Rare case of osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a postmenopausal woman.

Vertebral osteomyelitis is an infection of the vertebrae that can lead to spinal degeneration, most commonly caused by Staphylococcus aureus Here, we report an unusual case of pyogenic osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a 61-year-old postmenopausal woman. The patient presented with a 2-week history of worsening lower back pain and fever and a recent episode of cystitis following re-engagement of sexual activity. Imaging revealed a deterioration of vertebrae discs and spinal canal stenosis at the L3-L4 levels with a formation of abscess in the right psoas muscle. Needle aspiration of the abscess identified G. vaginalis and S. parasanguinis and the patient was successfully treated with a 6-week course of ceftriaxone and metronidazole. This case describes an unusual coinfection of two pathogens that normally reside in the urogenital tract and oral cavity, respectively, and highlights the risk posed when these organisms breach the body's normal barriers.

Disseminated septic arthritis caused by Streptococcus equi infection.

We describe a rare case of bloodstream infection and disseminated septic arthritis in a relatively fit and well 73-year-old retired farmer and gamekeeper, due to the zoonotic organism Streptococcus equi The presence of the organism in multiple joints led to slow clinical response to treatment and was complicated by relapse of infection and lengthy disability. Source control was achieved with multiple joint washouts and spinal cord decompression. Following this, a 6-week course of intravenous antibiotics was required for complete clearance of infection. After a long period of rehabilitation, the patient made a good recovery. This case demonstrates that S. equi can cause life threatening and difficult to treat sepsis in humans and requires a high index of suspicion in people who have regular contact with equine species, cattle and unpasteurised milk.

Continuous Epidural Irrigation and Drainage Combined with Posterior Debridement and Posterior Lumbar Inter-Body Fusion for the Management of Single-Segment Lumbar Pyogenic Spondylodiscitis.

Purpose: To observe the clinical curative effect of continuous epidural irrigation combined with posterior debridement and posterior lumbar inter-body fusion with instrumentation for the therapy of single-segment lumbar pyogenic spongdylodiscitis. Methods: From June 2010 to November 2013, surgical treatment was performed in 18 patients with pyogenic spondylodiscitis. The surgical indications were progressive biomechanical instability, epidural abscesses, deterioration of neurologic status, and intractable back pain. All these patients received posterior decompression with posterior instrumentation, debridement of infected tissue, and inter-body fusion. Visual Analogue Scale (VAS) scores were used to assess clinical outcomes. The neural function was evaluated by the Frankel grading system. Laboratory and radiologic results were recorded during clinical follow-up for at least one year. Results: The average follow-up period was 18 months after the operation. The VAS scores decreased from an average of 7.1 points before the procedure to 2.6 points after operation. The neurologic deficits of all the patients were recovered to Frankel grade E. All of the examined laboratory parameters were normalized gradually. Imaging-documented fusion was achieved in each patient, and no implants failure was noted. No patients showed any evidence of recurrence or persistence of infection. Conclusion: In carefully selected patients, single-segment lumbar pyogenic spondylodiscitis can be cured successfully with continuous epidural irrigation and drainage combined with posterior debridement and posterior lumbar inter-body fusion. Instrumentation could provide immediate stability and reconstruction of the spine column, and the presence of instrumentation did not result in any persistence or recurrence of infection. Continuous epidural irrigation and drainage is an effective method facilitating the elimination of residual infection.

Salmonella potsdam causing lumbar vertebral osteomyelitis: A case report.

RATIONALE: Salmonella osteomyelitis is an uncommon complication of salmonella infection, especially the salmonella vertebral osteomyelitis (SVO). PATIENT CONCERNS: We reported a case of a 29-year-old female who presented with serious lower back pain and severe limitation of motion for 50 days with no obvious inducements. She once had a fever up to 39.5°C. Physical examination only revealed limited motion of lower back without neurological complications. The laboratory results revealed no specificity. MRI of the lumbar spine revealed a spondylodiscitis at L4-L5. She underwent anterior lateral approach debridement and percutaneous posterior instrumentation. DIAGNOSES: Tissue and abscess culture grew showed Salmonella Potsdam infection. INTERVENTIONS: With susceptibility testing guidance, the patient was treated with intravenous levofloxacin and ceftazidime for a period of 3 weeks and another 3-week oral antibiotics therapy. OUTCOMES: The patient recovered well with no neurological deficits during the follow-up time. LESSONS: SVO is really rare and it alerts us the importance to consider uncommon pathogens in the differential diagnosis in which the etiological evidences are crucial of healthy individuals.

Prolonged and high dosage of tigecycline - successful treatment of spondylodiscitis caused by multidrug-resistant Acinetobacter baumannii: a case report.

BACKGROUND: The incidence of infectious spondylodiscitis has been increasing over the last few years. This reflects the expanding elderly and immunocompromised populations and the rising implementation of invasive spinal procedures. Infection may be inoculated into the disc space directly during invasive spinal procedures. Osteomyelitis caused by Acinetobacter species is rare and mainly caused by multidrug-resistant strains. CASE PRESENTATION: We present the case of a 72-year-old Greek woman with postoperative spondylodiscitis caused by a multidrug-resistant Acinetobacter baumannii strain that was successfully treated, after she declined surgical treatment, with prolonged and high dosage of tigecycline. She received intravenously administered tigecycline 200 mg per day for 60 days and then 100 mg per day for a total of 102 days and was infection-free. CONCLUSIONS: We reviewed the literature on the role of Acinetobacter baumannii as a cause of osteomyelitis, emphasizing the difficulty of treatment and the potential role of tigecycline in conservative treatment of the infection. We believe that 102 days in total is the longest time that any patient has received tigecycline in the literature, thus our patient is a unique case of successful treatment of spondylodiscitis.

Noncontiguous multi-tiered spinal tuberculosis associated with sternal localization: a case report.

BACKGROUND: Tuberculous spondylodiscitis is a frequent localization of tuberculosis. Multi-tiered involvement and an association with sternal localization are rare. CASE PRESENTATION: We report a case of multi-tiered tuberculous spondylodiscitis with sternal localization in an immunocompetent 41-year-old Arab woman who had inflammatory bilateral sciatica L5 and S1 and a history of low back pain caused by a trauma. Radiography, computed tomography, and a vertebral biopsy were useful for diagnosis. She reacted well to anti-bacillary treatment despite the occurrence of multiple paravertebral and subcutaneous abscesses. The medullar magnetic resonance imaging control performed at 4 months, 12 months, and 1 year after the end of treatment showed a favorable evolution. CONCLUSIONS: To avoid the delay of diagnosis, especially in our endemic context, tuberculosis must be evoked usually. This will improve the prognosis of our patients.

Tubercular spondylodiscitis in elderly is a more severe disease: a report of 66 consecutive patients.

PURPOSE: (1) To analyze peculiarities of presentation and prognosis of tubercular spondylodiscitis (TBS) in elderly. (2) To assess if associated co-morbidities and risks lead to poorer outcome (3) To observe if different management strategy needs to be implemented in them. METHODS: Retrospective analysis of 66 consecutive elderly TBS patients (>60 years) treated conservatively or surgically between January 2010 and July 2013 was performed. Details regarding clinical presentation (general health, ambulatory status, co-morbidities), neurological status, medical or surgical complications and outcome measurements [visual analog score, clinico-radiological evidence of healing and lumbar lordosis in lumbar (L) or lumbo-sacral (LS) or focal kyphosis in thoracic (T) or thoraco-lumbar (TL) disease] were analysed. RESULTS: Of 66 patients (mean age 67.9 years), 85% had at least one medical co-morbidity and only 45% were community ambulators. Mean delay in presentation was 132 days and lumbar disease was commonest. 35% had neuro-deficit. Most patients had stage 2 (38%) or 3 (42.4%) disease. 19 patients were conservatively managed, while others underwent surgery. Significant complications occurred in 23 patients, most common being liver dysfunction (9 patients). Five patients (8%) expired during treatment: three succumbed to multi-focal tubercular disease, while two expired secondary to medical illnesses. Mean loss of lordosis in conservatively treated (CG) L/LS disease was 8°, while lordosis was restored by 11.6° in operative group (OG). In T/TL disease, sagittal alignment correction by 12.6° was observed in OG as against 5.7° kyphotic collapse in CG patients. 92% patients were cured with no recurrences. The final VAS scores in operative and conservative groups were not significantly different (OG 1.4 ± 0.6, CG 1.9 ± 0.7). CONCLUSION: TBS in elderly differed from that in younger by having a higher co-morbidities, later presentation, higher neuro-deficit, greater mortality and increased complications. Nevertheless, in those who survived, clinico-radiological outcomes of both conservative and surgical treatments were good.

Periprosthetic UHMWPE Wear Debris Induces Inflammation, Vascularization, and Innervation After Total Disc Replacement in the Lumbar Spine.

BACKGROUND: The pathophysiology and mechanisms driving the generation of unintended pain after total disc replacement (TDR) remain unexplored. Ultrahigh-molecular-weight polyethylene (UHMWPE) wear debris from TDRs is known to induce inflammation, which may result in pain. QUESTIONS/PURPOSES: The purpose of this study was to determine whether (1) periprosthetic UHMWPE wear debris induces immune responses that lead to the production of tumor necrosis factor-α (TNFα) and interleukin (IL)-1ß, the vascularization factors, vascular endothelial growth factor (VEGF) and platelet-derived growth factor-bb (PDGFbb), and the innervation/pain factors, nerve growth factor (NGF) and substance P; (2) the number of macrophages is associated with the production of the aforementioned factors; (3) the wear debris-induced inflammatory pathogenesis involves an increase in vascularization and associated innervation. METHODS: Periprosthetic tissues from our collection of 11 patients with contemporary TDRs were evaluated using polarized light microscopy to quantify UHMWPE wear particles. The major reason for revision (mean implantation time of 3 years [range, 1-6 years]) was pain. For control subjects, biopsy samples from four patients with degenerative disc disease with severe pain and autopsy samples from three normal patients with no history of back pain were also investigated. Immunohistochemistry and histology were used to identify secretory factors, macrophages, and blood vessels. Immunostained serial sections were imaged at ×200 magnification and using MATLAB and NIH ImageJ, a threshold was determined for each factor and used to quantify positive staining normalized to tissue sectional area. The Mann-Whitney U test was used to compare results from different patient groups, whereas the Spearman Rho test was used to determine correlations. Significance was based on p < 0.05. RESULTS: The mean percent area of all six inflammatory, vascularization, and innervation factors was higher in TDR tissues when compared with normal disc tissues. Based on nonparametric data analysis, those factors showing the most significant increase included TNFα (5.17 ± 1.76 versus 0.05 ± 0.03, p = 0.02), VEGF (3.02 ± 1.01 versus 0.02 ± 0.002, p = 0.02), and substance P (4.15 ± 1.01 versus 0.08 ± 0.04, p = 0.02). The mean percent area for IL-1ß (2.41 ± 0.66 versus 0.13 ± 0.13, p = 0.01), VEGF (3.02 ± 1.01 versus 0.34 ± 0.29, p = 0.04), and substance P (4.15 ± 1.01 versus 1.05 ± 0.46, p = 0.01) was also higher in TDR tissues when compared with disc tissues from patients with painful degenerative disc disease. Five of the factors, TNFα, IL-1ß, VEGF, NGF, and substance P, strongly correlated with the number of wear particles, macrophages, and blood vessels. The most notable correlations included TNFα with wear particles (p < 0.001, ρ = 0.63), VEGF with macrophages (p = 0.001, ρ = 0.71), and NGF with blood vessels (p < 0.001, ρ = 0.70). Of particular significance, the expression of PDGFbb, NGF, and substance P was predominantly localized to blood vessels/nerve fibers. CONCLUSIONS: These findings indicate wear debris-induced inflammatory reactions can be linked to enhanced vascularization and associated innervation/pain factor production at periprosthetic sites around TDRs. Elucidating the pathogenesis of inflammatory particle disease will provide information needed to identify potential therapeutic targets and treatment strategies to mitigate pain and potentially avoid revision surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

First confirmed case of spondylodiscitis with epidural abscess caused by Parvimonas micra.

Parvimonas micra was renamed species as within Gram-positive anaerobic cocci and rarely causes severe infections in healthy people. We report the first confirmed case of spondylodiscitis with epidural abscess caused by P. micra in a healthy women. The patient has a pain in low back and anterior left thigh. Magnetic resonance imaging and computed tomography detected the affected lesion at the L2 and L3 vertebral bodies. All isolates from the surgical and needle biopsy specimens were identified as P. micra by 16S rRNA and MALDI-TOF. In this case, P. micra showed high sensitivity to antimicrobial therapy. She was successfully treated with debridement and sulbactam/ampicillin, followed by oral metronidazole for a total of 10 weeks. The causative microorganisms of spondylodiscitis are not often identified, especially anaerobic bacteria tend to be underestimated. On the other hand, antimicrobial therapy for spondylodiscitis is usually prolonged. Accordingly, we emphasize the importance of performing accurate identification including anaerobic bacteria.

Osteoarticular complications of brucellosis: The diagnostic value and importance of detection matrix metalloproteinases.

OBJECTIVES: Matrix metalloproteinases (MMPs) has been implicated in the pathogenesis of infective, cancer and autoimmune diseases. In this study, we investigated the serum level of MMPs and its clinical importance in human brucellosis. PATIENTS AND METHODS: This study included 60 brucellosis patients treated at the Clinic for Infectious Diseases, Clinical Centre, University of Sarajevo. Matrix metalloproteinases serum levels were quantified by ELISA. RESULTS: The investigation involved three groups: 30 patients with complications, 30 patients without complications of brucellosis and 30 healthy control examinees. The complications of human brucellosis varied but osteoarticular involvement dominated (n=21/30; 70%). Matrix metalloproteinases serum levels in the patients with complications were highest. The serum level of MMP-1 in patients with complications was the highest at 9.45; in patients without complications it was 3.78 and in the control examinees it was lowest at 3.62 (p=0.001). The serum level of MMP-9 in patients with complications was the highest at 105.66; in patients without complications 64.67, and in the control examinees it was lowest at 37.32 (p=0.001). The serum level of MMP-13 in patients with complications was highest at 138.86; in patients without complications at 64.85; and in the control examinees it was the lowest at 29.55 (p=0.001). Pearson's coefficient showed a statistically significant positive correlation between levels of tested matrix metalloproteinases and development complications in human brucellosis (p=0.001). CONCLUSION: This study showed the diagnostic value and importance of detection of matrix metalloproteinases in human brucellosis. MMPs are a useful serum biomarker for assessment of disease activity.

Biomechanical responses due to discitis infection of a juvenile thoracolumbar spine using finite element modeling.

Growth modulation changes occur in pediatric spines and lead to kyphotic deformity during discitis infection from mechanical forces. The present study was done to understand the consequences of discitis by simulating inflammatory puss at the T12/L1 disc space using a validated eight-year-old thoracolumbar spine finite element model. Changes in the biomechanical responses of the bone, disc and ligaments were determined under physiological compression and flexion loads in the intact and discitis models. During flexion, the angular-displacement increased by 3.33 times the intact spine and localized at the infected junction (IJ). The IJ became a virtual hinge. During compression loading, higher stresses occurred in the growth plate superior to the IJ. The components of the principal stresses in the growth plates at the T12/L1 junction indicated differential stresses. The strain increased by 143% during flexion loading in the posterior ligaments. The study indicates that the flexible pediatric spine increases the motion of the infected spine during physiological loadings. Understanding intrinsic responses around growth plates is important within the context of growth modulation in children. These results are clinically relevant as it might help surgeons to come up with better decisions while developing treatment protocols or performing surgeries.

Spinal infections with and without hardware: the viewpoint of an infectious disease specialist.

The incidence rate of spinal infections has been rising in last decades, and despite the advances in medicine, they still represent a therapeutic challenge, especially when related to spinal implants. The majority of spinal infections in developed world are caused by pyogenic bacteria, with Staphylococcus aureus as a leading cause among gram-positive cocci and Escherichia coli among gram-negative bacteria, whereas coagulase-negative staphylococci are frequently involved in implant-associated spinal infections. Implant-associated spinal infections are caused by bacteria capable of biofilm production on the implant surface rendering them resistant to majority of antimicrobial drugs. Spinal infections in patients without implants can be treated conservatively with pathogen-directed antimicrobial therapy, whereas in implant-associated spinal infections combined surgical and antibiotic therapy is necessary. Empiric antimicrobial treatment of spinal infections without microbiological diagnosis should be discouraged in the era of drug resistant pathogens.

Surgical results of long posterior fixation with short fusion in the treatment of pyogenic spondylodiscitis of the thoracic and lumbar spine: a retrospective study.

STUDY DESIGN: A single-institution, single-surgeon retrospective review. OBJECTIVE: To evaluate the clinical results of long posterior instrumentation with short posterior or posterolateral fusion for pyogenic spondylodiscitis of the thoracic and lumbar spine retrospectively. SUMMARY OF BACKGROUND DATA: There are controversies concerning the optimal treatment for pyogenic spondylodiscitis, in terms of approach, grafting, and instrumentation. Reports of long posterior fixation with short fusion without debridement of infected tissue for pyogenic spondylodiscitis are rare. METHODS: From June 1997 to June 2007, 48 patients with pyogenic spondylodiscitis were treated. The indications for surgery were neurological compromise, significant vertebral body destruction with kyphosis and segmental instability, failure of medical treatment, and the need for tissue diagnosis. All patients received long posterior instrumentation with or without posterior decompression, depending on whether the patients had neurological deficit. During operation, no debridement of infected tissue was done. Clinical outcomes were assessed using the criteria of Kirkaldy-Willis and the visual analogue scale for pain. The neurological outcome was graded using Frankel grading system. Segmental kyphotic angle and fusion were recorded and analyzed. RESULTS: The average follow-up time was 64 months. The visual analogue scale scores improved from an average of 7.2 before surgery to 2.2 after surgery. Twenty-eight patients with initial neurological impairment had an average improvement of 1.03 grades, using the Frankel grading system, at the final follow-up. The segmental kyphotic deformity improved by an average of 8.5° immediately after operation and lost an average correction of 3.0° at the final follow-up. No relapse of infection was found among these 48 patients. CONCLUSION: The posterior approach with long segmental fixation and short posterior or posterolateral fusion without debridement of the infected tissue was effective for pyogenic spondylodiscitis of the thoracic and lumbar spine.

Childhood discitis in a regional children's hospital.

Childhood discitis is rare, can be difficult to diagnose and it is unclear whether it is an infective or simply an inflammatory process. A departmental database search of 46 434 patients identified 12 cases from 1990-2008. The mean time to diagnosis from onset was 22 days. The children usually present with altered gait, a normal infection screen (temperature, white cell count, C-reactive protein, blood cultures) and radiographic loss of intervertebral disc height. Antibiotics were given in 11 cases and but no immobilization was used. Symptoms resolved by a mean of 6.5 weeks with no recurrence. This study highlights the unusual features of this rare condition which should be confirmed with MRI scanning.