Azole-resistant Candida albicans Spondylodiscitis After Bariatric Surgery: A Case Report.

CASE: We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up. CONCLUSION: Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.

Vertebral fractures in adult women with type 2 diabetes mellitus / Fracturas vertebrales en mujeres adultas con diabetes mellitus tipo 2

Introduction. Diabetes is a chronic disease associated with important comorbidities. Type 2 diabetes (T2DM) is associated with a three times increased risk of hip fracture but reports describing potential associations with vertebral fractures (VF) are contradictory. Our objective was to evaluate the factors involved in the prevalent VF in women with and without T2DM. Materials and methods. A cross-sectional design was used and the relationship between morphometric VF and T2DM in adult women was evaluated. The cases were adult women with morphometric VF and the controls were adult women without VF. Thoracic and spinal radiographs in lateral and antero-posterior projections were obtained. Bone mineral density (BMD) values of the lumbar spine (L-BMD) were measured by DXA. Results. A greater number of women with T2DM were found in the VF group (61% vs 31.5%). Non-T2DM women with VF were significantly older and with lower L-BMD than non-T2DM without VF. We observed a negative correlation between age and L-BMD (r=-0.463) in non-T2DM women, but not in the T2DM with FV group. T2DM was a risk factor for prevalent VF with OR of 3.540 (IC95% 1.750-7.160). Conclusion. Our study showed a higher prevalence of T2DM in the VF group. T2DM women with VF were younger and had higher L-BMD than non-T2DM women, L-BMD did not correlate with age and VF were not distributed according to BMD-L and age. (AU)

Introducción. La diabetes es una enfermedad crónica asociada con comorbilidades importantes. La diabetes tipo 2 (DM2) se asocia con un riesgo tres veces mayor de fractura de cadera pero la asociación con fracturas vertebrales (FV) es contradictoria. Nuestro objetivo fue evaluar los factores involucrados en las FV prevalentes en mujeres adultas con y sin DM2. Materiales y métodos. Se realizó un diseño transversal y se evaluó la relación entre FV morfométrica y DM2 en mujeres adultas. Los casos fueron mujeres adultas con FV morfométricas y los controles fueron mujeres adultas sin FV. Se obtuvieron radiografías torácicas y espinales en proyecciones lateral y anteroposterior. Los valores de densidad mineral ósea (DMO) de la columna lumbar (DMO-L) se midieron por DXA. Resultados. Se observó un mayor número de mujeres con DM2 en el grupo de FV (61% frente a 31.5%). Las mujeres sin DM2 con FV eran significativamente mayores y con una DMO-L más baja que las mujeres sin DM2 sin FV. Observamos una correlación negativa entre la edad y la DMO-L (r= -0.463) en mujeres sin DM2 y FV, pero no en DM2 con FV. La DM2 fue un factor de riesgo para FV prevalente con un OR 3.540 (IC95% 1.750-7.160). Conclusión. Nuestro estudio demostró una mayor prevalencia de DM2 en el grupo de FV. Las mujeres con DM2 y FV eran más jóvenes y tenían mayor DMO-L que las mujeres sin DM2, la DMO-L no correlacionó con la edad y las FV no se distribuyeron de acuerdo a la DMO-L y edad. (AU)

Efficacy and Safety of Posterior Versus Combined Posterior and Anterior Approach for the Treatment of Spinal Tuberculosis: A Meta-Analysis.

OBJECTIVE: Surgical treatment is an important strategy for the treatment of spinal tuberculosis (TB). Several approaches have been reported for the surgery. However, no single study has had a large enough sample population to definitively determine whether the single posterior approach is as effective and safe as the combined posterior and anterior approach for the treatment of spinal TB. A meta-analysis was conducted to evaluate the clinical efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal TB. METHODS: In this meta-analysis, electronic databases, such as PubMed, MEDLINE, EMBASE, Google scholar, and Cochrane library, were searched to select the potentially relevant reports that compared the outcomes of the posterior approach (group A) with the combined posterior and anterior approach (group B) in the treatment of spinal TB. Relevant journals and references were also searched manually. Data extraction and quality assessment were according with Cochrane Collaboration guidelines. Outcome assessments were operation time, blood loss, correction of angle, loss of correction, hospital stay, fusion time of the grafting bone, neurological improvement, and complications after surgery. Results were expressed as odds ratio for dichotomous outcomes and mean difference for continuous outcomes with 95% confidence interval. RESULTS: Five controlled clinical trials published between 2012 and 2014, involving 253 patients (group A, 129; group B, 124) with spinal TB were retrieved in this study. The overall meta-analysis showed that there were significant differences (P< 0.01) between groups A and B in operation time, blood loss, hospital stay, and complications after surgery. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after surgery between groups A and B. CONCLUSIONS: The posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of sinal TB. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making.

Disseminated coccidioidomycosis of the spine in an immunocompetent patient.

Coccidioidomycosis infections result from inhalation of the dimorphic fungus Coccidiodes immitis. Coccidioidomycosis typically is benign, but its extremely rare disseminated form can result in significant morbidity and mortality. Dissemination of the fungus to the spine is difficult to control and usually requires an aggressive combination approach (surgical/medical). In this article, we report the case of a 27-year-old Indonesian man with vertebral osteomyelitis caused by disseminated coccidioidomycosis. We outline the case management (includes 30-month follow-up) and review the treatment recommendations. The patient presented with an unstable C5 pathologic fracture caused by C immitis. After corpectomy and stabilization of the cervical spine along with antifungal therapy with amphotericin B and oral fluconazole, he developed multiple complications. This case illustrates some of the potential pitfalls in managing spinal osteomyelitis caused by C immitis and the need for continuous medical therapy after surgical treatment.

Is extended antibiotic prophylaxis necessary after penetrating trauma to the thoracolumbar spine with concomitant intraperitoneal injuries?

BACKGROUND: Prolonged courses of broad-spectrum antibiotics are often cited as standard care for the prevention of infectious complications in thoracolumbar or sacral (TLS) fractures following penetrating abdominal trauma. Perforation of a hollow viscus in addition to a TLS fracture is believed to be associated with a high incidence of spine infection. Because over use of antibiotics is associated with an increasing prevalence of multi-drug-resistant organisms, this study seeks to define the actual risk of infection of the spine and need for antibiotics in patients with TLS fractures and intraperitoneal injuries following penetrating trauma. METHODS: A retrospective review of 67 patients with penetrating abdominal trauma and concomitant TLS fracture was performed. Demographics, level of TLS fracture, associated spinal cord injury (SCI), need for operative intervention, presence of concomitant hollow viscus injury, and type and duration of antibiotic coverage were collected. In addition, associated infectious complications were reviewed. Spine infections were defined as spinal or paraspinal abscess, osteomyelitis of the spine, or meningitis. Intraabdominal infections were defined with imaging studies or positive peritoneal cultures. RESULTS: Sixty-seven patients (mean age of 27 ± 9 years) had an exploratory laparotomy and one or more TLS fractures. Four patients died within 24 h and were excluded from further study. Thirty-eight patients (60%) had one or more hollow viscus injuries, 13 (21%) had solid organ injuries alone and 12 (19%) had a non-therapeutic laparotomy. All patients received perioperative antibiotics; 92% received 48 h or less of antibiotic prophylaxis and 62% received only 24 h of antibiotics. In one patient with an isolated solid organ injury there was a spine infection (1%). CONCLUSIONS: In this study, 92% of patients received antibiotics for 48 h or less with no increased incidence of spine infections. Bacterial colonization of the vertebrae was not higher in patients with penetrating gastrointestinal injury. There is insufficient evidence to support the use of prolonged antibiotic prophylaxis to prevent spine infection in patients with penetrating abdominal trauma and TLS fracture.

[Tuberculous spondylitis of vertebra with fracture, paraparesis and pleural empyema complications--case report].

INTRODUCTION: Spine tuberculosis is caused by Micobacterium tuberculosis. It is localized in the vertebral body or intervertebral disc. Its diagnosis is often delayed because of nonspecific symptoms and neglected presence of tuberculosis, which leads to serious complications. CASE REPORT: This paper presents a case of tuberculous spondylitis, which was complicated with the fracture of vertebra, paraparesis of lower extremities and pleural empyema. The treatment with antituberculous drugs started after the fracture of 10th and 11th thoracic vertebras. The therapy brought some improvement but paraparesis of lower extremities remained. In the further course of disease, inflammatory process affected the pleura. Antibiotic and antitubercular therapy with puncture of pleura were not very effective. Operation was performed on December 20th 2011: Thoracotomia lat. dex. Decorticatio pulmonum lat.dex. Seven months after surgery, the patient was without symptoms. CONCLUSION: Tuberculous spondylitis occurs relatively frequently in clinical practice. Early diagnosis and adequate therapy of this disease can prevent the occurrence of its serious complications.

Odontoid process pathologic fracture in spinal tuberculosis.

Craniovertebral junction tuberculosis is a rare lesion in which treatment remains controversial. Options range from conservative treatment to surgery, independently of any associated neurological threat. We here report the first case of pathologic odontoid fracture in a context of spinal tuberculosis, complicated by unusual neurological evolution. The patient presented with non-contiguous multifocal tuberculosis, of which there have previously been only 6 reported cases.

An unusual case of spondylodiscitis.

STUDY DESIGN: A case report of spontaneous pyogenic spondylodiscitis and epidural abscess in vertebral fracture by an uncommon pathogen is described. OBJECTIVE: The uncommon presentation of spondylodiscitis with epidural abscess due to Gemella morbillorum after an acute lumbar vertebral fracture treated conservatively is discussed. SUMMARY OF BACKGROUND DATA: Spontaneous spondylodiscitis and epidural abscess in nonsurgical fractures is exceptionally rare. To date its colonization with Gemella morbillorum is not described in the literature. Its resistance to penicillin is also uncommon. METHODS: Diagnosis was based on clinical history, hemocultures, samples from CT-scan guided punction and, supported by magnetic resonance imaging. RESULTS: Clinical and radiologic improvement were observed after treatment based on a combined specific antimicrobial therapy and surgical drainage of epidural abscess. CONCLUSION: Spondylodiscitis and epidural abscess secondary to an acute nonsurgical vertebral fracture are rare manifestations. Microbiology and MRI are vital components in diagnosis. An emergency decompression and appropriate antibiotic regimen is the solution for a favorable outcome.

An extraordinary cause of vertebral fracture in pregnant woman: brucellosis.

Herein, we report the unique case of Brucella-related lumbar vertebral fracture in a first trimester pregnant woman. The unique effective treatment protocol for the infection is prolonged combined antibiotics and immobilization with follow-up, even in the presence of vertebral fracture related to spinal disease. With the accurate choice of anthiobitics (suitable, non-teratogenic and non-toxic for the fetus) therapeutic abortion is not indicated.

Infected vertebroplasty due to uncommon bacteria solved surgically: a rare and threatening life complication of a common procedure: report of a case and a review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: The aim of this work is to describe a case of infected vertebroplasty due to uncommon bacteria solved surgically with 2 years of follow-up and to discuss 6 other cases found in literature. SUMMARY OF BACKGROUND DATA: Vertebroplasty is a well-known and useful technique for the treatment of painful osteoporotic vertebral fractures. Complications, such as cord or root compression or pulmonary embolisms, are infrequent and are mainly related with the frequent escape of cement throughout the vertebral veins. Infection is even more rare, but when it occurs is difficult to manage and can be a life-threatening complication. METHODS: A 63-year-old-man had a spondylitis of L2 after vertebroplasty. The patient was initially managed with antibiotics without clinical improvement. Surgical treatment by anterior debridement and anterior and posterior stabilization was done. The bacteria isolated from the intraoperative cultures were Serratia marcescens, Stenotrophomonas maltophilia, and Burkholderia cepacia. After surgery, the patient was treated with antibiotics for 3 month. RESULTS: After 2 years of follow-up, the patient was free of pain, without signs of infection, and a correct fusion was achieved. CONCLUSION: When facing an infected vertebroplasty, initial conservative treatment with needle biopsy culture and antibiotic administration are a rational option to start. If this treatment fails, surgical debridement is then indicated in order to remove the infected tissue and the acrylic cement and to stabilize the spine. Although this can be an effective treatment, it could be a difficult and hazardous surgical procedure.

Sacral epidural abscess complicating closed sacral fracture: a case report.

OBJECTIVE: To describe the clinical course of the development of an epidural abscess with a rare localization. SUMMARY OF BACKGROUND DATA: Epidural abscess usually presents with severe back pain and neurologic deterioration. Spinal fracture may lead to the development of epidural abscess. To the author's knowledge, this is the first reported case of epidural abscess following sacral fracture. MATERIALS AND METHODS: The patient was observed closely in the hospital after a sacral fracture with bilateral S2, S3 dermotome numbness. Fever, bacteremia, and urinary tract infection developed. Fever responded partially with antibiotics. RESULTS: Sacral laminectomy for decompression was performed. Unexpectedly, sacral epidural abscess was found during the operation. Sacral roots were decompressed. Epidural abscess was drained. CONCLUSION: A rare case of sacral epidural abscess following sacral fracture was reported.

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'.

STUDY DESIGN: Case reports and survey of literature. OBJECTIVE: Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse. SETTING: Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted. RESULTS: After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated. CONCLUSIONS: Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.

Pyogenic vertebral osteomyelitis presenting as single spinal compression fracture: a case report and review of the literature.

STUDY DESIGN: A case report of pyogenic vertebral osteomyelitis (PVO) presenting as single collapsed vertebral body without narrowing of the intervertebral disc space, and review of the literature. OBJECTIVE: To describe an unusual case of PVO showing atypical radiological change and call attention to this condition so that others may avoid this diagnostic pitfall. SETTING: Japan. METHODS: A 62-year-old diabetic woman with suspected T12 pathological fracture of malignant spinal tumor and neurological involvement received urgent anterior decompression and spinal reconstruction without biopsy. RESULTS: Anterior decompression and spinal reconstruction was performed, but histological examination of the specimen after surgery unexpectedly revealed PVO. The surgery was followed by therapy with antibiotics for 7 months. A follow-up radiograph at 5 years after surgery revealed that solid consolidation has been achieved. CONCLUSIONS: Diagnosis of PVO presenting with single spinal compression fracture is very difficult. Although the finding of the high signal intensity in the lesion equal to or higher than that of the cerebrospinal fluid on T2-weighted MR image seemed to be the most reliable diagnostic modality retrospectively, diagnosis of this type of PVO is impossible without histology. A needle biopsy before surgery is strongly recommended.

[Cold retropharyngeal abscess associated with cervical vertebral tuberculosis]. / Absceso frío retrofaríngeo asociado a tuberculosis vertebral cervical.

A 38-year-old man, parenteral drug user affected by vertebral tuberculosis with involvement of the first, second and third cervical vertebrae associated with a cold retropharyngeal abscess is presented. Treatment and main clinical and histopathologic features of this very unusual location of tuberculosis are discussed.

Osteomyelitis of the spine in a burn patient due to Candida albicans.

A 38-year-old white-skinned male was burned in an ultralight plane crash and sustained a 59 per cent body surface area burn, mostly full thickness skin loss. A fracture of the first lumbar vertebra was noted at admission which was treated without surgery. Candida septicaemia was diagnosed and treated during the acute phase of injury. Extensive grafting was required. Following discharge, the patient began experiencing low-grade back pain which was aggravated on postburn day 277 by a fall down a flight of stairs. Spinal radiographs obtained following this fall revealed osteomyelitis at the level of the eighth and ninth vertebrae with an intervertebral abscess. Following evacuation of the disc space during surgery, the organism was identified as Candida albicans. Treatment with amphotericin B and later fluconazole was initiated. Recovery was uneventful. The infection, probably of a haematogenous origin, is the first such case reported in the literature to our knowledge.