A comparative perspective on brucellar, pyogenic, and tuberculous spondylodiscitis.

OBJECTIVE: Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes. PATIENTS AND METHODS: A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features. RESULTS: Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis. CONCLUSIONS: Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Early Diagnosis and Successful Empirical Treatment of L1-L2 Spondylodiscitis in a 21-Month-Old Girl: A Case Report.

BACKGROUND Infantile spondylodiscitis is a rare condition with a varied clinical presentation. Microbial infection may not always be identified, but early diagnosis and management are required to prevent long-term and irreversible complications, including spinal deformities and vertebral instability. CASE REPORT This report is of a 21-month-old girl with a 3-week history of difficulty in walking and constipation due to L1-L2 spondylodiscitis following a gluteal skin burn. The family had sought medical advice multiple times, but results of all investigations were unremarkable. Her initial spine X-ray was negative but her spine magnetic resonance imaging (MRI) showed a picture suggestive of spondylodiscitis, which then responded to empiric treatment with broad-spectrum antibiotics. The patient showed complete resolution of clinical symptoms and her bowel habits came back to normal after 6 months of complete antibiotics treatment. Her repeat spine MRI showed a significant improvement of her spondylodiscitis. CONCLUSIONS This report has highlighted the importance of rapid diagnosis and management of infantile spondylodiscitis and the challenging approach to treatment when no infectious organism can be identified, as well as the early initiation of antibiotics therapy when appropriate in pediatric patients to avoid serious neurological complications associated with spondylodiscitis. Thus, it is essential to assess children with refusal to walk, gait problems, or back discomfort, especially when they are associated with high inflammatory markers.

Differentiation of Native Vertebral Osteomyelitis: A Comprehensive Review of Imaging Techniques and Future Applications.

Native vertebral osteomyelitis, also termed spondylodiscitis, is an antibiotic-resistant disease that requires long-term treatment. Without proper treatment, NVO can lead to severe nerve damage or even death. Therefore, it is important to accurately diagnose the cause of NVO, especially in spontaneous cases. Infectious NVO is characterized by the involvement of 2 adjacent vertebrae and intervertebral discs, and common infectious agents include Staphylococcus aureus, Mycobacterium tuberculosis, Brucella abortus, and fungi. Clinical symptoms are generally nonspecific, and early diagnosis and appropriate treatment can prevent irreversible sequelae. Advances in pathologic histologic imaging have led physicians to look more forward to being able to differentiate between tuberculous and septic spinal discitis. Therefore, research in identifying and differentiating the imaging features of these 4 common NVOs is essential. Due to the diagnostic difficulties, clinical and radiologic diagnosis is the mainstay of provisional diagnosis. With the advent of the big data era and the emergence of convolutional neural network algorithms for deep learning, the application of artificial intelligence (AI) technology in orthopedic imaging diagnosis has gradually increased. AI can assist physicians in imaging review, effectively reduce the workload of physicians, and improve diagnostic accuracy. Therefore, it is necessary to present the latest clinical research on NVO and the outlook for future AI applications.

Clinical findings and outcome in goats with discospondylitis and vertebral osteomyelitis.

BACKGROUND: Vertebral infections, including vertebral osteomyelitis, septic physitis, and discospondylitis, are rarely reported in goats, and when reported, have been largely limited to necropsy case reports. OBJECTIVE: Describe clinical findings and outcome in goats with vertebral infections evaluated by computed tomography (CT). ANIMALS: Five goats with vertebral osteomyelitis, septic physitis, and discospondylitis evaluated by CT. METHODS: Retrospective case series. RESULTS: The most common presenting complaints were progressive weakness, paresis and recumbency. Three goats were tetraparetic and 2 goats had pelvic limb paraparesis. Clinicopathologic findings included leukocytosis, mature neutrophilia, and hyperfibrinogenemia. The most common vertebrae affected were C7-T1. All 5 goats had discospondylitis with or without vertebral osteomyelitis and septic physitis. Computed tomographic evidence of spinal cord compression was present in 4/5 goats. Medical management (antimicrobials, physical therapy, analgesia, supportive care) was attempted in 4 goats, and 1 goat was euthanized at the time of diagnosis. All 4 goats that were treated regained ambulatory ability and survived to hospital discharge. CONCLUSIONS AND CLINICAL IMPORTANCE: Despite severity of CT imaging findings, goats with discospondylitis, septic physitis, and vertebral osteomyelitis can successfully return to ambulatory function. Additional studies are required to determine ideal treatment regimens.

An Uncommon Cause of Nocturnal Crying and Discomfort: A Case of a 15-month-old Girl With Spondylodiscitis.

Nocturnal crying in toddlers has a broad spectrum of causes, including psychosocial and somatic causes, whereby the majority are self-limiting and do not need referral to specialist medical care. Although uncommon, atypical presentations of nocturnal crying-such as spondylodiscitis-require referral to specialist medical care, especially when combined with discomfort. In this case report, we present a case of a 15-month-old girl with an atypical presentation of nocturnal crying in combination with back pain.

Management of Postoperative Discitis with Debridement and Novel Technique of Local Antibiotic Instillation: Functional Outcomes from a Resource-Limited Setting.

BACKGROUND: Patients in low- and middle-income countries (LMICs) have substantial treatment abandonment and non-adherence with outpatient oral medications. This work sought to investigate outcomes of postoperative discitis treated with debridement and a novel technique focused on reducing outpatient antibiotic requirement in an LMIC setting. METHODS: This study, conducted and reported following STROBE guidelines, reviewed outcomes of all patients with postoperative discitis who had been debrided by 1 neurosurgeon in a resource-limited setting during 2008-2020. Patients had undergone single-level L4-L5 or L5-S1 discectomy elsewhere, later developing magnetic resonance imaging-confirmed discitis. After non-response or deterioration following intravenous antibiotics, patients underwent early debridement, followed by in-patient antibiotic instillation into disc space for 2 weeks via drain. Study outcomes were modified Kirkaldy-Willis Grade, Japan Orthopaedic Association (JOA) score, and visual analog scale (VAS) score, all assessed at 1 year. RESULTS: Twelve patients were included, 10 male and 2 female, with median age of 46 (IQR 3.5) years. Debridement was done after median 82.5 (IQR 35) days and took median time of 105 (IQR 17.5) minutes. VAS scores (mean ± SD) decreased from 9.25 ± 0.75 preoperatively to 0.67 ± 0.89 1 year postoperatively (mean difference 8.58, 95% CI 8.01-9.15, P < 0.001). JOA scores (mean ± SD) improved from 4.5 ± 2.94 to 26.42 ± 1.31 1 year postoperatively (mean difference 21.92, 95% CI 20.57-23.26, P < 0.001). Kirkaldy-Willis grade was excellent in 6 (50%) patients, good in 5 (41.7%), and fair in 1 (8.3%). Patients became ambulatory within 2 weeks, with no major complications during 4.15 (IQR 3.45) years of median follow-up. CONCLUSIONS: In LMICs, patients with medically refractory postoperative discitis potentially have good outcomes after debridement plus 2-week local antibiotic instillation.

Pyogenic spondylodiscitis in HIV-positive patients under antiretroviral therapy: A case series.

Background: The incidence of pyogenic spondylodiscitis has been increasing in countries of Europe and North America, probably due to an increasing number of persons with risk factors for this infection. It is unclear whether HIV infection in the era of antiretroviral therapy (ART) increases the risk for spondylodiscitis. Method: We present 7 cases of pyogenic spondylodiscitis of the cervical, thoracic, and lumbar spine in six individuals living with HIV under ART with suppressed viral load. Results: All patients presented with severe non-radicular pain and elevated inflammatory markers. Diagnosis was confirmed by magnetic resonance imaging (MRI) scan and isolation of the pathogen. Staphylococcus aureus was the causative pathogen in five patients. One patient suffered from an infection with Klebsiella pneumoniae followed by a mixed infection with Cutibacterium acnes and Bacillus circulans 18 months later. All patients needed surgical intervention, and the mean duration of antibiotic treatment was 17 weeks (range 12-26). Five patients recovered fully, including two persons who also suffered from endocarditis. One patient died from multi-organ failure. Conclusion: Spondylodiscitis may be seen more frequently in persons living with HIV as they grow older and suffer from comorbidities which put them at risk for this infection. HIV physicians should be aware of the infection and its risk factors.

Typhoid spondylodiscitis of the cervical spine.

Spinal infection comprises pyogenic and non-pyogenic spondylodiscitis. This condition may manifest with non-specific clinical symptoms, elevated infective parameters and imaging findings that are difficult to distinguish. The cornerstone of a definitive diagnosis and subsequent successful treatment lies in tissue analysis through culture and histopathological studies. In this context, we present a case of Salmonella pyogenic spondylodiscitis affecting the C5/C6 vertebrae, complicated by Salmonella bacteraemia and characterised by mechanical neck pain that curtails daily activities and overall functioning, although without neurological deficits. The uniqueness of this case stems from its occurrence in an immunocompetent individual from a non-endemic area, with no identifiable sources of Salmonella infection or preceding gastrointestinal symptoms.

Metagenomic next-generation sequencing identifying a rare case of Mycobacterium xenopi discitis.

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient's discitis resolved with an M. xenopi-directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings.

Antibiotic therapy for osteoarticular infections in 2023: Proposals from the Pediatric Infectious Pathology Group (GPIP).

Most osteoarticular infections (OAI) occur via the hematogenous route, affect children under 5 years of age old, and include osteomyelitis, septic arthritis, osteoarthritis and spondylodiscitis. Early diagnosis and prompt treatment are needed to avoid complications. Children with suspected OAI should be hospitalized at the start of therapy. Surgical drainage is indicated in patients with septic arthritis or periosteal abscess. Staphylococcus aureus is implicated in OAI in children at all ages; Kingella kingae is a very common causative pathogen in children from 6 months to 4 years old. The French Pediatric Infectious Disease Group recommends empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus (MSSA) with high doses (150 mg/kg/d) of intravenous cefazolin. In most children presenting uncomplicated OAI with favorable outcome (disappearance of fever and pain), short intravenous antibiotic therapy during 3 days can be followed by oral therapy. In the absence of bacteriological identification, oral relay is carried out with the amoxicillin/clavulanate combination (80 mg/kg/d of amoxicillin) or cefalexin (150 mg/kg/d). If the bacterial species is identified, antibiotic therapy will be adapted to antibiotic susceptibility. The minimum total duration of antibiotic therapy should be 14 days for septic arthritis, 3 weeks for osteomyelitis and 4-6 weeks for OAI of the pelvis, spondylodiscitis and more severe OAI, and those evolving slowly under treatment or with an underlying medical condition (neonate, infant under 3 months of old, immunocompromised patients). Treatment of spondylodiscitis and severe OAI requires systematic orthopedic advice.

Multifocal tuberculosis in children: A case of spinal tuberculosis.

Multifocal tuberculosis (TB) accounts for up to one-third of all cases of TB and children are at higher risk for extrapulmonary TB than adults. Spinal TB is the regular form of skeletal TB. Spondylodiscitis TB represents 47%-94% of spinal TB. Cervical localization is rare but remains dangerous because of diagnostic difficulties and severe complications. We report a case of a 10-year-old Moroccan girl, bacille Calmette-Guerin vaccinated, with no medical history or trauma, parents and siblings are healthy and no contact with TB. The patient was complaining of neck pain, asthenia, and loss of weight for 1 year. During this period, she had been treated with analgesics and anti-inflammatory drugs, with no clinical evolution. The parents consulted the pediatric emergency room when they noticed a tumefaction in the middle thoracic region. Physical examination found a pectus carinatum deformity, palpable axillary, and submandibular lymph node, and a fixed palpable median thoracic mass fistulized to the skin. The GeneXpert MTB/RIF and QuantiFERON-TB Gold assay were positive. Chest computed tomography showed cervicodorsal spondylodiscitis staged at C5-D10, with abscessed perivertebral and peristernal collections, with epidural extension at C5-C6 and pleural level. The presence of an axillary lymph node with necrotic center. The skin biopsy showed a morphological appearance of epithelial and gigantocellular granulomatous inflammation. The patient had pharmacological treatment anti-TB drug with fixed-dose combination regimen and supportive therapy for pain management.

Elevated regulatory T cells after antibiotic treatment of infectious spondylodiscitis as biomarker of recovery?

Dysregulated systemic immune responses during infectious spondylodiscitis (IS) may impair microbial clearance and bone resorption. Therefore, the aim of the study was to examine whether circulating regulatory T cells (Tregs) are elevated during IS and whether their frequency is associated with alterations in T cells and the presence of markers of bone resorption in the blood. A total of 19 patients hospitalized with IS were enrolled in this prospective study. Blood specimens were obtained during hospitalization and 6 weeks and 3 months after discharge. Flow cytometric analysis of CD4 and CD8 T cell subsets, the percentage of Tregs and serum levels of collagen type I fragments (S-CrossLap) were performed. Out of 19 enrolled patients with IS, microbial etiology was confirmed in 15 (78.9%) patients. All patients were treated with antibiotics for a median of 42 days, and no therapy failure was observed. Next, a significant serum C-reactive protein (S-CRP) decrease during the follow-up was observed, whereas the frequencies of Tregs remained higher than those of controls at all-time points (p < 0.001). In addition, Tregs demonstrated a weak negative correlation with S-CRP and S-CrossLap levels were within the norm at all-time points. Circulating Tregs were elevated in patients with IS and this elevation persisted even after the completion of antibiotic therapy. Moreover, this elevation was not associated with treatment failure, altered T cells, or increased markers of bone resorption.

A case of spondylodiscitis by Ureaplasma urealyticum in an immunocompetent adult with spine stabilization.

Ureaplasma urealyticum is part of the normal genital flora of many sexually experienced people, thereby it is mostly associated with genitourinary tract infections. Here, we present the first case reported in the literature of spondylodiscitis caused by U. urealyticum in a 62-year-old immunocompetent subject. U. urealyticum was detected through broad-range bacterial polymerase chain reaction in all samples obtained by T11 bone biopsy, while cultures were all negative. Due to the technical difficulties in removing the spinal osteosynthesis devices, no neurosurgical intervention was planned, therefore a suppressive therapy with moxifloxacin was administered. After 7 months, the patient underwent T10-11 partial vertebrectomy, insertion of an expandable cage at that level, the substitution of T11 screws, and prolongation of stabilization from T6 to ilium due to a fracture of T11 and T12; the remaining spinal osteosynthesis material was not removed. A computed tomography scan of the spine did not show features compatible with spondylodiscitis. Moxifloxacin was stopped after 15 months without any recurrence of U. urealyticum infection. Our case highlights the importance of considering U. urealyticum as a potential etiological germ in culture-negative spondylodiscitis.

Serious spondylodiscitis, septic sacroiliitis and multiple abscesses after ozone therapy for low back pain: A case report on good response to combined treatment with empiric antibiotic and neridronate.

Ozone therapy is a minimally invasive technique now widely used for the treatment of pain due to herniated discs. In literature there are conflicting results concerning its real effectiveness and few data about its possible complications. In this case report we present a case of spondylodiscitis, septic arthritis and gluteal abscess following the execution of 4 sessions of ozone therapy. Given the impossibility of isolating the etiological agent, an empirical antibiotic therapy with an overall duration of 6 weeks was set up, initially with daptomycin and ceftriazone, to which was added after 2 days metronidazole, administered intravenously; after 20 days the cephalosporin was replaced with oral amoxicillin/clavulanate. Neridronate was added to treat bone edema and to avoid bone erosion. The patient showed improvement of both clinical conditions and inflammation indexes, and was discharged after 4 weeks without further complications at follow-up. Few cases are reported in the literature about spondylodiscitis secondary to ozone treatment, and just 1 case is described about the use of neridronate as additive drug to antibiotic treatment in spondylodiscitis to avoid bone disruption and surgery complications.

Meningitis and spondylodiscitis due to Nocardia nova in an immunocompetent patient.

BACKGROUND: Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova. CASE PRESENTATION: We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years. CONCLUSIONS: Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR.

Image-Guided Biopsy in Acute Diskitis-Osteomyelitis: A Systematic Review and Meta-Analysis.

BACKGROUND. The reported sensitivity and yield of image-guided biopsies for diskitis-osteomyelitis vary widely. OBJECTIVE. The purpose of this study was to perform a systematic review of the literature and meta-analysis of pooled sensitivity data to elucidate strategies for optimal image-guided biopsies among patients suspected to have diskitis-osteomyelitis. EVIDENCE ACQUISITION. A comprehensive literature search was performed for studies of patient populations with proven or suspected diskitis-osteomyelitis that included percutaneous image-guided biopsy as part of the workup algorithm. Type of pathogens, imaging modality used for biopsy guidance, tissue targeted, antibiotic administration at the time of biopsy, true microbiology positives, true microbiology negatives, false microbiology positives, false microbiology negatives, disease (i.e., diskitis-osteomyelitis) positives as determined by reference standard, true infection positives (i.e., positive microbiology or pathology results), and total number of biopsies performed were extracted from the studies. Microbiology sensitivity, microbiology biopsy yield, and infection sensitivity were calculated from the pooled data. These terms and the data required to calculate them were also defined in detail. EVIDENCE SYNTHESIS. Thirty-six articles satisfied inclusion criteria and were used for analysis. The pooled microbiology sensitivity, infection sensitivity, and microbiology biopsy yields were 46.6%, 70.0%, and 26.7%, respectively. Mycobacterium tuberculosis-only microbiology sensitivity was significantly higher than both pyogenic bacteria and mixed-organism microbiology sensitivity (p < .001). Staphylococcus aureus was the most common causative organism (28.6%). Pooled microbiology sensitivity was not significantly different for CT guidance and fluoroscopy guidance (p = .16). There was a statistically significant difference between pooled microbiology sensitivity of bone/end plate (45.5%) and disk/paravertebral soft-tissue (64.8%) image-guided biopsies (p < .001). There was no statistically significant difference in pooled microbiology sensitivities for patients who received antibiotics before the procedure (46.2%) and those who did not (44.6%) (p = .70). CONCLUSION. Image guidance by CT or fluoroscopy does not affect microbiology yield, disk and paravertebral soft-tissue biopsies should be considered over bone and end plate biopsies, and preprocedural antibiotic administration does not appear to impact biopsy results. CLINICAL IMPACT. Understanding and correctly applying reported statistics contribute to appropriate interpretation of the abundant literature on this topic and optimization of care for patients with diskitis-osteomyelitis.

Spondylodiscitis of lumbar complicated with spinal epidural abscess caused by Parvimonas micra: A case report and literature review. / å¾®å°å°å•èƒžèŒè °æ¤Žé—´ç›˜ç‚Žå¹¶æ¤Žç®¡å† ç¡¬è†œå¤–è„“è‚¿1例及文献回顾.

Spinal infection caused by Parvimonas micra (P. micra) is a rare infection. The characteristic imageology includes spondylodiscitis, spondylitis, paravertebral abscess, and epidural abscess. One case of spondylodiscitis of lumbar complicated with spinal epidural abscess caused by P. micra was admitted to the Department of Spinal Surgery, Xiangya Hospital, Central South University on February, 2023. This case is a 60 years old man with lower back pain and left lower limb numbness. MRI showed spondylitis, spondylodiscitis, and epidural abscess. The patient underwent debridement, decompression and fusion surgery. The culture of surgical sample was negative. P. micra was detected by metagenomic next-generation sequencing (mNGS). The postoperative antibiotic treatment included intravenous infusion of linezolid and piperacillin for 1 week, then intravenous infusion of ceftazidime and oral metronidazole for 2 weeks, followed by oral metronidazole and nerofloxacin for 2 weeks. During the follow-up, the lower back pain and left lower limb numbness was complete remission. Spinal infection caused by P. micra is extremely rare, when the culture is negative, mNGS can help the final diagnosis.