Pyogenic Vertebral Column Osteomyelitis in Adults: Analysis of Risk Factors for 30-Day and 1-Year Mortality in a Single Center Cohort Study

STUDY DESIGN: Retrospective cohort study. PURPOSE: To describe our experience in the management and outcomes of vertebral column osteomyelitis (VCO), particularly focusing on the risk factors of early and late mortality. OVERVIEW OF LITERATURE: Previous reports suggest a global increase in spinal column infections highlighting significant morbidity and mortality. To date, there have been no reports from our local population, and no previous report has assessed the potential relationship of frailty with mortality in a cohort of patients with VCO. METHODS: We reviewed 76 consecutive patients with VCO between 2009 and 2016 in Waikato Hospital, New Zealand. Demographic, clinical, microbiological, and treatment data were collected. Comorbidities were noted to calculate the modified Frailty Index (mFI). Mortality at 30 days and 1 year was recorded. Univariate and multivariate analyses were used to identify the predictors of mortality. RESULTS: The mean age of patients was 64.1 years, with 77.6% being male. Most patients presented with axial back pain (71.1%), with the lumbar spine most commonly affected (46%). A mean of 2.1 vertebral bodies was involved. Methicillin-sensitive Staphylococcus aureus was the most common organism of infection (35.5%), and 15.8% of patients exhibited polymicrobial infection. Twenty patients (26.3%) underwent surgical intervention, which was more likely in patients with concomitant spinal epidural abscess (odds ratio [OR], 4.88) or spondylodiscitis (OR, 3.81). Mortality rate was 5.2% at 30 days and 22.3% at 1 year. The presence of frailty (OR, 13.62) and chronic renal failure (OR, 13.40) elevated the 30-day mortality risk only in univariate analysis. An increase in age (OR, 1.07) and the number of vertebral levels (OR, 2.30) elevated the 1-year mortality risk in both univariate and multivariate analyses. CONCLUSIONS: Although the mFI correlated with 30-day mortality in univariate analysis, it was not a significant predictor in multivariate analysis. An increase in age and the number of levels involved elevated the 1-year mortality risk.

Late-Onset Candida Vertebral Osteomyelitis in Two Young Patients Who Underwent Heart Transplant Surgery / 대한정형외과학회잡지

Candida vertebral osteomyelitis (CVO) is a rare disease that is a complication of intravenous drug use, but recently it has been recognized as mostly an opportunistic infection. Because CVO appears to mimic pyogenic spondylodiscitis in terms of the clinical and radiologic presentations, it is often neglected in a usual clinical setting. The clinical, radiological, and biological characteristics of CVO are often used to make a differential diagnosis with vertebral osteomyelitis from other etiologies. Once an initial proper diagnosis was performed, the treatment relies on the prompt initiation of appropriate pharmacotherapy and serial monitoring of the clinical progress. This paper report late-onset CVO in two young patients who underwent a heart transplant surgery and had postoperative systemic candidiasis. These two cases are a good reminder of the potential of CVO in immunosuppressive patients treated with anti-fungal agents. This paper presents these two cases with a review of the relevant literature.

The Value of T-SPOT.TB in Evaluating Treatment Effect of Tuberculous Vertebral Osteomyelitis / 昆明医科大学学报

Objective To investigate the treatment evaluating value of ESAT－6 and CFP－10 in T－SPOT.TB kit for tuberculous vertebral osteomyelitis.Medthods This retrospective study analyzed 29 cases diagnosed as TVO in the First Affiliated Hospital of Kunming Medical University from January 2013 to January 2016. All cases were the first－time consultancy. The Wilcoxon－singed－rank－test and chi－square test were used to analyze the changes of ESAT－6 and CFP－10 in the procedure of treatment. The linear－regression analysis was used to analyze the relationship between ESR, CRP, VAS and two specific antigens.Results The pretherapeutic spot counts of ESAT－6 and CFP－10 were compared with the first and the last follow－up respectively. The results of two antigenic spots change showed a higher consistency (P＜0.05) .The positive rates of CFP－10 at the prior treatment, the first follow－up and the last follow－up were 86.20% , 79.31% and 58.62% respectively. The result of chi－square test showed a higher consistency (P＜0.05) . ESAT－6 only correlated with VAS. CFP－10 had the relationship with VAS and ESR. But all of these relativities were weak.Conclusion The decrease in the spot counts of ESAT－6 and CFP－10 suggest that the treatment is effective,and CFP－10 may be one available index to evaluate the treatment effect.

Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment

Pyogenic vertebral osteomyelitis (PVO) may result in neurological deficits and sequelae, so early diagnosis and appropriate treatment are critical. Many previous studies on PVO exist, but our paper has aimed to comprehensively summarize the clinical aspects of PVO. Through review of the vast literature on the clinical research of PVO an overview of the clinical characteristics, diagnostic methods, treatment and prognosis is provided.

Síndrome Rendu Osler Weber asociado a Espondilodiscitis por Staphylococcus aureus / Osler Weber Rendu syndrome associated with Staphylococcus aureus Spondylodiscitis

ResumenLa telangiectasia hemorrágica hereditaria o síndrome de Rendu-Osler-Weber, es un desorden autonómico dominante, debido a mutaciones del gen de la endoglina o del gen de la cinasa análoga al receptor de activina. Dicha enfermedad se caracteriza por la presencia de telangiectasias en piel y mucosas, epistaxis recurrente y espontánea, además de malformaciones arteriovenosas en pulmones, cerebro y sistema gastrointestinal. Se ha reportado la asociación entre esta entidad e infecciones en diferentes sitios por Staphylococcus aureus. Los mecanismos de dicha predisposición incluyen la presencia de fístulas arteriovenosas y disfunción polimorfonuclear. Se reporta el caso de una paciente portadora de la enfermedad que asoció osteomielitis vertebral; requirió tratamiento antibiótico prolongado y cirugía de fusión e instrumentación de la columna vertebral a nivel torácico. Es necesario considerar este tipo de infecciones en pacientes con tal enfermedad, lo cual puede ayudar a la escogencia del tratamiento antibiótico y del manejo del paciente más expedito.

AbstractHereditary Hemorrhagic Telangiectasia or Osler-Weber-Rendu syndrome is a dominant autonomic disorder caused by mutations of the endoglin gene or the kinase gene similar to the activin receptor. This disease is characterized by the presence of telangiectasia on skin and mucous, recurrent and spontaneous epistaxis, as well as arteriovenous malformations in lungs, brain and gastrointestinal system. The association between this disease and infections in several places of the body with Staphylococcus aureushas been reported. The mechanisms of this predisposition include the presence of arteriovenous fistulas and polymorphonuclear dysfunction. A case is reported about a patient carrying the disease associated with vertebral osteomyelitis, who required a prolonged antibiotic treatment and instrumentation of the vertebral column at thoracic level. It is necessary to consider this type of infections in patients with this disease, which may help when choosing the antibiotic treatment and a more expeditious patient management.

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.

A Case of Redo Aortic Valve Replacement for Bioprosthetic Aortic Valve Endocarditis Combined with Pyogenic Vertebral Osteomyelitis, Causing Prosthetic Valve Deterioration despite Effective Antibiotic Therapy / 日本心臓血管外科学会雑誌

Infective endocarditis in association with pyogenic vertebral osteomyelitis is rarely observed. We report an 80-year-old man with infective endocarditis and pyogenic vertebral osteomyelitis requiring reoperation due to aortic prosthetic valve dysfunction. He suffered from back pain as the initial symptom, and he was admitted to our hospital. On magnetic resonance imaging, vertebral osteomyelitis was revealed, and antibiotics were started. On blood sampling α-streptococcus was identified and infective endocarditis was diagnosed. He responded to the antibiotic treatment. Despite the improvement in his general condition and the inflammatory parameters of blood samples, the aortic prosthetic valve dysfunction progressed. On echocardiography, aortic regurgitation worsened to 4/4, and the ejection fraction decreased from 72 to 46%. As heart failure was apparent, we performed a redo aortic valve replacement. Tears were found in the leaflets of the removed prosthetic valve (Hancock II). The 21-mm Carpentier-Edwards PERIMOUNT valve (CEP Magna Ease TFX) was replaced. His post-operative course was uneventful, and intravenous administration of ampicillin was continued. Oral rifampicin was also continued. On the 69th post-operative day, he was discharged and was ambulatory. Although we have no evidence that the tissue valve deterioration had resulted from bacterial damage, we were able to confirm that the structural valve deterioration involved bacterial contact in this case. Patients with infective endocarditis and pyogenic vertebral osteomyelitis should be treated cautiously regardless of whether or not the inflammation is controlled.

A Case of Pyogenic Spondylitis Due to Aggregatibacter aphrophilus / 대한임상미생물학회지

Aggregatibacter aphrophilus, a normal component of oral cavity flora, mostly causes infective endocarditis and only rarely causes spondylitis; no spondylitis cases have been previously reported in Korea. We report a case of pyogenic spondylitis due to A. aphrophilus without endocarditis. A 64-year-old man was admitted for back pain lasting 3 weeks. There was severe tenderness on lumbar spines but no fever. Laboratory evaluation showed leukocytosis and elevated C-reactive protein. Blood cultures were negative. Magnetic resonance imaging showed psoas abscess and vertebral inflammation. Pus was obtained by computerized tomography-guided aspiration from the psoas abscess and inoculated into blood culture bottles. After 5 days of incubation, growth was detected: the isolate was a Gram-negative short rod bacteria identified as A. aphrophilus by the automated system; this was confirmed by 16S ribosomal RNA sequencing. There was no evidence of endocarditis in echocardiography and retinal examination. Back pain persisted despite 8 weeks of antibiotic treatment, so vertebral corpectomy was performed. A. aphrophilus, a rare cause of pyogenic spondylitis, can induce spondylitis without endocarditis. If a patient with pyogenic spondylitis shows negative routine bacterial cultures, fastidious organisms such as A. aphrophilus should be suspected and the blood culture bottles could be used.

Osteomielitis vertebral lumbar / Ostéomyélite vertébrale lombaire / Lumbar vertebral osteomyelitis

Se mostró la terapéutica médica y quirúrgica ante un caso con osteomielitis vertebral secundaria a discectomía, mediante el estudio observacional descriptivo en un paciente de 50 años de edad, afecto de hernia discal del 5to. espacio lumbar, a quien se le había practicado discectomía abierta; que ingresó a los 15 días con un cuadro doloroso lumbar e hipertermia de 39 °C.Se hizo una revisión actualizada del tema de osteomielitis vertebral y se expuso la terapéutica quirúrgica y antimicrobiana realizada al paciente. Luego de desbridamientos quirúrgicos seriados demandantes y secuenciales, así como de irrigación continua, se observó la resolución del cuadro infeccioso y del cuadro radicular que presentaba el paciente. En consulta externa se reflejó la negatividad de las investigaciones analíticas de infección a los 4 meses de evolución. Se concluyó que es importante ante los signos clínicos de infección (dolor, fiebre), realizar una tomografía axial computarizada en un paciente con discectomía abierta, para ver la repercusión ósea y operar lo antes posible. La modalidad de desbridamiento secuencial y demandante con una irrigación continua de solución salina fisiológica 0,9 por ciento con antibiótico sensible al microorganismo, da resultados satisfactorios(AU)

Surgical and medical therapy was shown in a case of vertebral osteomyelitis secondary to disectomy by means of a descriptive observational study conducted in a 50 years old patient affected by herniation of the fifth lumbar disk that had undergone open disectomy; who was admitted 15 days after this with a painful lumbar manifestation and hyperthermia of 39 °C. An updated review of the topic of vertebral osteomyelitis was made and the surgical and antimicrobial therapy followed in the patient was shown. After demanding sequential serial surgical debridements with continuous irrigation, the resolution of the infectious and radicular manifestation that the patient presented was observed. The negative impacts of the analytical investigations of infection were presented in the outpatient consultation after four months of evolution. It was concluded that, in the presence of clinical signs of infection such as pain and fever, it is important to indicate a CT-scan to a patient who had undergone open disectomy to observe the osseous percussion and operate on as soon as possible. The modality of demanding sequential serial surgical debridement with continuous irrigation with 0.9 percent physiological saline solution and a sensitive antibiotic to the microorganism gives satisfactory results(AU)

Une étude observationnelle descriptive d'un patient âgé de 50 ans, atteint de hernie discale du 5e espace lombaire et d'ostéomyélite vertébrale, après discectomie ouverte, a permis de montrer la thérapeutique médicale et chirurgicale à suivre dans ces cas. Ce patient avait été hospitalisé 15 jours auparavant avec un tableau douloureux lombaire et une hyperthermie de 39 °C. Après avoir fait une révision actualisée du sujet de l'ostéomyélite vertébrale, une thérapeutique chirurgicale et antimicrobienne a été proposée. Des débridements chirurgicaux sériés et séquentiels, ainsi qu'irrigation continue, ont assuré la résolution de l'infection et du syndrome radiculaire affectant le patient. En consultation externe, les examens ont été négatifs d'infection en 4 mois. On a conclu qu'il est important d'effectuer une tomographie axiale informatisée chez un patient traité par discectomie ouverte avec des signes cliniques d'infection tels que douleur et fièvre, afin de déceler des séquelles osseuses et d'opérer le plus rapide que possible. La technique de débridement séquentiel, avec irrigation continue par solution saline physiologique à 0,9 pourcent et antibiothérapie sensible au micro-organisme, a des résultats satisfaisants(AU)

Vertebral osteomyelitis and epidural abscesses caused by Prevotella oralis: a case report

An interesting case of pyogenic vertebral osteomyelitis with multiple epidural abscesses caused by non-pigmented Prevotella oralis is reported. The patient was a 68-year-old female who presented to the emergency room (ER) with severe pain and tenderness in her lower back with fever. She had recently undergone esophagogastroduodensoscopy (EGD) for complaints of esophageal reflux, which showed submucosal cyst in the esophagus. Magnetic resonance imaging (MRI) of the thoracic spine revealed multiple spinal epidural abscesses with signal enhancement at the level of T6 and T7, suggestive of vertebral osteomyelitis. Two blood cultures drawn one hour apart grew Prevotella oralis. The body fluid aspirated from the abscesses was also positive for the anaerobic commensal P. oralis. Necrosis associated with the submucosal cyst was implicated as the cause of sepsis and osteomyelitis due to this organism.

Espondilodiscitis infecciosa / Infectious spondylodiscitis

Introducción: la osteomielitis vertebral o espondilodiscitis es una enfermedad poco frecuente. Su incidencia ha aumentado en los últimos años debido a una mayor cantidad de procedimientos quirúrgicos espinales, de bacteriemia nosocomial, el envejecimiento de la población y la adicción a drogas intravenosas. La infección hematógena es la causa más común de espondilitis. El tratamiento antimicrobiano prolongado y la cirugía son esenciales para controlar la infección y prevenir la aparición de secuelas. Objetivos: señalar la importancia del diagnóstico y la terapéutica correcta, así como profundizar en el conocimiento de esta entidad. Descripción: se presentó un paciente masculino de 58 años de edad, que después de realizar un esfuerzo físico intenso comenzó con dolor en la columna lumbosacra; tuvo febrículas en 2 ocasiones, que se correspondió con un hematoma del psoas infectado secundariamente y una presentación clínica solapada, donde la resonancia magnética nuclear resultó la técnica de imagen que permitió arribar al diagnóstico. Su tratamiento definitivo fue la antibioticoterapia prolongada por más de 8 semanas con protección de la columna vertebral mediante una ortesis (corsé de Taylor). Se hizo un diagnóstico precoz y se impuso un tratamiento adecuado. Conclusiones: con un diagnóstico oportuno y apropiado se evitan otras complicaciones y mejoran las expectativas de vida del paciente. Se debe hacer la mayor divulgación científica posible sobre esta enfermedad poco común, que adolece de escases de pensamiento clínico en el medio cubano y, por lo tanto, no se sospecha ni se diagnostica precozmente

Introduction: the vertebral osteomyelitis or spondylodiscitis is an uncommon disease. Its incidence has increased in past years due to a significant quantity of spinal surgical procedures, to nosocomial bacteremia, aging of population and the addiction to intravenous drugs. The hematogenic infection is the commonest cause of spondylitis. The lengthy antimicrobial treatment and surgery are essential to control infection and to prevent appearance of sequelae. Objectives: to emphasize the significance of diagnosis and appropriate therapeutics, as well as to deepen in the knowledge of this entity. Description: this is the case of a male case aged 58 who after perform an intensive physical effort had an spinal low back pain, he had febricula in two occasions corresponding with a hematoma of the secondarily infected psoas and an overlapped clinical presentation where the nuclear magnetic resonance was the imaging technique allowed to made diagnosis. Its definitive treatment was the lengthy antibiotic therapy for more than 8 weeks with protection of the spinal column by means of orthesis (Taylor'corset). An early diagnosis was made imposing an appropriate treatment. Conclusions: with an appropriate and timely diagnosis it is possible to avoid complications and to improve the patient's life expectancies. It is necessary the great possible scientific popularization on this uncommon disease with a lack of clinical thought in the Cuban environment and thus, it is neither early suspected or diagnosed

Vertebral Osteomyelitis caused by Mycobacterium abscessus in an Immunocompetent Patient / 감염과화학요법

Vertebral osteomyelitis caused by nontuberculous mycobacteria (NTM) is rarely reported, especially in an immunocompetent host. NTM are usually not susceptible in vitro to antituberculous drugs, and appropriate antimicrobial therapy for treatment of NTM infection is based on susceptibility results, which vary between different NTM species; therefore, treatment of vertebral osteomyelitis caused by NTM is challenging. We report on the first case of vertebral osteomyelitis caused by M. abscessus in an otherwise healthy individual, confirmed by cultures of bone tissue obtained during surgery. Clinical cure was achieved with a combination of antimicrobial therapy and surgery. We also review previous reports of vertebral osteomyelitis caused by NTM.

A Case of Mycobacterium Abscessus Spondylitis / 대한내과학회지

The designation nontuberculous mycobacteria (NTM) applies to mycobacterial species other than organisms of the Mycobacterium tuberculosis complex and Mycobacterium leprae. In recent decades, the prevalence of human disease caused by NTM has increased; thus, the clinical significance of NTM is increasing. Mycobacterium abscessus is a rapidly growing nontuberculous mycobacterial species that is usually associated with chronic pulmonary disease, posttraumatic soft-tissue infections, nosocomial bloodstream infections, wound infections, and abscesses at the site of prior intramuscular injections; however, vertebral osteomyelitis due to this species is rare. Here, we present a case of vertebral osteomyelitis due to M. abscessus that occurred in a patient with iatrogenic Cushing's syndrome and a history of acupuncture who was treated with wide surgical excision and prolonged combined antibiotic treatment.

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.

Cervical Epidural Abscess in Haemodialysis Patients by Catheter Related Infection: Report of Two Cases

Despite advances in neuroimaging and neurosurgical treatment modalities, spinal epidural abscess remains a challenging problem. Early diagnosis is often difficult and treatment is always delayed. Spinal epidural abscess usually develops in patients with predisposing factors such as IV drug abuse, senillity, diabetes mellitus, spinal attempts, alcoholism, immunosuppression, liver diseases and catheterizations. It is rarely seen in cervical region. A successful treatment is only possible with early diagnosis and accurate surgical and medical treatment. Optimal management is unclear and morbidity and mortality are significant. We present two adult haemodialysis patients with end-stage renal insufficiency who developed cervical epidural abscess following central venous catheter placement. Early surgical intervention is mandatory in cases those have progressive neurological deficit and spinal deformity, and this is also increases the success rate of medical therapy.

Tricuspid Valve Repair for Active Infective Endocarditis Complicated by Vertebral Osteomyelitis and a Pancreatic Abscess / 日本心臓血管外科学会雑誌

A 65-year-old man was admitted with a high fever and back pain. Because magnetic resonance imaging revealed osteomyelitis in the lumbar spine, we started antibiotic therapy. Echocardiography revealed large vegetation on the tricuspid valve, and abdominal contrast computed tomography revealed a pancreatic abscess. As the vegetation increased in size and mobility it became non-responsive to medical treatment, and surgical removal of the vegetation with tricuspid valve repair were therefore performed. After additional antibiotic therapy, he was discharged 42 days after surgery. No further recurrence of endocarditis has been observed as of the time of writing.

Osteomielitis vertebral piógena / Pyogenic vertebral osteomyelitis

La osteomielitis vertebral piógena (OVP) es una localización poco frecuente (2-7%) Se confirma con el aislamiento de un microorganismo de una vértebra, disco intervertebral, absceso epidural o paravertebral. Se describe una serie de casos por la infrecuente presentación de esta enfermedad, que puede ser consulta inicial en los servicios de clínica médica y por su sintomatología inespecífica que supone una dificultad diagnóstica. Tanto la columna lumbar como la dorsal fueron los sitios más afectados. El dolor dorsolumbar y la paraparesia fueron los síntomas más frecuentes de presentación. En ocho pacientes se aislaron Staphylococcus aureus, en uno Escherichia coli y en el restante Haemophylus sp. Se observó leucocitosis sólo en tres pacientes, y en dos velocidad de sedimentación globular mayor de 100 mm/h. Los diez pacientes presentaron imágenes características de osteomielitis vertebral piógena en la resonancia nuclear magnética. Dentro de las complicaciones, los abscesos paravertebrales y epidurales fueron los más frecuentes (en cinco enfermos). Además, un paciente presentó empiema pleural. De los diez pacientes de esta serie, siete recibieron inicialmente tratamiento médico empírico y luego específico para el germen aislado. En los restantes el tratamiento fue guiado de acuerdo al antibiograma. A dos enfermos fue necesario realizarles laminectomía descompresiva por compromiso de partes blandas y a otros dos estabilización quirúrgica por inestabilidad espinal, observándose buena evolución en todos los casos. Esta serie demuestra que, ante un paciente con dolor dorsolumbar y síntomas neurológicos se deberá tener en cuenta esta entidad para evitar un retraso en el tratamiento.

Pyogenic osteomyelitis seldom affects the spine (2-7%). It is diagnosed by the isolation of a bacterial agent in the vertebral body, the intervertebral disks or from paravertebral or epidural abscesses. We report a retrospective study of ten patients who attended a medical clinic with this disease to emphasize its unusual presentation and difficult diagnosis. Lumbar and dorsal spine were the most common sites affected. Dorsolumbar pain and paraparesis were the most frequent symptoms. Staphylococcus aureus were isolated in eight patients, Escherichia coli in one and Haemophilus sp. in other Leukocytosis was observed in only three patients. Erythrocyte sedimentation rate was higher than 100 mm in the first hour in two patients. Typical images of pyogenic vertebral osteomyelitis were observed in all these patients with magnetic resonance imaging. The main complications were paravertebral and epidural abscesses that were found in five patients. One patient also presented an empyema, seven of them initially received empiric medical treatment, and later specific antibiotics according to the culture and sensitivity results. The rest of the patients were initially treated according to the sensitivity of the isolated germ. Surgical intervention was performed in two patients to drain soft tissue involvement, and in two other to stabilize the spine. All four surgical patients had a full recovery. This report is intended to point out that in patients with dorsolumbar pain and neurological symptoms pyogenic vertebral osteomyelitis is a possible diagnosis and has to be treated without delay.

Epidural Abscess and Vertebral Osteomyelitis Induced by Epidural Injection: A case report

Epidural abscess and vertebral osteomyelitis induced by epidural injection is rare but one of the most serious complications. A 58-year old woman complained of aggrevating radicular pain to bilteral lower legs, tenderness on coccygeal area and claudication, after epidural injection for management of intractable sciatica. MRI and ultrasound revealed epidural abscess compressing dural sac at the level of L5-S1 vertebral body, sacrococcygeal abscess, and later S5- 1stcoccyx osteomyelitis. We report epidural abscess and vertebral osteomyelitis induced by caudal epidural injection.

Vertebral Osteomyelitis due to Salmonella enterica serovar Othmarschen in an Immunocompetent Patient / 감염과화학요법

Salmonellae have been recognized as uncommon etiological organisms causing osteomyelitis in patients with sickle cell anemia and other immunocompromised conditions. A 34-year old man who had no underlying illness except for congenital block vertebrae at T10-11 vertebrae was admitted to the hospital due to lower back pain and fever for a week. Vertebral osteomyelitis was diagnosed and surgical drainage was performed. Salmonella enterica serovar Othmarschen was isolated from the drained pus. Therapy with ciprofloxacin for 8 weeks was successful without relapse. We describe here a case of vertebral osteomyelitis which was caused by S. Othmarschen in an immunocompetent patient.

A Case of Vertebral Osteomyelitis with Spinal Epidural Abscess Caused by Streptococcus constellatus / 감염과화학요법

We report a case of vertebral osteomyelitis with epidural abscess caused by Streptococcus constellatus. The patient was present with fever, back pain, and dyspnea for 1 week. The patient was previously healthy and did not have any predisposing factor. After evaluation, the patient was diagnosed as Streptococcus constellatus vertebral osteomyelitis. He was successfully treated with surgical debridement and antibiotic therapy. To the best of our knowledge, this is the first case of S. constellatus vertebral osteomyeltis with epidural abscess to be reported in Korea.