Espondilodiscitis por haemophilus parainfluenzae: un reporte de caso / Spondylodiscitis due to haemophilus parainfluenzae: a case report

INTRODUCCIÓN Haemophilus parainfluenzae (HP) es un cocobacilo gram negativo y un patógeno oportunista. Rara vez se asocia a infecciones vertebrales o musculoesqueléticas, y está muy poco reportado en la literatura. PRESENTACIÓN DELO CASO Una mujer de 45 años, sana, que presentaba un historial de dos semanas de lumbalgia progresiva, fiebre, coriza y congestión nasal, y que tenía discitis intervertebral causada por HP, confirmada por dos hemocultivos positivos y hallazgos progresivos de resonancia magnética (RM) de columna lumbar. Los hallazgos de la RM fueron atípicos, y consistían en un absceso del psoas y pequeñas colecciones de líquido epidural e intraespinal anterior asociadas con espondilodiscitis. El diagnóstico inicial se retrasó debido a que la RM inicial no reveló hallazgos que sugirieran un proceso infeccioso. El tratamiento consistió en un ciclo prolongado de administración intravenosa seguida de antibióticos orales, lo que finalmente produjo una buena respuesta clínica. DISCUSIÓN Y CONCLUSIÓN El HP es un patógeno muy raro en la espondilodiscitis. No obstante, debe tenerse en cuenta, especialmente en pacientes que presentan lumbalgia y fiebre y/o bacteriemia por microorganismos gram negativos. El estudio inicial debe incluir una RM de la columna con contraste. Aunque es poco común, la espondilodiscitis y un absceso del psoas pueden presentarse concomitantemente. Los antibióticos prolongados son el pilar del tratamiento.

INTRODUCTION Haemophilus parainfluenzae (HP) is a gram-negative coccobacillus and an opportunistic pathogen. It is rarely associated with spinal- and musculoskeletal-site infections, and very little reported in the literature. CASE PRESENTATION An otherwise healthy, 45-year-old woman who presented with a two-week history of progressive low back pain, fever, coryza and nasal congestion, was found to have intervertebral discitis caused by HP, confirmed by two positive blood cultures and progressive lumbar spine magnetic resonance imaging (MRI) findings. The MRI findings were atypical, consisting of a psoas abscess and small anterior epidural and intraspinal fluid collections associated with spondylodiscitis. The initial diagnosis was delayed because the initial MRI failed to reveal findings suggestive of an infectious process. The treatment consisted of a long course of intravenous followed by oral antibiotics, ultimately yielding a good clinical response. DISCUSSION AND CONCLUSION Haemophilus parainfluenzae is a very rare pathogen in spondylodiscitis. Nonetheless, it should be considered, especially in patients presenting with low back pain and fever and/or gram negative bacteremia. The initial work-up should include contrast-enhanced MRI of the spine. Although rare, spondylodiscitis and a psoas abscess can present concomitantly. Prolonged antibiotics are the mainstay of treatment.

Analysis of results of open and percutaneous disc biopsy in the diagnosis of spondylodiscitis. / Análisis de los resultados de la biopsia discal abierta y percutánea en el diagnóstico de la espondilodiscitis.

INTRODUCTION: Spinal disc biopsy is a necessary tool in diagnosing and treating spondylodiscitis. Its profitability varies according to the technique, concomitant antibiotics therapy or causative germ. We studied the results of this procedure in our institution. MATERIALS AND METHODS: Retrospective analysis of all cases requiring disc biopsy due to possible spondylodiscitis over a 5year period, both percutaneous (26 cases) and open (13 cases). We collected filiation and clinical data, comorbidity, concomitant antibiotic therapy, imaging tests, biopsy type, cultures results and clinical evolution. RESULTS: 39 patients; 66.7% male, 66.9years of average age. 74% has known risk factors. The main symptom was pain (89.7%). Fever occurred in 5%. MRI performed in 87%. Lumbar involvement in 76.9%. 9 patients (23%) received antibiotic treatment simultaneously with biopsy. In these cases biopsy always yielded a negative result, but positive in patients without antibiotics at the time of the biopsy (53.3%), with statistical significance. Most frequent isolated microorganisms were gram-negative bacilli (31.2%) and gram-positive cocci (31.2%). We found 2 deaths during admission for sepsis (within the first month after diagnosis). Of the rest of patients, 5 died late during the follow-up: 3 due to new infections and 2 due to subsequent complications of previous pathologies. The remaining patients with final diagnosis of spondylodiscitis evolved satisfactorily with antibiotic therapy. CONCLUSIONS: Spondylodiscitis is potentially serious and requires an adequate diagnosis, with disc biopsy being a necessary procedure on occasions. Patients poor clinical condition can make it impossible to withdraw antibiotics, which drastically reduces the performance of the biopsy.

Analysis of results of open and percutaneous disc biopsy in the diagnosis of spondylodiscitis / Análisis de los resultados de la biopsia discal abierta y percutánea en el diagnóstico de la espondilodiscitis

Introduction: Spinal disc biopsy is a necessary tool in diagnosing and treating spondylodiscitis. Its profitability varies according to the technique, concomitant antibiotics therapy or causative germ. We studied the results of this procedure in our institution.Materials and methods: Retrospective analysis of all cases requiring disc biopsy due to possible spondylodiscitis over a 5year period, both percutaneous (26 cases) and open (13 cases). We collected filiation and clinical data, comorbidity, concomitant antibiotic therapy, imaging tests, biopsy type, cultures results and clinical evolution. Results: 39 patients; 66.7% male, 66.9years of average age. 74% has known risk factors. The main symptom was pain (89.7%). Fever occurred in 5%. MRI performed in 87%. Lumbar involvement in 76.9%. 9 patients (23%) received antibiotic treatment simultaneously with biopsy. In these cases biopsy always yielded a negative result, but positive in patients without antibiotics at the time of the biopsy (53.3%), with statistical significance. Most frequent isolated microorganisms were gram-negative bacilli (31.2%) and gram-positive cocci (31.2%). We found 2 deaths during admission for sepsis (within the first month after diagnosis). Of the rest of patients, 5 died late during the follow-up: 3 due to new infections and 2 due to subsequent complications of previous pathologies. The remaining patients with final diagnosis of spondylodiscitis evolved satisfactorily with antibiotic therapy. Conclusions: Spondylodiscitis is potentially serious and requires an adequate diagnosis, with disc biopsy being a necessary procedure on occasions. Patients poor clinical condition can make it impossible to withdraw antibiotics, which drastically reduces the performance of the biopsy.(AU)

Introducción: La biopsia discal es una herramienta necesaria en el proceso diagnóstico y terapéutico de las espondilodiscitis. Su rentabilidad es variable según condicionantes como la técnica utilizada, el uso concomitante de antibióticos o el germen causante. Estudiamos los resultados de este procedimiento en nuestro centro en un periodo de 5años. Material y métodos: Análisis retrospectivo de todos los casos que requirieron biopsia discal por posible espondilodiscitis en nuestro centro entre enero de 2015 y noviembre de 2019, tanto percutánea (26 casos) como abierta (13 casos). Recogemos datos de filiación y clínicos, comorbilidad, antibioterapia concomitante, pruebas de imagen, tipo de biopsia, resultado de cultivos y evolución clínica. Resultados: Treinta y nueve pacientes: 66,7% varones, 66,9años de edad media. El 74% con factores de riesgo conocidos. El síntoma principal es dolor mayoritariamente (89,7%) y fiebre en el 5%. La RMN en la prueba más frecuentemente realizada (87%). Los segmentos lumbares se afectaron en el 76,9%, por el 23% los dorsales. En 9 casos (23%) los pacientes reciben tratamiento antibiótico simultáneamente a la realización de la biopsia. En estos casos la biopsia siempre arrojó un resultado negativo. Los cultivos fueron positivos más frecuentemente en los pacientes sin antibióticos en el momento de la biopsia (53,3%), con significación estadística. Los microorganismos aislados de manera más repetida fueron los bacilos gramnegativos (31,2%) y los cocos grampositivos (31,2%). Constatamos 2 fallecimientos durante el ingreso por sepsis (dentro del primer mes tras el diagnóstico). Del resto de los pacientes fallecieron 5 de manera tardía durante el seguimiento: 3 por nuevas infecciones complicadas de manera tardía y 2 por complicaciones ulteriores de patologías previas. El resto de pacientes con diagnóstico final de espondilodiscitis evolucionaron satisfactoriamente con antibioterapia.(AU)

Análisis de los resultados de la biopsia discal abierta y percutánea en el diagnóstico de la espondilodiscitis / Analysis of results of open and percutaneous disc biopsy in the diagnosis of spondylodiscitis

Introducción: La biopsia discal es una herramienta necesaria en el proceso diagnóstico y terapéutico de las espondilodiscitis. Su rentabilidad es variable según condicionantes como la técnica utilizada, el uso concomitante de antibióticos o el germen causante. Estudiamos los resultados de este procedimiento en nuestro centro en un periodo de 5años. Material y métodos: Análisis retrospectivo de todos los casos que requirieron biopsia discal por posible espondilodiscitis en nuestro centro entre enero de 2015 y noviembre de 2019, tanto percutánea (26 casos) como abierta (13 casos). Recogemos datos de filiación y clínicos, comorbilidad, antibioterapia concomitante, pruebas de imagen, tipo de biopsia, resultado de cultivos y evolución clínica. Resultados: Treinta y nueve pacientes: 66,7% varones, 66,9años de edad media. El 74% con factores de riesgo conocidos. El síntoma principal es dolor mayoritariamente (89,7%) y fiebre en el 5%. La RMN en la prueba más frecuentemente realizada (87%). Los segmentos lumbares se afectaron en el 76,9%, por el 23% los dorsales. En 9 casos (23%) los pacientes reciben tratamiento antibiótico simultáneamente a la realización de la biopsia. En estos casos la biopsia siempre arrojó un resultado negativo. Los cultivos fueron positivos más frecuentemente en los pacientes sin antibióticos en el momento de la biopsia (53,3%), con significación estadística. Los microorganismos aislados de manera más repetida fueron los bacilos gramnegativos (31,2%) y los cocos grampositivos (31,2%). Constatamos 2 fallecimientos durante el ingreso por sepsis (dentro del primer mes tras el diagnóstico). Del resto de los pacientes fallecieron 5 de manera tardía durante el seguimiento: 3 por nuevas infecciones complicadas de manera tardía y 2 por complicaciones ulteriores de patologías previas. El resto de pacientes con diagnóstico final de espondilodiscitis evolucionaron satisfactoriamente con antibioterapia.(AU)

Introduction: Spinal disc biopsy is a necessary tool in diagnosing and treating spondylodiscitis. Its profitability varies according to the technique, concomitant antibiotics therapy or causative germ. We studied the results of this procedure in our institution.Materials and methods: Retrospective analysis of all cases requiring disc biopsy due to possible spondylodiscitis over a 5year period, both percutaneous (26 cases) and open (13 cases). We collected filiation and clinical data, comorbidity, concomitant antibiotic therapy, imaging tests, biopsy type, cultures results and clinical evolution. Results: 39 patients; 66.7% male, 66.9years of average age. 74% has known risk factors. The main symptom was pain (89.7%). Fever occurred in 5%. MRI performed in 87%. Lumbar involvement in 76.9%. 9 patients (23%) received antibiotic treatment simultaneously with biopsy. In these cases biopsy always yielded a negative result, but positive in patients without antibiotics at the time of the biopsy (53.3%), with statistical significance. Most frequent isolated microorganisms were gram-negative bacilli (31.2%) and gram-positive cocci (31.2%). We found 2 deaths during admission for sepsis (within the first month after diagnosis). Of the rest of patients, 5 died late during the follow-up: 3 due to new infections and 2 due to subsequent complications of previous pathologies. The remaining patients with final diagnosis of spondylodiscitis evolved satisfactorily with antibiotic therapy. Conclusions: Spondylodiscitis is potentially serious and requires an adequate diagnosis, with disc biopsy being a necessary procedure on occasions. Patients poor clinical condition can make it impossible to withdraw antibiotics, which drastically reduces the performance of the biopsy.(AU)

Espondilodiscitis por Streptococcus suis: 2 nuevos casos y revisión bibliográfica / Streptococcus suis spondylodiscitis: 2 new cases and a literature review

IntroducciónLa infección por Streptococcus suis (S. suis) es una zoonosis poco descrita en nuestro país, que se relaciona con la exposición al ganado porcino o su carne. La forma de presentación más frecuente es la meningitis, mientras que la afectación de la columna vertebral es rara.MétodosPresentamos 2 casos de infección por S. suis y realizamos una revisión sistemática de los trabajos publicados sobre espondilodiscitis por S. suis entre enero de 1994 y mayo de 2020 con el objetivo de definir las características clínicas, sus factores predisponentes y su evolución.ResultadosSe describen 17 casos, el 76,5% varones con una edad media de 57,6 años, generalmente sin enfermedad de base asociada. El enolismo fue un factor presente en casi el 17,6% de los pacientes. Un 70,6% presentaron exposición a ganado porcino o su carne y un 20% heridas en manos. La duración media de los síntomas fue de 10,2 días y el segmento más afectado fue el lumbar. Un 70,6% cursó con meningitis. Todos se trataron con betalactámicos con una duración media de 53,2 días. Hubo una recidiva y ninguno falleció.ConclusiónExisten pocos casos de espondilodiscitis por S. suis en la literatura. Cuando ocurre, se asocia a otro tipo de infección en la mayoría de los casos. Presentan buena respuesta al tratamiento médico y buen pronóstico.

IntroductionStreptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spinés involvement is rare.MethodsWe report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution.Results17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died.ConclusionThere are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis.

CT-Guided Needle Biopsy in Vertebral Osteomyelitis: Study of Factors That Could Influence in Culture Yield.

OBJECTIVE: The aim of this study was to analyze which are the main factors that could influence the result of a CT guided biopsy in vertebral osteomyelitis (VO) patients. METHODS: A single center retrospective observational study was performed including adult patients who had been diagnosed with VO and undergone CT guided needle biopsy from January 2010 to January 2020. Demographical features, concurrent diseases, laboratory findings, microbiological diagnosis, radiological data, medical complications, antibiotic exposure were compiled. Multivariate analysis was performed with a logistic regression comparing the patients depending on the culture result. RESULTS: Seventy-seven patients were included in the study. Baseline characteristics were comparable between groups. Sample culture was positive in 43 cases (56%). Microorganism isolated were gram+(72%), gram-(14%), mycobacteria (7%) and fungi (7%). Delay in the procedure, antibiotic exposure and blood culture positivity were also similar among both groups. The biopsy results were not influenced by the CRP value, the presence of fever nor antibiotic exposure. The longer duration of back pain was associated to a lower probability of a positive culture. CONCLUSIONS: In conclusion, our study displays an acceptable reliability of CT guided needle biopsy in VO patients, even in cases under antibiotic treatment. The presence of fever or CRP values did not predict a positive culture. Delay in diagnosis could impact negatively on culture yield.

CT-Guided Needle Biopsy in Vertebral Osteomyelitis: Study of Factors That Could Influence in Culture Yield / Punción asistida por TC en pacientes con osteomielitis vertebral: análisis de los factores que condicionan su rentabilidad

Objective: The aim of this study was to analyze which are the main factors that could influence the result of a CT guided biopsy in vertebral osteomyelitis (VO) patients. Methods: A single center retrospective observational study was performed including adult patients who had been diagnosed with VO and undergone CT guided needle biopsy from January 2010 to January 2020. Demographical features, concurrent diseases, laboratory findings, microbiological diagnosis, radiological data, medical complications, antibiotic exposure were compiled. Multivariate analysis was performed with a logistic regression comparing the patients depending on the culture result. Results: Seventy-seven patients were included in the study. Baseline characteristics were comparable between groups. Sample culture was positive in 43 cases (56%). Microorganism isolated were gram+(72%), gram−(14%), mycobacteria (7%) and fungi (7%). Delay in the procedure, antibiotic exposure and blood culture positivity were also similar among both groups. The biopsy results were not influenced by the CRP value, the presence of fever nor antibiotic exposure. The longer duration of back pain was associated to a lower probability of a positive culture. Conclusions: In conclusion, our study displays an acceptable reliability of CT guided needle biopsy in VO patients, even in cases under antibiotic treatment. The presence of fever or CRP values did not predict a positive culture. Delay in diagnosis could impact negatively on culture yield.(AU)

Objetivo: El propósito del presente estudio es analizar qué factores pueden influir en el resultado del cultivo de las muestras obtenidas por punción guiada por TC en pacientes con osteomielitis vertebral. Métodos: Se realizó un estudio en un único centro, retrospectivo y observacional en pacientes diagnosticados de osteomielitis vertebral, que fueron subsidiarios de punción-biopsia entre enero de 2010 y enero de 2020. Se recogieron para su análisis, variables demográficas, comorbilidades, resultados de laboratorio, radiología, el tratamiento previo con antibióticos y la demora previa a la realización de la técnica. Se realizó un análisis multivariante mediante regresión logística. Resultados: Se incluyó a un total de 77 pacientes que fueron sometidos a la técnica. Sus características basales fueron similares. El cultivo fue positivo en 43 casos (56%). Los microorganismos aislados fueron gram + (72%), gram – (14%), micobacterias (7%) y hongos (7%). El retraso en la ejecución de la técnica y el tratamiento previo con antibióticos fue similar en ambos grupos. Ni el valor de PCR, la presencia de fiebre ni la antibioterapia tuvieron influencia en el resultado del cultivo. Se observó que una mayor duración del dolor lumbar se relacionó con una menor probabilidad de obtener un resultado positivo en el cultivo. Conclusiones: Incluso bajo exposición antibiótica, la punción asistida por TC mostró una rentabilidad aceptable. La presencia de fiebre o valores elevados de PCR no fueron predictivos de positividad del cultivo. El retraso diagnóstico sí podría impactar negativamente en la rentabilidad diagnóstica del cultivo procedente de la biopsia.(AU)

Streptococcus suis spondylodiscitis: 2 new cases and a literature review.

INTRODUCTION: Streptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spine's involvement is rare. METHODS: We report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution. RESULTS: 17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died. CONCLUSION: There are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis.

Morphological aspect of pyogenic spinal epidural abscesses. part i / Aspecto morfológico dos abscessos peridurais piogênicos da coluna. parte i / Aspecto morfológico de los abscesos epidurales espinales piógenos. parte i

ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa's coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.

RESUMO Introdução: O abscesso peridural piogênico da coluna (PSEA) é de difícil diagnóstico e pode ter consequências devastadoras. A ressonância magnética (RM) tem alta sensibilidade e especificidade, que são aumentadas ainda mais com contraste. Existem várias classificações dos processos infecciosos vertebrais, com ênfase em espondilodiscite. Objetivo: Analisar os parâmetros morfológicos e sua reprodutibilidade; e analisar as diferentes sequências de imagens de ressonância. Métodos: A partir de um banco de imagens, foi planejada uma classificação morfológica do PSEA, com cinco parâmetros: Região (R) que indica os limites superior e inferior do abscesso; Localização (U), indicando se o abscesso é anterior ou posterior dentro do canal; Comprometimento (C), meníngeo ou de conteúdo das estruturas; Associação (A), discite, osteomielite ou ambas e Perivertebral (P), abscesso extravertebral anterior, lateral ou posterior. Os três primeiros parâmetros dão uma ideia do volume da PSEA, enquanto os dois últimos mostram os focos infecciosos relacionados. Trinta e cinco casos foram analisados usando o coeficiente de Kappa. Resultados: A reprodutibilidade global intra e interobservador foi Kappa 0,81. Os resultados para cada parâmetro foram os seguintes: R = 0,95, U = 0,92, C = 0,66, A = 0,70 e P = 0,80. Os três primeiros dão uma noção de volume e os dois últimos se relacionam com a presença de focos infecciosos vertebrais fora do canal. A RM ponderada em T2 com contraste foi considerada a sequência de imagens mais eficaz. Conclusões: A classificação morfológica é simples de usar e tem excelente reprodutibilidade. Os parâmetros com maior reprodutibilidade foram região e localização com valores > 0,92. A adição do contraste de gadolínio aumentou a sensibilidade do diagnóstico; o uso de imagens sagitais e axiais em RM T2 foi a sequência de imagens mais sensível. Nível de Evidência III; Original.

RESUMEN Introducción: El absceso epidural espinal piógeno (PSEA) es difícil de diagnosticar y puede tener consecuencias devastadoras. La resonancia magnética (RM) tiene una alta sensibilidad y especificidad, que aumentan aún más con el contraste. Existen varias clasificaciones de los procesos infecciosos vertebrales, con énfasis en la espondilodiscitis. Objetivo: Analizar los parámetros morfológicos y su reproducibilidad; y analizar las diferentes secuencias de imágenes de resonancia. Métodos: Utilizando un banco de imágenes, se planificó una clasificación morfológica del PSEA, con 5 parámetros: Región (R), que indica los límites superior e inferior del absceso; Ubicación (U), que indica si el absceso es anterior o posterior dentro del canal; Compromiso (C), meníngeo o contenido de las estructuras; Asociación (A), discitis, osteomielitis o ambas; y absceso perivertebral (P), anterior, lateral o posterior extravertebral. Los tres primeros parámetros dan una idea del volumen del PSEA y los dos últimos los focos infecciosos relacionados. Se analizaron 35 casos mediante el coeficiente Kappa. Resultados: La reproducibilidad general intra e interobservador fue Kappa 0,81. Los resultados de cada parámetro fueron los siguientes:: R=0,95, U=0,92, C=0,66, A=0,70 y P=0,80. Los tres primeros dan una noción de volumen y los dos últimos se relacionan con la presencia de focos infecciosos vertebrales fuera del canal. La resonancia magnética ponderada en T2 con contraste se consideró la secuencia de imágenes más eficaz. Conclusiones: La clasificación morfológica es sencilla de utilizar y tiene una excelente reproductividad. Los parámetros con mayor reproducibilidad fueron la región y ubicación con valores > 0,92. La adición de contraste de gadolinio aumentó la sensibilidad del diagnóstico; el uso de imágenes sagitales y axiales en RM T2 fue la secuencia de imágenes más sensible. Nivel de Evidencia III; Original.

Infecciones piógenas de la columna vertebral / Pyogenic spinal infections

Las infecciones espinales son cuadros clínicos poco frecuentes, que exigen un alto índice de sospecha. La prevalencia de infecciones piógenas de la columna ha ido en aumento, en parte debido al envejecimiento de la población y a un mayor número de pacientes inmunocomprometidos. El estudio imagenológico se puede iniciar con radiografías simples, pero la resonancia magnética es el examen imagenológico de elección, ya que puede dar resultados positivos de forma precoz, entregando información más detallada del compromiso vertebral y tejidos blandos adyacentes. Aunque la clínica y los hallazgos imagenológicos nos pueden orientar, es importante intentar un diagnóstico microbiológico tomando cultivos y muestras para identificar al agente causal antes de iniciar los antibióticos; aunque es óptimo un tratamiento agente-específico, hasta un 25% de los casos queda sin diagnóstico del agente. El tratamiento es inicialmente médico, con antibióticos e inmovilización, pero se debe considerar la cirugía en casos de compromiso neurológico, deformidad progresiva, inestabilidad, sepsis no controlada o dolor intratable. El manejo quirúrgico actual consiste en el aseo y estabilización precoz de los segmentos vertebrales comprometidos. Descartar una endocarditis concomitante y el examen neurológico seriado son parte del manejo de estos pacientes.

Spinal infections are unusual conditions requiring a high index of suspicion for clinical diagnosis. There has been a global increase in the number of pyogenic spinal infections due to an aging population and a higher proportion of immunocompromised patients. The imaging study should start with plain radiographs, but magnetic resonance imaging (mri) is the gold standard for diagnosis. Mri can detect bone and disc changes earlier than other methods, and it provides detailed information on bone and adjacent soft tissues. Blood cultures and local samples for culture and pathology should be obtained, trying to identify the pathogen. According to the result, the most appropriate drug must be selected depending on susceptibility and penetration into spinal tissues. Treatment should start with antibiotics and immobilization; surgery should be considered in cases with neurological impairment, progressive deformity, spine instability, sepsis, or non-controlled pain. Current surgical treatment includes debridement and early stabilization. Practitioners should rule out endocarditis and perform a serial neurological examination managing these patients.

Streptococcus suis spondylodiscitis: 2 new cases and a literature review. / Espondilodiscitis por Streptococcus suis: 2 nuevos casos y revisión bibliográfica.

INTRODUCTION: Streptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spinés involvement is rare. METHODS: We report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution. RESULTS: 17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died. CONCLUSION: There are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis.

Vertebral osteomyelitis: Clinical, microbiological and radiological characteristics of 116 patients.

INTRODUCTION/OBJECTIVES: To describe the clinical, radiological and microbiological characteristics of vertebral osteomyelitis patients, analysing the factors that played a role on their outcome. PATIENTS AND METHODS: Single-centre retrospective observational study including patients diagnosed with vertebral osteomyelitis, based on the combination of clinical presentation with either a definitive bacteriological diagnosis and/or imaging studies. RESULTS: 116 adult patients were included with a mean age of 62.75 (14.98) years. Males predominated (68.10%). Eighteen patients (15.51%) were immunosuppressed. The most frequent symptom was back pain (99.14%) followed by fever, which was detected in 45 patients (38.79%). Puncture-aspiration or biopsy was performed in 84 patients (72.10%) and its culture was positive in 48 samples (57.14%). Gram positive species predominated (73.86%) on cultures, followed by Gram negative (12.5%), mycobacteria (10.23%) and fungi (3.41%). No microorganism was identified in 28 patients (24.14%). On imaging, most of the patients (92.24%) had paravertebral or epidural abscess. 63 cases (54.31%) showed vertebral destruction and 39 (33.62%) cord compression. Twenty-two patients (18.97%) required further surgical procedures and 13 (11.21%) died. CONCLUSIONS: The average patient is middle aged (often male) with a history of subacute back pain, sometimes presenting fever and/or neurological damage on diagnosis. Acute phase reactants are frequently raised. Diabetes mellitus, endocarditis and immunosuppressed patients may have the worst chance of a good outcome, therefore these patients should be more carefully managed (always try to obtain an imaging-guided biopsy, correct antibiotic treatment, and a functional and clinical follow-up).

Serratia marcescens as a cause of cervical myelopathy / Serratia marcescens como causa de mielopatia cervical / Serratia marcescens como causa de mielopatía cervical

ABSTRACT Introduction: The main causative agent of spinal infections is Mycobacterium Tuberculosis, followed by saprophytes of the skin. The most affected segment is the lumbar, followed by the thoracic. Objective: Case report. Results: A previously healthy 40-year-old man with posterior cervical pain and myelopathy was referred to our spine service for vertebral destruction syndrome in C3-C4 and altered carbohydrate metabolism. Microdiscectomy and abscess drainage were performed and a biopsy was taken for definitive diagnosis. Multiresistant Serratia Marcescens was isolated in the culture. Both the myelopathy and carbohydrate intolerance were resolved as the infection was resolved. Conclusion: The significance of this case lies in the infective presentation of the S. Marcescens in an immunocompetent person, since it is mainly an opportunistic microorganism, and in the atypical location. The most commonly isolated pathogen is Mycobacterium Tuberculosis, followed by Staphylococcus aureus. Identification of the causative agent is essential to the initiation of antibiotic therapy. Therefore, microbiological isolation plays a fundamental role in the treatment, recovery and quality of life of the patient. Level of evidence V; Case report.

RESUMO Introdução: O principal agente causador das infecções da coluna vertebral é o Mycobacterium tuberculosis, seguido pelos saprófitos da pele. O segmento mais afetado é o lombar, seguido pelo torácico. Objetivo: Relato de caso. Resultados: Um homem, anteriormente saudável, de 40 anos, com dor cervical posterior e mielopatia como principal sintomatologia, foi encaminhado ao nosso serviço de coluna vertebral com síndrome de destruição vertebral em C3-C4 e alteração do metabolismo de carboidratos. A microdiscectomia e a drenagem de abscessos foram realizadas e uma biópsia foi feita para diagnóstico definitivo. A Serratia marcescens multirresistente foi isolada na cultura. Tanto a mielopatia como a intolerância a carboidratos foram resolvidas, uma vez que a infecção foi tratada. Conclusão: A importância desse caso reside na apresentação infecciosa da S. marcescens em uma pessoa imunocompetente, uma vez que esse é principalmente um microrganismo oportunista e por sua localização atípica. O patógeno mais comumente isolado é o Mycobacterium tuberculosis, seguido pelo Staphylococcus aureus. A identificação do agente causador é essencial para início da terapia com antibióticos. Portanto, o isolamento microbiológico desempenha um papel fundamental no tratamento, recuperação e qualidade de vida do paciente. Nível de evidência: V; Relato de caso.

RESUMEN Introducción: El principal agente causal de las infecciones de columna es la Mycobacterium Tuberculosis seguido de los saprófitos de la piel y el principal segmento afectado es el lumbar, seguido del torácico. Objetivo: Reporte de caso. Resultados: Presentamos un masculino de 40 años previamente sano, referido al servicio de columna por síndrome de destrucción vertebral C3-C4, con dolor cervical posterior y mielopatía como principal sintomatología, y alteración del metabolismo de carbohidratos. Se realizó microdiscectomía y drenaje de absceso con toma de biopsia para diagnóstico definitivo. En el cultivo se aisló Serratia Marcescens, multirresistente. La mielopatía y la intolerancia a los carbohidratos se resolvieron una vez resuelta la infección. Conclusión: La importancia de este caso radica en la presentación infectante de la S. Marcescens en una persona inmunocompetente ya que esta es principalmente un microorganismo oportunista y por su localización atípica. El patógeno más comúnmente aislado es Mycobacterium Tuberculosis seguido de Staphylococcus aureus. La identificación del agente causal es fundamental para iniciar la terapéutica antibiótica. Por lo tanto, el aislamiento microbiológico tiene un papel fundamental en el tratamiento, la recuperación y calidad de vida del paciente. Nivel de evidencia V; Reporte de caso.

Role of Nuclear Medicine in the diagnosis of musculoskeletal infection: a review. / Revisión del papel de la Medicina Nuclear en el diagnóstico de la infección musculoesquelética.

Inflammatory and infectious osteoarticular diseases can cause serious consequences for the patient if they are not diagnosed on time. In the last decades, different modalities of nuclear medicine have allowed to study the physiopathology of these processes, and nowadays, they play an important role in diagnosis, characterization and monitoring of musculoskeletal infectious diseases. Therefore, it is essential that every nuclear medicine physician have a vision of the advantages and disadvantages of each method and know how to use them correctly in the diagnosis of the patient. This article highlights the role of nuclear medicine in standardizing the diagnostic approach in patients with infectious/inflammatory diseases, in particular in peripheral osteomyelitis, septic arthritis, prosthetic joint infections, infected diabetic foot and spinal infections. The authors reveal the role of the most common radionuclides tests, with their advantages and clinical indications, to achieve an adequate diagnosis of infection and inflammation.

Caracterización y asociación clínico bacteriológica en la espondilodiscitis piógena / Bacteriological-clinical association and characterization in Pyogenic Spondylodiscitis

Resumen: Objetivo: Determinar la asociación entre las características clínicas y estudios de laboratorio con el tipo de microorganismo aislado en hemocultivos de pacientes con espondilodiscitis piógena. Material y métodos: Es un estudio transversal analítico, se revisaron expedientes clínicos de pacientes con espondilodiscitis piógena desde Enero de 2013 hasta Enero de 2017. Se realizó análisis descriptivo univariado usando frecuencias y porcentajes para variables cualitativas, medidas de tendencia central y dispersión para las cuantitativas. Análisis bivariado mediante prueba de χ2 o test exacto de Fisher. Análisis de variables cuantitativas mediante t Student o U de Mann-Whitney. Se usó coeficiente de correlación de Spearman. Considerando significancia estadística p < 0.05. Resultados: Se obtuvo una muestra de 34 pacientes, 20 (58%) fueron mujeres, mediana (Me) de edad 60 años (52-66). Se aisló en hemocultivos, bacterias Gram positivas 11 (32.4%) y Gram negativas 23 (67.6%). El microorganismo aislado más frecuente fue Escherichia coli 12 (35.3%). Los pacientes con espondilodiscitis por Gram negativas presentaron dolor leve y velocidad de sedimentación globular (VSG) Me 26 mm/hra P (18-36), los pacientes con espondilodiscitis por Gram positivas presentaron dolor severo y VSG Me 38 mm/h P (34-40) (p = 0.000 y 0.028, respectivamente). La VSG y dolor en el grupo de pacientes con espondilodiscitis por bacterias Gram negativas tuvo un coeficiente de correlación de Spearman moderado 0.418, (p = 0.047); en el grupo de Gram positivas, un coeficiente de correlación de Spearman bajo 0.228, (p = 0.507). Conclusión: Existe una asociación clínica y estadística de manera significativa entre los tipos de microorganismo aislado en hemocultivo, la intensidad del dolor valorado en escala visual análoga (EVA) y los niveles de VSG.

Abstract: Objective: Determine the association between clinical characteristics and laboratory studies with the type of isolated microorganism in blood cultures of patients with Pyogenic Spondylodiscitis. Material and methods: It is a cross-analytical study, clinical records of patients with Pyogenic Spondylodiscitis were reviewed from January 2013 to January 2017. Univariate descriptive analysis was performed using frequencies and percentages for qualitative variables, central trend measures and dispersion for quantitative ones. Bivariate analysis by testing of χ2 or Fisher's exact test. Analysis of quantitative variables using T Student or Mann-Whitney U. Spearman's correlation coefficient was used. Considering statistical significance p < 0.05. Results: A sample of 34 patients was obtained, 20 (58%) were women, median (Me) of age 60 years (52-66). Was isolated into blood cultures, Gram-positive bacteria 11 (32.4%) gram negatives 23 (67.6%). The microorganism most common isolate was Escherichia coli 12 (35.3%). Patients with Gram-negative spondylodiscitis had mild pain and globular sedimentation rate (VSG) Me 26 mm/hra P (18-36), patients with Gram-positive spondylodyscitis had severe pain and VSG Me 38 mm/h P (34-40) (p= 0.000 and 0.028, respectively). VSG and pain in the group of patients with gram-negative bacteria spondylodiscitis had a moderate Spearman correlation coefficient of 0.418, (p = 0.047); in the Gram positives group, a low correlation coefficient of Spearman 0.228, (p = 0.507). Conclusion: There is a clinical and statistical association significant between types of isolated microorganism in blood culture, pain intensity valued on analog visual scale (EVA) and VSG levels.

Absceso de psoas iliaco: un desafío diagnóstico / Psoas-Iliac Abscess a dignotic challengen

El absceso de músculo psoas iliaco se considera una rare-za. Su detección ha mejorado con la utilización de imágenes como la tomografía computada o la resonancia magnética. Presentamos una revisión de casos de absceso de psoas-iliaco internados entre julio de 2015 y febrero de 2018 en un hospital de CABA, Argentina.En este periodo se diagnosticaron un paciente conside-rado de origen primario y ocho de origen secundario. Se observó predominio de colecciones asociadas a es-pondilodiscitis. El síntoma más frecuente fue la fiebre. Staphylococcus aureus fue el germen más rescatado en muestras microbiológicas. Se debe tener alto índice de sospecha de esta patología ante la presencia de fiebre, dolor lumbar y en ocasiones alteración de la marcha. El empleo de antibióticos de amplio espectro sumado a la evacuación de colecciones constituyen la estrategia más efectiva

Psoas-iliac muscle abscess is considered a rarity, the use of images such as computed tomography or magnetic reso-nance imaging has improved its detection.This study reviews cases of psoas-iliac abscess in hospi-talized patients between July 2015 and February 2018 in a hospital in CABA, Argentina.In one of the patients the origin was considered primary ,while in the other eight it was secondary. There was a pre-dominance of collections associated with spondylodiscitis. The most frequent symptom was fever. Staphylococcus au-reus was the most frequent organism obtained in microbio-logical samples. A high level of suspicion must be held in the presence of fever, lumbar pain and sometimes alteration of the gait. The use of broad spectrum antibiotics in addition to evacuation of collections is the most effective strategy.

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

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

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

[Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients]. / Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos.

OBJECTIVE: To describe and discuss the role of surgery in the management of spontaneous spondylodiscitis. PATIENTS AND METHODS: Retrospective review on the outcome and complications of a cohort of patients undergoing surgery for spontaneous (non-postoperative) spondylodiscitis of any spinal level or aetiology. RESULTS: From 1995 to 2014, 83 patients (45% females, median age 66) with spondylodiscitis were treated. Microbiological confirmation was obtained in 67.4%. Forty-four percent of patients presented with neurological defect. The most common affected level was thoracic (54.2%). The most frequent isolations were Mycobacterium tuberculosis (229%), Staphylococcus aureus (20.5%) and MRSA (7.2%). Eighty-one patients underwent surgery: simple laminectomy and/or biopsy (22.2%), debridement and posterior fixation (43.2%) and debridement and anterior fixation (34.5%). Improvement of pain or neurological defect was achieved in 86.7% of the patients; 7 patients stabilized and 2 worsened. Complications occurred in 35 patients, mainly pleural effusion (9), anaemia (7) and need for re-debridement (7). Median postoperative stay was 14days. After a median follow up of 8.5 months, 46 patients were considered completely cured, 10 presented sequelae, 22 patients were lost and 5 patients died. No readmissions occurred because of the infectious episode. CONCLUSIONS: Although prolonged and specific antibiotic therapy remains the mainstay of treatment in spontaneous spondylodiscitis, surgery provides samples for microbiological confirmation and histopathologic study, allows debridement of the infectious foci and stabilizes the spine. In our experience, the use of internal metallic fixation material accelerates recovery and does not predispose to chronic infection.

Primary infectious spondylodiscitis in 51 patients over 75 years old: A comparative study. / Espondilodiscitis infecciosa primaria en 51 pacientes mayores de 75 años: estudio comparativo.

BACKGROUND AND OBJETIVE: The incidence of infectious spondylodiscitis has been shown to rise with age; however, they had not been extensively investigated in the very elderly. MATERIAL AND METHODS: This retrospective, monocentric study included patients hospitalized in our department of rheumatology for primary infectious spondylodiscitis between 2000 and 2015, and compared over 75-year-olds with younger patients. RESULTS: Of the 152 patients, 51 (33.6%) were≥75 years old, 59 were 61-74, and 42 were≤60. Patients≥75 years old were more often institutionalized (7.8 vs. 0; P=.02), were less often subject to infection risk factors (27.5 vs. 54.5%; P=.02), but did not differ from the others as regards the frequency of diabetes and cancer. Time to diagnosis was shorter for the under 60-year-olds (23 vs. 30 vs. 30 day for each age group, respectively; P<.05). There were no differences among the age groups in terms of spondylodiscitis localization, frequency of neurological symptoms and fever, frequency or intensity of inflammatory syndrome, imaging use, frequency of microorganism identification, blood culture positivity, or use and efficacy of disco-vertebral biopsy. Microorganism distribution was comparable among the groups, except for Gram-negative bacilli, with Escherichia coli more common in over 75-year-olds (7/8 vs. 4/14; P=.02). Duration of antibiotherapy and hospitalization was comparable across the age groups. Five patients died, all over 75 years old (5/51 vs. 0/101; P=.001). CONCLUSION: Age is a risk factor for primary spondylodiscitis, associated with significant mortality in over 75-year-olds (10%). For these elderly patients, spondylodiscitis does not bear any other distinguishing features.

Actualidades en infecciones vertebrales / Actualités sur les infections vertébrales

Introducción: las infecciones vertebrales constituyen una afección de baja incidencia, pero con incremento importante en años recientes, el cual está en relación con una población más susceptible por diversas razones. A pesar de nuevos métodos para el diagnóstico, la demora constituye un importante problema.Propósito: revisar y discutir algunos temas actuales acerca de las infecciones vertebrales, la epidemiologia, etiología, fisiopatología, diagnóstico y tipos de tratamientos.Método: se seleccionó la literatura apropiada usando las bases de datos Pubmed, Hinari y Clinical Key.Resultados: la literatura muestra la importancia del correcto y rápido diagnóstico; determinar el agente causal es de primordial importancia para aplicar una adecuada terapia antimicrobiana. El tratamiento conservador produce, generalmente, buenos resultados y el quirúrgico está indicado en déficit o sepsis neurológicos, inestabilidad espinal y/o deformidad y fallo del tratamiento conservador. Se muestra algoritmo para diagnóstico y tratamiento.Conclusiones: aplicar una metodología correcta para el diagnóstico y tratamiento de las infecciones vertebrales, logra resultados satisfactorios(AU)

Introduction: vertebral infections are a disease of low incidence, but with significant increase in recent years. This increase is related to a more susceptible population due to various reasons. Despite the new methods for diagnosis, its delay is a major problem.Objective: review and discuss some current issues about the spine infections, epidemiology, etiology, pathophysiology, diagnosis and types of treatment.Method: select the appropriate literature using PubMed database, Hinari and Clinical Key.Results: the literature shows the importance of correct and rapid diagnosis, which determine the causal agent, is primordial to implement appropriate antimicrobial therapy. Conservative treatment generally produces good results and surgery is indicated in neurological deficit or sepsis, spinal instability and / or deformity and failure of conservative treatment. Diagnostic and treatment algorithm is shown.Conclusions: applying correct methodology for the diagnosis and treatment of spinal infection, satisfactory results are achieved(AU)