1 intervertebral discs. Etiology was established by means of histology and culturing a surgical specimen of disc materials. Our patient survived after a surgical debridement and amphotericin B administration with a total dose of 2.0 g. Discitis caused by Aspergillus terreus is a very rare event. A. terreus is one of the invasive Aspergillus species. The pathogenetic mechanism is discussed and the literature is reviewed.