Espondilodiscitis por Kingella kingae: A propósito de un caso de presentación atípica / Atypical presentation of Spondylodiscitis by Kingella Kingae: a case report

La espondilodiscitis infecciosa es una infección poco frecuente en niños, con mayor incidencia en menores de 6 años. Se presenta el caso de una paciente de 8 años, que se internó por dolor lumbar de 2 meses de evolución, afebril. La radiografía, tomografía e imagen por resonancia magnética nuclear fueron compatibles con espondilodiscitis a nivel de L4-L5. Luego de 10 días de antibioticoterapia empírica con clindamicina, con regular respuesta, se realizó punción ósea y se aisló Kingella kingae. Existe un aumento en la incidencia de infecciones osteoarticulares por Kingella kingae en lactantes y niños pequeños. La reemergencia en los últimos años se justifica por la optimización en las técnicas de cultivo, el uso de sistemas automatizados y de técnicas moleculares de diagnóstico. Kingella kingae es un patógeno que ha adquirido importancia en los últimos años en las infecciones osteoarticulares.

Infectious Spondylodiscitis is a rare infection in children. It is more frequent in patients under 6 years of age. We report the case of an 8-year-old patient with lumbar pain for 2 months, without fever. Xrays, computed tomography and magnetic resonance imaging all three showed spondylodiscitis L4-L5. After a 10-day antibiotic treatment with clindamycin with regular response, a bone puncture was performed isolating Kingella kingae (Kk). Ostearticular infections caused by Kk have increased among infants and children. Due to improvement in culture techniques, the usage of automatic systems and assessment molecular techniques, these infections re-emerged in the past few years. Kk is a pathogen that has lately become significant in osteoarticular infections.

High cervical spine spondylodiscitis management and literature review / Espondilodiscite da coluna cervical alta: manejo e revisão da literatura

Summary Spondylodiscitis affecting the cervical spine is the most unusual type. Disease progression can be dramatic, even causing quadriplegia and death. We present an unusual case that progressed with osteolytic lesions between C2 and C3, causing cord compression and epidural abscess. The patient was treated surgically by a double approach and improved without neurological deficits and with better inflammatory markers. We reviewed the current literature on the subject.

Resumo A espondilodiscite, que acomete a coluna cervical, é a de localização mais rara. Pode ter uma evolução dramática, inclusive causando tetraplegia e óbito. Apresentamos um caso atípico que evoluiu com lesões osteolíticas entre C2 e C3, causando compressão medular e abscesso epidural. O paciente foi submetido a tratamento cirúrgico por dupla abordagem e evoluiu bem, sem déficits neurológicos e com melhora dos marcadores inflamatórios. Revisamos a literatura vigente sobre o assunto.

Espondilodiscitis: experiencia clínica en un hospital general de Chile / Spondylodiscitis: clinical experience in a Chilean general hospital

Introducción: La espondilodiscitis (ED) implica prolongados períodos de hospitalización, de latencia diagnóstica y riesgo de complicaciones a largo plazo. No existen publicaciones recientes en Chile al respecto. Objetivos: Caracterizar un grupo de pacientes con ED. Pacientes y Métodos: Serie clínica, que incluyó pacientes en un período de ocho años. Resultados: 37 pacientes, 37,8% mujeres y 62,2% hombres, con promedio etario 66,8 años; 64,9% adultos mayores, 35,1% diabéticos y 21,6% con co-morbilidad urológica. Los principales síntomas fueron dolor y fiebre. 89,2% tuvo elevación de VHS. 86,5% contó con resonancia magnética, que siempre fue confirmatoria, siendo la columna lumbar la localización más frecuente (43,2%). Se identificó etiología en 28/37 pacientes: en 71,4% cocáceas grampositivas (Staphylococcus aureus predominantemente), sólo en 10,7% M. tuberculosis. Staphylococcus aureus estuvo asociado a co-morbilidades médicas en forma significativa (p < 0,05) y el grupo de bacilos gramnegativos a historia hepatobiliar y/o intestinal (p < 0,05). El método de mayor rendimiento fue el cultivo obtenido por punción quirúrgica. El tratamiento antimicrobiano fue indicado en promedio por 63,8 días (IQR 53-72), con reacciones adversas en 18,9%. La estadía hospitalaria fue 38,9 días promedio, no existiendo fallecidos durante este período. 18,9% presentó secuelas motoras. Discusión: La mayoría de pacientes con ED correspondió a adultos mayores, siendo S. aureus la principal etiología. Hubo una baja frecuencia de M. tuberculosis. Resultó considerable la magnitud de efectos adversos asociados a la terapia antimicrobiana y las complicaciones neurológicas.

Background: Spondylodiscitis (SD) involves long periods of hospitalization, diagnostic latency and risk of long-term complications. No updated series are available in Chile and a change in demographic features and etiology is suspected. Aim: To characterize a group of patients with SD. Patients and Methods: Clinical series including patients over an 8 year period. Results: We identified 37 patients; 37.8% women and 62.2% men (mean age 66.8 years); 64.9% were elderly; 35.1% had diabetes and 21.6% urological comorbidity. Main symptoms were pain and fever. Erythrocyte sedimentation rate was elevated in 89.2%, and 86.5% patients had MRI, which was always confirmatory. Lumbar spine was the most common site of infection (43.2%). Etiology was identified in 28/37 patients: 71.4% yielded grampositive cocci (Staphylococcus aureus predominantly), Mycobacterium tuberculosis was identified in only 10.7%. Staphylococcus aureus was associated to medical comorbidities (p < 0,05) and gramnegative bacilli to hepatobiliar or intestinal symptoms (p < 0,05). Culture obtained by a surgical procedure had the highest yield. The average duration of antibiotic therapy was 63.8 days (IQR 53-72). Treatment-related side effects were detected in 18.9% of patients. The average hospital stay was 38.9 days. No deaths occurred during hospitalization. Motor sequelae were present in 18.9% of this series. Discussion: Most patients with SD were older adults. Staphylococcus aureus was predominant and M. tuberculosis was uncommon. Antibiotic side effects were relevant as well as the neurological complications.

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.

Espondilodiscitis con absceso intrarraquídeo y paraespinal causada por bacilo de Calmette-Guérin (BCG) / Spondilodyscitis with medullary and spinal abscess caused by Bacillus Calmette-Guérin (BCG)

Intravesical therapy with live-attenuated Mycobacterium bovis strain have demonstrated to be effective in the treatment of recurrent and high-grade superficial bladder tumors. The use of this therapy is widely extended; however spreading of bacillus from the injection site could be one rare complication that may cause infection in different locations. An appropriate anamnesis is very important to establish an etiological diagnostic of possible infections caused by M. bovis BCG. Laboratory diagnosis at species level is difficult because of the high genetic similarity (99.9%) with the other member of Mycobacterium tuberculosis complex. We present a case report who developed tuberculous spondylodiscitis by M. bovis BCG, which had a history of intravesical instillation for treatment of bladder cancer.

Las instilaciones intravesicales con la cepa viva atenuada de Mycobacterium bovis han demostrado su eficacia en el tratamiento de cáncer urotelial de vejiga. Su uso está ampliamente difundido; sin embargo, una reacción adversa infrecuente es la extravasación del bacilo del lugar de acción pudiendo causar infecciones en otras localizaciones. Una correcta anamnesis del paciente ayuda a orientar la etiología de posibles infecciones relacionadas con éste microorganismo. El diagnóstico de laboratorio a nivel de especie es dificultoso ya que comparte un 99,9% de identidad genética con los otros miembros del complejo Mycobacterium tuberculosis. Se presenta el caso de un paciente que desarrolló una espondilodiscitis tuberculosa por M. bovis BCG, el cual tenía antecedentes de instilaciones intravesicales para el tratamiento del cáncer de vejiga.

Bacteriemias por Streptococcus gallolyticus (ex S. bovis) y su relación con patología colónica o hepatobiliar y endocarditis / Streptococcus gallolyticus (ex S. bovis) bacteremia and its relationship with colonic or hepatobiliary disease and endocarditis

Background: Bacteremia due to Streptococcus bovis (now S. gallolyticus) has been traditionally associated to colon or hepatobiliar disease and endocarditis but there is no information on this matter in Chile. Aims: To describe clinical features of adult patients suffering bacteremia by S. bovis/S. gallolyticus, identify the source of the bacteremia and the frequency of endocarditis. Methods: Retrospective-descriptive study using laboratory records. Results: Between January 2003 and August 2014, 23 S. bovis/S. gallolyticus bacteremic events were identified among 22 patients. Mean age was 72.7 years (range 46-96). Co-morbidities were frequent (9.1 to 47.6%). The primary source of bacteremia was intestinal in 52.2%; hepatobiliar in 17.4% and in 34.8% it was not elucidated. Six patients had infective endocarditis (26.1%) and one patient had espondylodiscitis (4.3%). S. bovis represented 39.1% of isolates (all until 2008), S. gallolyticus subsp pasteurianus 39.1% and, S. gallolyticus subsp infantarius and S. gallolyticus subsp gallolyticus 8.7% each one, respectively. Association studies between the bacteremic source or endocarditis with specific S. gallolyticus subspecies were limited by the small number of isolates. Seven patients (30.4%) underwent surgical interventions. In-hospital mortality reached 21.7% (n = 5). Conclusions: Although infrequent, bacteremic events by S. gallolyticus/S. bovis have increased in-hospital mortality, require surgical intervention and affect older patients with co-morbidities. Near two-thirds suffer from colonic or hepatobiliary disease that act as the primary source of bacteremia. In addition, near one fourth is affected by infective endocarditis. Detection of S. gallolyticus/S. bovis in blood cultures prompts a thorough clinical evaluation in order to clarify the source of the bloodstream infection and the presence of complications.

Antecedentes: Los cuadros de bacteriemia por Streptococcus bovis (actualmente S. gallolyticus) han sido tradicionalmente asociados a patología colónica o hepatobiliar y endocarditis pero no se conoce de estudios en Chile que hayan abordado este tema. Objetivos: Describir aspectos clínicos de pacientes adultos afectados por bacteriemias por S. bovis/S. gallolyticus, identificar la fuente de la bacteriemia y la frecuencia de endocarditis. Métodos: Diseño de tipo retrospectivo, descriptivo, con el registro de casos bacteriemia. Resultados: Entre enero de 2003 y agosto de 2014 se identificaron 23 eventos de bacteriemia por S. bovis/S. gallolyticus en 22 pacientes. La edad promedio fue de 72,7 años (rango 46-96). La prevalencia de diferentes co-morbilidades fue elevada (9,1 a 47,6%). El foco primario de la bacteriemia fue intestinal en 52,2%, hepatobiliar en 17,4% y, en 34,8% no se aclaró el foco. Seis pacientes presentaron endocarditis infecciosa (26,1%) y uno espondilodiscitis (4,3%). S. bovis representó 39,1% de los aislados (todos hasta el 2008), S. gallolyticus subsp pasteurianus 39,1%, S. gallolyticus subsp infantarius y S. gallolyticus subsp gallolyticus 8,7%, respectivamente. Los estudios de asociación estuvieron limitados por el bajo número de aislados. Siete pacientes (30,4%) debieron ser intervenidos quirúrgicamente. La mortalidad hospitalaria fue de 21,7% (n: 5). Conclusiones: Aunque infrecuentes, los eventos de bacteriemia por S. gallolyticus/S. bovis tienen una elevada mortalidad hospitalaria, requieren con frecuencia procedimientos quirúrgicos y afectan a pacientes mayores con co-morbilidades. Cerca de dos tercios padecen de una patología colónica o hepatobiliar que actúa como foco primario y cerca de un cuarto presenta endocarditis infecciosa. La detección de este grupo bacteriano en los hemocultivos requiere una evaluación para establecer el origen de la bacteriemia y la presencia de complicaciones.

Espondilodiscitis por Fusobacterium nucleatum: nueva forma de diagnóstico / Spondylodiscitis due to Fusobacterium nucleatum: New diagnostic method

Fusobacterium spp. son bacterias anaerobias Gram negativas. La osteomielitis vertebral por dichas bacterias es muy rara, de hecho, sólo podemos encontrar 11 casos en la literatura. Se presenta un caso de un varón de 46 años con dolor lumbar irradiado a la pierna derecha, de varias semanas de evolución y que no respondió al tratamiento con AINEs. Para el diagnóstico se utiliza la RMN, una biopsia con drenaje de la colección y una PCR universal seguida de secuenciación de ADNr 16S, con la que se obtuvo el diagnóstico microbiológico del paciente, identificando un Fusobacterium nucleatum como responsable. Posteriormente se pautó clindamicina como tratamiento final. En conclusión, la espondilodiscitis por Fusobacterium spp. es una entidad rara y su diagnóstico es a menudo difícil, tanto por las características clínicas como por la dificultad de obtener el diagnóstico microbiológico apropiado. La biopsia vertebral y las técnicas moleculares microbiológicas como la PCR ADNr Universal, son esenciales para la identificación del organismo y permiten la determinación de un diagnóstico y un tratamiento antibiótico apropiados.

Fusobacterium spp. are Gram negative anaerobe bacteria. Vertebral osteomyelitis caused by these bacteria is very unusual; in fact, we could only find 11 cases in the literature. We report the case of a male, 46 year-old patient who had had lumbar pain for several weeks that irradiated to the right leg, and did not respond to NSAID treatment. The work-up included MRI, biopsy with draining of the collection and a universal PCR followed by 16S rDNA sequencing. The latter was used to make the microbiologic diagnosis, which identified Fusobacterium nucleatum as the causative agent. Final treatment consisted of clindamycin. In conclusion, spondylodiscitis due to Fusobacterium spp. is a rare and difficult to diagnose entity, due both to its clinical characteristics and to the difficulty in making the right microbiologic diagnosis. Vertebral biopsy and molecular microbiologic techniques such as Universal PCR rDNa, are essential to identifying the organism, making the diagnosis and prescribing appropriate antibiotic therapy.

Espondilodiscitis causada por Kingella kingae en pediatría: reporte de un caso / Espondilodiskitis caused by Kingella kingae in children: a case report

During the last years, spondilodiskitis due to Kingella kingae has been a new target of interest, since it is the second agent that causes non tuberculous espondilodiskitis in children, after Staphylococcus aureus. Its clinical presentation is very inespecific, sometimes with fever, abdominal or lumbar disconfort, nocturnal pain, altered walking and sedestation. Images, culture methods and PCR (polymerase chain reaction) can be helpful for diagnosis, although in an important percent of the cases, etiology cannot be determined. Although there are no established guidelines for treatment, before the suspicion, empiric antibiotic treatment should be started for good prognosis. We describe a case of a 3 year old boy, who had this disease and then a review about spondilodiskitis in childhood and microbiological aspects of Kingella kingae.

La espondilodiscitis por Kingella kingae ha sido blanco de mayor interés en los últimos años, dado que constituye el segundo agente etiológico, luego de Staphylococcus aureus en espondilodiscitis no tuberculosa en niños. Clínicamente presenta sintomatología inespecífica, a veces acompañada de fiebre y de molestias abdominales o lumbares, con dolor de predominio nocturno y con alteraciones en la marcha y en la sedestación. El diagnóstico se puede ayudar con imágenes y métodos de cultivo o RPC (reacción polimerasa en cadena), aunque en un gran porcentaje de los casos no se logra determinar la etiología. Sin embargo, pese a que no exista un protocolo establecido para el tratamiento, ante la sospecha se debe iniciar tratamiento empírico, con buen pronóstico. Describimos un caso de un paciente de tres años que cursó con esta patología y posteriormente se expone una revisión sobre espondilodiscitis en la infancia y los aspectos microbiológicos de K. kingae.

Spondylodiscitis and endocarditis caused by S. vestibularis

Streptococcus vestibularis is a recently described member of the viridans group that was first isolated from the vestibular mucosa of the human oral cavity and described as a new species in 1988. It has been rarely associated with human infections. In few papers, it has been reported as a causal agent of systemic infection in immunosupressed adults and in those with other severe underlying diseases, like coronary valve diseases. A 65-year-old woman was admitted to the hospital with complaints of fever for three months, general malaise, effort dyspnea, weight loss, back pain and myalgia. Both native aortic valve endocarditis and spondylodiscitis due to Streptococcus vestibularis were detected. The patient was successfully treated with intravenous potassium penicillin G and gentamicin for six weeks, followed by oral amoxicillin for three months, in addition to aortic valve replacement. In all patients with spondylodiscitis, infective endocarditis should be considered, particularly in patients with heart valve disease history, since spondylodiscitis may be the presenting sign of an infective endocarditis. Cardiac valve replacement surgery should be performed if the course of fever and inflammatory syndrome is unfavorable after appropriate antibiotic treatment. We report the first case with both native aortic valve endocarditis and spondylodiscitis due to Streptococcus vestibularis.

Endoscopia lombar póstero-lateral com sistema YESS: resultados preliminares / Endoscopia lumbar póstero lateral con sistema YESS: reporte preliminar / Lumbar disc herniation treated with post lateral lumbar endoscopy by YESS system: preliminary results

Introducción: en los pacientes con diagnóstico de hernia de disco lumbar, los cuales son candidatos a tratamiento quirúrgico, la disectomía posterior abierta ha sido por muchos anos el estándar de oro. Sin embargo, las complicaciones de este procedimiento, en el que se invade el canal medular, han hecho que se busquen otros métodos menos invasivos. Uno de estos procedimientos es la disectomía endoscópica lateral con el método YESS (Young Endoscopic Spine System). Objetivo: revisar los resultados por dos años de cien pacientes diagnosticados con hernia de disco lumbar, tratados con endoscopia lateral con sistema YESS. Métodos: se estudiaron cien pacientes con diagnóstico de hernia de disco lumbar comprobada con resonancia magnética y discografía evocativa positiva. Todos los pacientes nunca habían hecho un tratamiento quirúrgico y se les dio seguimiento durante dos años. Resultados: los resultados se clasificaron en buenos, regulares, y malos. Se encontraron buenos resultados en 82 pacientes, regulares en 10, y malos en 8. Conclusiones: los resultados del tratamiento de la hernia de disco lumbar con la endoscopia lateral y sistema YESS son, hasta el momento, similares con el abordaje posterior abierto, aunque el tiempo de recuperación y capacidad son menores así también como el costo, ya que es un procedimiento ambulatorio.

Introdução: nos pacientes com diagnóstico de hérnia de disco lombar, candidatos ao tratamento cirúrgico, a discectomia posterior aberta tem sido por muitos anos o padrão-ouro. Embora as complicações deste procedimento, no qual se invade o canal medular, têm levado a procurar outros métodos menos invasivos. Um destes procedimentos é a discectomia endoscópica lateral com o método YESS (Young Endoscopic Spine System). Objetivo: revisar os resultados por dois anos de cem pacientes com diagnóstico de hérnia de disco lombar tratados com endoscopia lateral, com sistema YESS. Métodos: foram estudados cem pacientes com diagnóstico de hérnia de disco lombar, comprovada com ressonância magnética e discografia evocativa positiva. Todos os pacientes nunca tinham passado por um tratamento cirúrgico e foi feito um seguimento por dois anos. Resultados: os resultados foram classificados em bons, regulares e ruins. Foram encontrados bons resultados em 82 pacientes, regulares em 10 e ruins em 8. Conclusões: os resultados do tratamento da hérnia de disco lombar, com a endoscopia lateral e com o sistema YESS são, até o momento, similares àqueles com abordagem posterior aberta, mesmo que o tempo de recuperação e a capacidade sejam menores, assim como também o custo, pois é um procedimento ambulatório.

Introduction: in the patients with lumbar disc herniation, who are candidates to surgical procedures, the open diskectomy has been the gold standard for many years. Nevertheless, the complications of this procedure, in which the medullar canal is invaded, have caused other means to be developed. One of them is the YESS system (Young Endoscopic Spine System). Objective: to examine the results of one hundred patients with lumbar disc herniation, treated with the YESS system. Methods: it was studied one hundred patients with lumbar disc herniation, which was proved with magnetic resonance imaging and discography, and their results were positive. None of the patients had ever undergone a surgical procedure; therefore, they were tracked for two years. Results: results were classified into good, regular, and bad. In 82 patients good results were found, 10 were regular, and 8 were bad. Conclusions: the results of the treatment for a lumbar disc herniation with the YESS system are so far similar to open back surgery, even though the time of recovery, disability, and costs are lower because it is an ambulatory procedure.

Salmonella enteritidis spondylodiscitis: case report and review of literature

Extraintestinal manifestions of Salmonellosis are rare. Most of cases reported presented gastrointestinal symptoms, and were immunologically compromised. We report a case of a young immunocompetent patient with Salmonella enteritidis spondylodiscitis. She did not present any digestive symptoms. The tomodensitometric exam revaled L2 L3 spondylodiscitis. The culture of the biopsy yielded S. enteritidis. In the litterature, 115 cases of non-typhoidal salmonellosis were reported. Most of cases occur in patients immunologically compromised by sickle cell disease. Salmonella enteritidis, Salmonella typhimurium and Salmonella choleraesuis were the most common serotypes described

Disseminated infection due to Mycobacterium chelonae with scleritis, spondylodiscitis and spinal epidural abscess

Mycobacteria other than tuberculosis (MOTT) have a low incidence as pathogens in human pathology. The most frequent clinical expression is the disseminated disease in subjects with compromised cellular immunity. Bacteriological characteristics in culture can generate confusion with other pathogens, which delays the appropriate diagnosis and treatment. We present a case of a disseminated infection due to Mycobacterium chelonae with scleritis, spondylodiscitis and spinal epidural abscess in a man with a medical background of cellular immunity deficit induced by therapeutic drugs. The antibiotic scheme of twenty-one weeks, during the follow-up period, controlled the infection, however, the optimum duration of treatment has not been established.

Spondylodiscitis associated with recurrent Serratia bacteremia due to a transjugular intrahepatic portosystemic shunt (TIPS): a case report

We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection.

Espondilodiscite por brucelose: relato de caso / Brucellosis spondylodiscitis: case report

Relata-se um caso de espondilodiscite por Brucella em um paciente do sexo masculino, 56 anos, fazendeiro, com manifestações sistêmicas da doença. O diagnóstico foi realizado por sorologia com título de 1/160, hemocultura positiva, o VHS foi elevado, bem como alterações radiológicas mostraram espondilodiscite ao nível de T8/T9 compatíveis com a patologia. O paciente foi tratado com estreptomicina 1gIM/dia por 15 dias, doxaciclina e rifampicina por seis semanas, com melhora clínica do quadro. O envolvimento vertebral na brucelose é uma complicação de ocorrência variável na literatura, mas considerado pouco freqüente, de difícil diagnóstico principalmente em regiões com alta prevalência de tuberculose, visto que esta pode mimetizar o quadro de brucelose. Chama-se atenção a um caso raro de espondilodiscite por brucelose, dada a necessidade de diagnóstico precoce e tratamento a fim de se evitar possíveis seqüelas.

A case of spondylodiscitis due to Brucella with systematic manifestation of the disease, in a 56-year-old male patient who was a farmer, is reported. The diagnosis was made from serological tests, with a titer of 1/160. The blood culture was positive and the blood sedimentation rate was high. Radiological abnormalities showed spondylodiscitis at the T8/T9 level that were compatible with this disease. The patient was treated with streptomycin at 1g IM/day for 15 days, and doxycycline plus rifampicin for six weeks, with a clinical improvement in the condition. Vertebral involvement in brucellosis is a complication of variable occurrence in the literature. However, it is considered to be infrequent and difficult to diagnose, particularly in regions with high prevalence of tuberculosis, given that this may mimic conditions of brucellosis. Attention is drawn to this rare case of spondylodiscitis due to brucellosis, given the need for early diagnosis and treatment in order to avoid possible sequelae.

PCR identification of Mycobacterium tuberculosis complex in a clinical sample from a patient with symptoms of tuberculous spondylodiscitis

A 42-year-old male complaining of thoracic spine pain was admitted to the hospital for evaluation. An X-ray and computer tomography of the thoracic spine showed spondylodiscitis of the L3 lumbar and L2-L3 intervertebral disk. The tuberculin skin test (PPD) was strongly positive. A radioscopy-guided fine needle aspirate of the affected area was cultured but did not reveal the cause of the disease. Two biopsy attempts failed to reveal the cause of the disease by culturing or by acid-fast-resistant staining (Ziehl Neelsen) of the specimens. A third biopsy also failed to detect the infectious agent by using microbiological procedures, but revealed the presence of a 245-bp amplicon characteristic of the Mycobacterium tuberculosis complex after PCR of the sample. The result demonstrates the efficacy of PCR for the identification of M. tuberculosis in situations in which conventional diagnosis by culturing techniques or direct microscopy is unable to detect the microorganism. Following this result the patient was treated with the antituberculous cocktail composed by rifampicin, pirazinamide and isoniazid during a six-month period. At the end of the treatment the dorsalgia symptoms had disappeared.

Pyogenic discitis in female after delivery and pelvic surgery

Pyogenic discitis most frequently occurs after home delivery, hemorridectomy, and dilatation and curettage. Discitis is generally due to blood borne bacterial invasion of the disc from adjacent end-plate via communicating vessels. Infective discitis remains an uncommon, but potentially serious cause for back pain. Delayed diagnosis can occur and a high index of suspicion may occur. The study included 30 patients suffering from localized low back pain with limitation of movement. Diagnosis was made by history, physical examination and investigation mainly E.S.R and MRI. 50.3% of patient with discitis had a history of vaginal delivery, 15% had a history of hemorridectomy and 10% had a history of dilatation and curettage and cesarean section surgery. All patients had elevated E.S.R, Positive C-reactive protein and positive MRI finding. We must think of Pyogenic discitis in any patient with sever backache, fever, local tenderness, and high ESR

Espondilodiscitis y absceso epidural candidiásico / Candida spondylodiscitis and epidural abscess

Candida spondylodiscitis associatd with epidural abscess is rarely seen. We present a patient with Hodgkin lymphoma who received chemotherapy and developed systemic Candida infection, which was complicated by Candida spondylodiscitis and epidural abscess

Candida spondylodiscitis associatd with epiduralabscess is rarely seen. We present a patient with Hodgkin lymphoma who received chemotherapyand developed systemic Candida infection, which was complicated by Candida spondylodiscitis and epiduralabscess

Tratamento da discite na criança / Treatment of discitis in the child

OBJETIVO: Foram avaliados retrospectivamente nove casos de discite na infância, confirmando suas formas variadas de apresentação, que levam ao atraso e dificuldades no diagnóstico. MÉTODOS: Os autores demonstraram que as radiografias iniciais podem se apresentar sem alterações, sendo importantes os exames de cintilografia ou ressonância magnética, nesses casos. RESULTADOS E CONSLUSÕES: Um paciente necessitou de tratamento cirúrgico para descompressão do canal lombar, devido à presença de abscesso discal. Os demais pacientes foram tratados conservadoramente, através de repouso, antibioticoterapia adequada e imobilização. Todos os pacientes evoluíram satisfatoriamente, e não apresentavam queixas nas suas avaliações finais.