Detection Ewingella americana from a patient with Andersson lesion in ankylosing spondylitis by metagenomic next-generation sequencing test: a case report.

BACKGROUND: Andersen's lesion (AL) is a rare complication of ankylosing spondylitis (AS), characterized by nonneoplastic bone destruction, typically manifested as bone destruction and sclerosis in the vertebral body and/or intervertebral disc area. At present, there is no consensus on the pathology and etiology of AL. Repeated trauma, inflammation in essence and part of the natural history of Ankylosing spondylitis itself are the most widely recognized theories of the etiology of AL. However, positive bacteria cultured in bone biopsy of Andersen's lesion (AL) in Ankylosing spondylitis patients are extremely rare. Herein, we report a rare case of detecting Ewingella americana from a patient with Andersson lesion in ankylosing spondylitis by Metagenomic Next-Generation Sequencing (mNGS) Test. CASE PRESENTATION: This case involved a 39-year-old male with a history of AS for 11 years, who developed AL (T11/12) in the thoracic vertebrae. After sufficient preoperative preparation, we successfully performed one-stage posterior approach corrective surgery and collected bone biopsies samples for examination. Cultured bacteria were not found, and pathological histology indicated infiltration of inflammatory cells. However, it is worth noting that we discovered a gram-negative bacterium, the Ewingella americana, through mNGS testing. Further histopathological examination suggests chronic inflammatory cell infiltration. After one-stage posterior approach corrective surgery, the patient's condition significantly improved. At the 6-month follow-up, the pain significantly decreased, and the patient returned to normal life. CONCLUSION: We detected Ewinia americana in the bone biopsies of Andersson lesion (AL) in ankylosing spondylitis patient by mNGS.

Efficacy analysis of one-stage posterior-only surgical treatment for thoracic spinal tuberculosis in the T4-6 segments with minimum 5-year follow-up.

In recent years, with the in-depth research on spinal tuberculosis, posterior surgery alone has been praised highly by more and more surgeons due to the better correction of kyphosis, better maintenance of spinal physiological curvature, smaller surgical trauma and fewer surgical complications. However, there is currently lack of relevant reports about the efficacy of posterior surgery alone in the treatment of tuberculosis in the T4-6 segments. This study aimed to evaluate the clinical study efficacy and feasibility of one-stage posterior-only surgical treatment for thoracic spinal tuberculosis in the T4-6 segments. 67 patients with tuberculosis in T4-6 segments who underwent one-stage posterior-only surgery were included in this study. The clinical efficacy was evaluated using statistical analysis based on the data about erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Oswestry Dability Index (ODI) score, Visual Analogue Scale (VAS) score and Cobb angle before surgery, after surgery and at the last follow-up. All patients completed fusion during the follow-up period of 6-9 months. ESR and CRP were returned to normal for all patients at 6 months follow-up. In the meanwhile, among the 27 patients combined with neurological impairment, neurological functions of 22 cases (81.48%) recovered completely at the last follow-up (P < 0.05). Cobb angle of the kyphosis was improved from preoperative 34.8 ± 10.9° to postoperative 9.6 ± 2.8°, maintaining at 11.3 ± 3.2° at the last follow-up, The ODI and VAS scores were improved by 77.10% and 81.70%, respectively. This 5-year follow-up study shows that better clinical efficacy can be achieved for tuberculosis in T4-6 segments using one-stage posterior-only approach by costotransverse debridement in combination with bone graft and internal fixation. The posterior surgical method cannot only effectively accomplish debridement, obtain satisfactory clinical results, but also well correct kyphotic deformity and maintain it.

Differentiating brucella spondylitis from tuberculous spondylitis by the conventional MRI and MR T2 mapping: a prospective study.

BACKGROUND: Brucella spondylitis (BS) and tuberculous spondylitis (TS), caused initially by bacteremia, are the two leading types of granulomatous spinal infections. BS is easy to miss or may be misdiagnosed as TS. Our purpose aims to differentiate BS from TS in conventional MR imaging and MR T2 mapping. METHODS: We performed on 26 BS and 27 TS patients conventional MR imaging and MR T2 mapping. We analyzed the features in conventional MR imaging and measured T2 values of the lesion vertebrae (LV) and unaffected adjacent vertebrae (UAV) in BS and TS patients, respectively. RESULTS: There were no significant differences in sex, age, national between BS and TS. There was significantly lower severity of vertebral destruction, vertebral posterior convex deformity, dead bone, and abscess scope in BS when compared to TS (p < 0.001, p = 0.048, p < 0.001, p < 0.001, respectively). The vertebral hyperplasia was significantly higher in BS when compared to TS (p < 0.001). The T2 value of the LV with BS was markedly higher than that in the UAV with BS and that in the LV and UAV with TS (p < 0.001, p < 0.037, p < 0.001, respectively). The T2 value of the LV with TS was significantly higher than that of the UAV in TS and BS (p < 0.001, p < 0.001, respectively). There were no significant differences in the T2 value of the UAV between BS and TS (p = 0.568). CONCLUSIONS: The qualitative and quantitative evaluation may differentiate BS from TS. The conventional MR imaging helps to distinguish BS from TS by several distinctive features. MR T2 mapping has the additional potential to provide quantitative information between BS and TS.

A rare case of thoracic brucellosis misdiagnosed as malignant tumor and literature review.

Brucellosis remains a major public health problem worldwide. It is commonly found in most developed and developing countries, such as the Mediterranean region, the Middle East, and Latin America. In China, brucellosis is mainly distributed in some of the northern provinces and is relatively rare in Shandong province. Brucellosis has a variety of clinical manifestations, with fever, sweating, fatigue, and migratory joint pain being the most common. Because of the non-specific clinical symptoms, brucellosis is often misdiagnosed as other diseases. Here, we report a rare case of brucellosis of thoracic vertebrae misdiagnosed as thoracic malignant tumor and present a review of related literature.

An unusual Staphylococcus saccharolyticus spondylodiscitis post kyphoplasty: a case report.

BACKGROUND: Staphylococcus saccharolyticus is a rarely encountered coagulase-negative, which grows slowly and its strictly anaerobic staphylococcus from the skin. It is usually considered a contaminant, but some rare reports have described deep-seated infections. Virulence factors remain poorly known, although, genomic analysis highlights pathogenic potential. CASE PRESENTATION: We report a case of Staphylococcus saccharolyticus spondylodiscitis that followed kyphoplasty, a procedure associated with a low rate but possible severe infectious complication (0.46%), and have reviewed the literature. This case specifically stresses the risk of healthcare-associated S. saccharolyticus infection in high-risk patients (those with a history of alcoholism and heavy smoking). CONCLUSION: S. saccharolyticus infection is difficult to diagnose due to microbiological characteristics of this bacterium; it requires timely treatment, and improved infection control procedure should be encouraged for high-risk patients.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis - a long-term retrospective study of 106 cases.

BACKGROUND: Minimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy. METHODS: A total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI). RESULTS: The mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination. CONCLUSION: MIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

Clinical Efficacy of Three Surgical Approaches for the Treatment of Cervicothoracic Tuberculosis: A Multicenter Retrospective Study.

OBJECTIVE: To evaluate the efficacy of three surgical approaches for the treatment of cervicothoracic tuberculosis. METHODS: This is a multicenter retrospective study. We analyzed 74 patients with cervicothoracic tuberculosis who were treated in six institutions between January 2000 and January 2015. There were 37 male and 37 female patients, with an average age of 24 years (range, 5-62 years). The operative method was selected according to the indications. A total of 33 patients underwent one-stage anterior surgery (group A); 16 underwent a combined anterior and posterior surgery (group B) and 25 underwent one-stage posterior surgery (group C). Clinical outcomes, laboratory indexes, and radiological results were analyzed. RESULTS: All cases were followed up for approximately 36-96 months post-surgery (average, 39 months). At the last follow-up, patients in all three groups had achieved bone fusion, with pain relief and neurological recovery. No major vessel and nerve injuries were found during the operation. There were significant differences before and after treatment for visual analogue scale (VAS), neck disability index (NDI), and Japanese Orthopedic Association (JOA) score (P < 0.001). Three surgical strategies significantly improved kyphosis (P < 0.001). CONCLUSION: The choice of operation for cervicothoracic tuberculosis should be selected based on the pathological changes, scope, and general physical condition of the patient. The indication for a posterior approach is narrow and it should be used selectively. The combined anterior and posterior approach involved a longer operating time, larger blood loss, and greater trauma, and also required a higher level of surgical skill. Therefore, the indications for this approach should be strictly controlled. Anterior approach surgery for the treatment of cervicothoracic tuberculosis showed excellent efficacy and fewer complications.

Establishment and Initial Testing of a Medium-Sized, Surgically Feasible Animal Model for Brucellar Spondylodiscitis: A Preliminary Study.

Brucellar spondylodiscitis, the most prevalent and significant osteoarticular presentation of human Brucellosis, is difficult to diagnose and usually yields irreversible neurologic deficits and spinal deformities. However, no animal models of Brucellar spondylodiscitis exist, allowing for preclinical investigations. The present study investigated whether intraosseous injection of attenuated Brucella melitensis vaccine into rabbits' lumbar vertebrae imitates the radiographic and histopathological characteristics of human Brucellar spondylodiscitis. Radiographic and histopathological analyses at 8 weeks postoperatively revealed radiographic changes within vertebral bodies and intervertebral discs, abscesses formation within the paravertebral soft tissue, and typical prominent inflammation response without caseous necrosis, which were largely comparable to human Brucellar spondylodiscitis. Such a medium-sized, surgically feasible rabbit model provides a promising in vivo setting for further preclinical investigation of Brucellar spondylodiscitis.

A travel-loving woman in her eighties with lower back pain and weight loss. / En reiseglad 80-åring med ryggsmerter og vekttap.

BACKGROUND: This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding. CASE PRESENTATION: A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis. INTERPRETATION: An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

A case of Klebsiella pneumoniae spondylitis and bacteremia potentially due to inflammation around a fecalith.

We herein report a case of Klebsiella pneumoniae (K. pneumoniae) spondylitis and bacteremia in a 90-year-old man with diabetes mellitus who had undergone sigmoidectomy and had a fecalith. Two months prior to admission, he had received antimicrobial treatment for 2 weeks for K. pneumoniae bacteremia whose entry was unclear and he was readmitted to our hospital owing to fever and stomachache. K. pneumoniae was isolated from two sets of blood cultures, and computed tomography and magnetic resonance imaging revealed inflammation and destruction of the 8th and 9th thoracic vertebra. The diagnosis was spondylodiscitis secondary to K. pneumoniae bacteremia. Although the entry point for K. pneumoniae was unclear, we suggest that inflammation of the mucosa around the fecalith might have caused the Enterobacteriaceae bacteremia.

Can a posterior approach effectively heal thoracic and lumbar tuberculosis? Microbiology outcomes of the operative area.

BACKGROUND: There was a controversy about surgery approach of thoracic and lumbar tuberculosis (TB) treatment. The aim of this study was to compare the microbiology outcomes of the drainage liquid and the clinical outcomes of a posterior and anterior approach in the treatment of thoracic and lumbar TB. MATERIALS AND METHODS: A total of 105 patients were enrolled in this prospective study from February 2011 to September 2015. Patients were divided into two groups: group A (51 patients, posterior approach surgery) and group B (54 patients, anterior approach surgery). Intraoperative TB samples were sent for Mycobacterium tuberculosis culture (MTBC). Drainage fluid was postoperatively collected for polymerase chain reaction (PCR), acid-fast strains (AFS), MTBC, and DNA molecular detection (DNAMD) analyses. Compare the drainage liquid positive rate of the two groups and estimate relationship between the positive results of drainage fluid and the lesion region. In addition, the clinical outcomes including the bony fusion, relapse rate, complications, and neurological status were collected. RESULTS: There was no significant difference in the positive rate of AFS, PCR, DNAMD, MTBC, or any positive rate (APR) of drainage liquid between the two groups (P > 0.05). In both groups, the MTBC-positive rate of postoperative drainage fluid was significantly lower than that of the intraoperative sample (P < 0.01). There was no significant relationship between APR and the lesion region (P > 0.05). All the patients had at least 2 years of follow-up, with an average of 34.4 ± 15.8 months. There were four patients in group A and two patients in group B who had recurrent spine TB, and the rest of the patients had fusion in the surgical area. There was no significant difference in the incidence of TB recurrence or other complications between the two groups (P > 0.05). All the patients with neurological dysfunction had improved after surgery. CONCLUSION: Compared with anterior approach surgery, posterior approach surgery had equal effectiveness of debridement. The two kinds of surgery can effectively clear the lesions surrounding the spine and heal thoracic and lumbar TB.

Minimally invasive direct lateral interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosisMini-DLIF for the thoracic and lumbar spinal tuberculosis.

BACKGROUND: To investigate the clinical efficacy of minimally invasive direct lateral approach debridement, interbody bone grafting, and interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosis. METHODS: From January 2013 to January 2016, 35 cases with thoracic and lumbar spinal tuberculosis received direct lateral approach debridement, interbody bone grafting, and interbody fusion. Of the 35 cases, 16 patients were male and 19 were female and the median age was 55.2 (range 25-83). The affected segments were single interspace, and the involved vertebral bodies included: 15 cases of thoracic vertebrae (1 cases of T5/6, 2 cases of T6/7, 4 cases of T7/8, 3 cases of T8/9, 5 cases of T9/10) and 20 cases of lumbar spine (2 cases of L1/2, 6 cases of L2/3, 6 cases of L3/4, 6 cases of L4/5). After MIDLIF operation, all the patients received medication of four anti-tubercular drugs for 12 to18 months. RESULTS: The patients were followed up for 7 to 40 months with an average of 18.5 months. The visual analogue scale (VAS) at the last follow-up was 2.8 ± 0.5, which was significantly different from the preoperative VAS (8.2 ± 0.7). After MIDLIF, there was 5 cases occurred with transient numbness in one side of the thigh or inguinal region, and 10 cases suffered from flexion hip weakness. All the bone grafts were fused within 6~ 18 months (average of 11.5 months) after the operation. CONCLUSION: Minimally invasive lateral approach interbody fusion technology have the advantage of less injury and quick recovery after surgery, which is the effective and safe treatment for thoracic and lumbar spinal tuberculosis.

[Research progress of surgical treatment of thoracolumbar spinal tuberculosis].

Objective: To review the progress of surgical treatment for the thoracolumbar spinal tuberculosis. Methods: The related literature of surgical treatment for the thoracolumbar spinal tuberculosis was reviewed and analyzed from the aspects such as surgical approach, fixed segments, fusion ranges, bone graft, and bone graft material research progress. Results: Most scholars prefer anterior or combined posterior approach for surgical treatment of thoracic and lumbar tuberculosis because it possessed advantage of precise effectiveness. In recent years, a simple posterior surgery achieved satisfactory effectiveness. The fixation segments are mainly composed of short segments or intervertebral fixation. The interbody fusion is better for the bone graft fusion range and manner, and the bone graft materials is most satisfied with autologous iliac Cage or titanium Cage filled with autologous cancellous bone. Conclusion: The perfect strategy for treating the thoracolumbar spinal tuberculosis has not yet been developed, and the personalized therapy for different patients warrants further study.

Treatment of tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis: A case series and a literature review.

RATIONALE: Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis is a rare disease but with very high mortality. We review the literature and find 19 reports with 22 patients. Here we report three cases with vertebral tuberculosis, who also have tuberculous pseudoaneurysm of the aorta. These patients were treated by different methods. We try to analyze the epidemiology, pathogenesis, presentation, and management of this disease to find the best treatment. PATIENT CONCERNS: The patients presented with different symptoms such as pain (chest, abdominal or back), fever, blood volume reduction or hemorrhagic shock symptoms. Large mass also could be observed by imaging. In addition to clinical manifestations, enhanced computed tomography or magnetic resonance imaging could also help the diagnosis of this disease. DIAGNOSES: Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis. INTERVENTIONS: Three patients were treated with anti-tuberculosis(TB) drugs or combined with different sequences surgical treatment: Case 1 refused to receive pseudoaneurysm surgery and only had anti-TB drug treatment; Case 2 received thoracic spinal surgery first; Case 3 received endovascular stent grafting. OUTCOMES: Two patients (case 1 and case 2) who refused to undergo aneurysm surgery died. The last patient (case 3) underwent endovascular repair and antibiotic therapy for tuberculosis, and the postoperative course was uneventful; the patient recovered and survived. LESSONS: Once the diagnosis of tuberculous pseudoaneurysm is confirmed, surgical treatment should be provided immediately combined with anti-tuberculosis drugs. The aim of the treatment is to save lives, prevent relapse, and facilitate the return to normal life, regardless of the size of the pseudoaneurysm. The pseudoaneurysm should be treated first to prevent aneurysm rupture before the vertebral tuberculosis surgery.

Vertebral Osteomyelitis Caused by Helicobacter cinaedi Identified Using Broad-range Polymerase Chain Reaction with Sequencing of the Biopsied Specimen.

A 65-year-old man presented with gradually exacerbating low back pain. Magnetic resonance imaging revealed vertebral osteomyelitis in the Th11-L2 vertebral bodies and discs. The patient showed negative findings on conventional cultures. Direct broad-range polymerase chain reaction (PCR) with sequencing of the biopsied specimen had the highest similarity to the 16S rRNA gene of Helicobacter cinaedi. This case suggests that direct broad-range PCR with sequencing should be considered when conventional cultures cannot identify the causative organism of vertebral osteomyelitis, and that this method may be particularly useful when the pathogen is a fastidious organism, such as H. cinaedi.

Histoplasmosis mimicking metastatic spinal tumour.

Histoplasmosis is an infection caused by a fungus called Histoplasma. Diagnosis of histoplasmosis is based on the culture of biological samples and detection of fungus in tissues. Histoplasmosis can mimic malignant lesions. We report a 65-year-old, immunocompetent, male patient with back pain. We describe the main clinical and radiological characteristics in our patient who had vertebral histoplasmosis that mimicked cancer. A computed tomography scan showed lytic lesions of the right side of T4, T5, and T6 vertebral bodies. Magnetic resonance imaging displayed abnormal marrow signals in T4, T5, and T6 vertebral bodies (low signal on T1, high on T2 and short time inversion recovery (STIR)). Which was mimicking malignancy, such as haematological malignancy and metastatic bone cancer. Therefore, thoracic spinal surgery using the anterior approach was performed. An intraoperative frozen section examination and routine postoperative pathology showed thoracic histoplasmosis infection. Treatment of histoplasmosis was performed with oral itraconazole. The lesions did not progress and the patient symptomatically improved at a follow-up of 26 months.

Pathogenesis of Enterococcal Spondylitis Caused by Enterococcus cecorum in Broiler Chickens.

Enterococcal spondylitis (ES) is a disease of commercial broiler chickens, with a worldwide distribution. Symmetrical hind limb paralysis typical of ES results from infection of the free thoracic vertebra (FTV) by pathogenic strains of Enterococcus cecorum . To determine the pathogenesis of ES, birds with natural and experimental ES were studied over time. In natural disease, case birds (n = 150) from an affected farm and control birds (n = 100) from an unaffected farm were evaluated at weeks 1-6. In control birds, intestinal colonization by E. cecorum began at week 3. In case birds, E. cecorum was detected in intestine and spleen at week 1, followed by infection of the FTV beginning at week 3. E. cecorum isolates recovered from intestine, spleen, and FTV of case birds had matching genotypes, confirming that intestinal colonization with pathogenic strains precedes bacteremia and infection of the FTV. Clinical intestinal disease was not required for E. cecorum bacteremia. In 1- to 3-week-old case birds, pathogenic E. cecorum was observed within osteochondrosis dissecans (OCD) lesions in the FTV. To determine whether OCD of the FTV was a risk factor for ES, 214 birds were orally infected with E. cecorum, and the FTV was evaluated histologically at weeks 1-7. Birds without cartilage clefts of OCD in the FTV did not develop ES; while birds with OCD scores ≥3 were susceptible to lesion development. These findings suggest that intestinal colonization, bacteremia, and OCD of the FTV in early life are crucial to the pathogenesis of ES.

Spinal Infections Among Patients With Long-Term Central Venous Catheters for Home Parenteral Nutrition.

Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.