Espondilodiscite em idade pediátrica ­ uma doença rara, um diagnóstico difícil / Spondylodiscitis in pediatric age ­ a rare disease, a difficult diagnosis

Introdução e objetivo: a espondilodiscite é a infeção que atinge o disco intervertebral e as vértebras contíguas e representa dois a quatro % do total das infeções osteoarticulares em idade pediátrica. O agente patogénico é identificado em cerca de metade dos casos, sendo o Staphylococcus aureus o mais frequentemente isolado. Estudos recentes demonstram que entre os seis meses e os quatro anos a Kingella kingae tem um papel etiológico importante. O objetivo da exposição deste caso clínico foi chamar atenção para esta patologia rara cujo diagnóstico é difícil e exige um elevado nível de suspeição. Descrição do caso: criança de 16 meses, sexo masculino, com antecedentes de obstipação, é trazida múltiplas vezes à Urgência Pediátrica por quadro com mais de um mês de evolução de irritabilidade persistente, dor abdominal e recusa da marcha de agravamento progressivo. Na segunda vinda à Urgência Pediátrica apresentava dorsolombalgia à palpação da coluna dorsolombar e diminuição da lordose lombar, o que motivou a realização de avaliação analítica, sumária de urina, ecografia renal e vesical e radiografia dorsolombar sem alterações. Na terceira vinda à Urgência Pediátrica foi decidido internamento e solicitada ressonância magnética nuclear dorsolombar e cintigrafia óssea que revelaram espondilodiscite em D7-D8. Parâmetros analíticos sem alterações valorizáveis, exceto discreta elevação da velocidade de sedimentação. Hemoculturas e restante estudo etiológico negativo. Iniciou terapêutica endovenosa com cefu-roxime e flucloxacilina, com melhoria progressiva das queixas álgicas. Aquando da alta, assintomático, mantendo flucloxacilina oral até completar seis semanas de tratamento. Reavaliado posteriormente, encontrando-se assintomático, com um exame físico, reavaliação analítica e radiografia dorsolombar sem alterações. Conclusões: a espondilodiscite é uma identidade de difícil diagnóstico, especialmente na criança, devido à sua raridade, clínica inespecífica, impossibilidade de as crianças verbalizarem os seus sintomas e aos sinais radiológicos tardios, requerendo um alto índice de suspeição. O intervalo médio de tempo entre o início dos sintomas e o diagnóstico é de três semanas a três meses. A ressonância magnética é o exame de escolha. As hemoculturas são, muitas vezes, negativas. O pilar do tratamento é a antibioterapia por várias semanas, mas a sua escolha e duração são controversas. O tratamento inadequado pode originar dor crônica, sequelas ortopédicas graves e complicações neurológicas devastadoras. Quando atempada e adequadamente tratada, a maioria dos casos apresenta uma evolução clínica benigna e autolimitada.

Introduction and objective: spondylodiscitis is an infection that affects the intervertebral disc and the contiguous vertebrae. It represents two to four % of all osteoarticular infections in pediatric age. The pathogen is identified in about half of the cases, with Staphylococcus aureus being the most frequently isolated. Recent studies show that between six months and four years, Kingella kingaehas an important etiological role. The purpose of the presentation of this clinical case was to draw attention to this rare pathology whose diagnosis is difficult and requires a high level of suspicion. Clinical case description: a sixteen-month-old male, with a history of constipation, is brought multiple times to the Pediatric Emergency Department for a clinical picture with more than a month of evolution of persistent irritability, abdominal pain and refusal to walk, with progressive worsening. On the second visit to the Pediatric Emergency Department, he presented dorsolombalgia on palpation of the dorsolumbar spine and decreased lumbar lordosis, which led to the performance of analytical evaluation, urinalysis, renal and bladder ultrasound and dorsolumbar radiography, all without changes. On the third visit to the Pediatric Emergency Department, hospitalization was decided and dorsolumbar nuclear magnetic resonance and bone scintigraphy were requested, revealing spondylodiscitis in D7-D8. Analytical parameters had no changes, except for a slight increase in erythrocyte sedimentation rate. Blood cultures and remaining etiological study negatives. Intravenous therapy with cefuroxime and flucloxacillin was started with progressive improvement of pain. Upon discharge he was asymptomatic and maintained oral flucloxacillin until a total of six weeks of treatment. He was subsequently reassessed and remained asymptomatic, with a physical examination, analytical evaluation and dorsolumbar radiography without changes. Conclusions: spondylodiscitis is an identity that is difficult to diagnose, especially in children, due to its rarity, unspecific clinic, inability for children to verbalize their symptoms and late radiologic signs, requiring a high index of suspicion. The average time between the onset of symptoms and the diagnosis is three weeks to three months. Magnetic resonance imaging is the exam of choice. Blood cultures are often negative. The mainstay of treatment is antibiotic therapy for several weeks, but its choice and duration are controversial. Inappropriate treatment can lead to chronic pain, severe orthopaedic sequelae and devastating neurological complications. When timely and properly treated, most cases have a benign and self-limited clinical course.

Espondilodiscitis: experiencia clínica en un hospital general de Chile / Spondylodiscitis: clinical experience in a Chilean general hospital

Introducción: La espondilodiscitis (ED) implica prolongados períodos de hospitalización, de latencia diagnóstica y riesgo de complicaciones a largo plazo. No existen publicaciones recientes en Chile al respecto. Objetivos: Caracterizar un grupo de pacientes con ED. Pacientes y Métodos: Serie clínica, que incluyó pacientes en un período de ocho años. Resultados: 37 pacientes, 37,8% mujeres y 62,2% hombres, con promedio etario 66,8 años; 64,9% adultos mayores, 35,1% diabéticos y 21,6% con co-morbilidad urológica. Los principales síntomas fueron dolor y fiebre. 89,2% tuvo elevación de VHS. 86,5% contó con resonancia magnética, que siempre fue confirmatoria, siendo la columna lumbar la localización más frecuente (43,2%). Se identificó etiología en 28/37 pacientes: en 71,4% cocáceas grampositivas (Staphylococcus aureus predominantemente), sólo en 10,7% M. tuberculosis. Staphylococcus aureus estuvo asociado a co-morbilidades médicas en forma significativa (p < 0,05) y el grupo de bacilos gramnegativos a historia hepatobiliar y/o intestinal (p < 0,05). El método de mayor rendimiento fue el cultivo obtenido por punción quirúrgica. El tratamiento antimicrobiano fue indicado en promedio por 63,8 días (IQR 53-72), con reacciones adversas en 18,9%. La estadía hospitalaria fue 38,9 días promedio, no existiendo fallecidos durante este período. 18,9% presentó secuelas motoras. Discusión: La mayoría de pacientes con ED correspondió a adultos mayores, siendo S. aureus la principal etiología. Hubo una baja frecuencia de M. tuberculosis. Resultó considerable la magnitud de efectos adversos asociados a la terapia antimicrobiana y las complicaciones neurológicas.

Background: Spondylodiscitis (SD) involves long periods of hospitalization, diagnostic latency and risk of long-term complications. No updated series are available in Chile and a change in demographic features and etiology is suspected. Aim: To characterize a group of patients with SD. Patients and Methods: Clinical series including patients over an 8 year period. Results: We identified 37 patients; 37.8% women and 62.2% men (mean age 66.8 years); 64.9% were elderly; 35.1% had diabetes and 21.6% urological comorbidity. Main symptoms were pain and fever. Erythrocyte sedimentation rate was elevated in 89.2%, and 86.5% patients had MRI, which was always confirmatory. Lumbar spine was the most common site of infection (43.2%). Etiology was identified in 28/37 patients: 71.4% yielded grampositive cocci (Staphylococcus aureus predominantly), Mycobacterium tuberculosis was identified in only 10.7%. Staphylococcus aureus was associated to medical comorbidities (p < 0,05) and gramnegative bacilli to hepatobiliar or intestinal symptoms (p < 0,05). Culture obtained by a surgical procedure had the highest yield. The average duration of antibiotic therapy was 63.8 days (IQR 53-72). Treatment-related side effects were detected in 18.9% of patients. The average hospital stay was 38.9 days. No deaths occurred during hospitalization. Motor sequelae were present in 18.9% of this series. Discussion: Most patients with SD were older adults. Staphylococcus aureus was predominant and M. tuberculosis was uncommon. Antibiotic side effects were relevant as well as the neurological complications.

Absceso del psoas como presentación de tuberculosis vertebral: reporte de un caso / Psoas abscess as spinal tuberculosis presentation: case report

Introducción: El absceso del psoas es un cuadro infrecuente cuyo principal agente etiológico es el Staphyloccocus aureus, y que con baja frecuencia puede ser de etiología tuberculosa como complicación de una afección vertebral por Mycobacterium tuberculosis. Presentación del caso: Mujer de 58 años, mapuche, con antecedentes de enfermedad pulmonar obstructiva crónica y alcoholismo crónico, consultó por cuadro de dos meses de evolución de dolor lumbar, baja de peso y paresia de extremidad inferior derecha que impedía la marcha. Tomografía computada (TC) de columna evidenció espondilodiscitis y absceso del psoas derecho, iniciándose tratamiento antibiótico cubriendo Staphyloccocus aureus. Los hemocultivos y los cultivos de la colección resultaron negativos por lo que se decidió mantener tratamiento ambulatorio. Paciente consultó cuatro meses después por exacerbación de su disnea basal de dos semanas de evolución, radiografía de tórax y TC de tórax de alta resolución compatibles con tuberculosis pulmonar con diseminación miliar bilateral, por lo cual, se inició tratamiento antituberculoso, realizándose baciloscopías que resultaron negativas. Además, se solicitó identificación del bacilo de Koch mediante reacción de polimerasa en cadena que resultó positiva, con lo que se confirmó el diagnóstico de tuberculosis miliar y mal de Pott. Se decidió reevaluar con TC de columna una vez finalizado el tratamiento antituberculoso para decidir conducta quirúrgica. Discusión: Es importante la sospecha activa de etiología tuberculosa ante una espondilodiscitis y un absceso del psoas, pese a su baja frecuencia. El inicio del tratamiento en forma precoz puede modificar la progresión de una infección que puede ser invalidante e incluso mortal.

Introduction: The Psoas abscess is an infrecuent condition which main ethiology is the Staphyloccocus aureus and with less frequency can be a vertebral tuberculosis complication caused by Mycobacterium tuberculosis. Case Report: a 58 years old female, Mapuche, with Chronic Obstructive Pulmonar Disease and chronic alcoholism antecedents, was admitted in the emergency room with a two month old lumbar pain, loss of weight and right inferior extremity paresia which didn't allowed her to walk. The column's Computed Tomography (CT) showed spondylodiscitis and a right psoas abscess, the antibiotherapy, covering Staphyloccocus aureus, was started. The hemoculives and abscess' cultives were negative, so it was decided to continue with ambulatory treatment. The patient was admitted four month later because of two weeks of exacerbation of her basal dysnea. The thorax Radiography and high resolution CT were compatibles with pulmonary tuberculosis with bilateral miliar disemination. Antituberculosis treatment was started, bacilloscopies were negative, also, a Polymerase Chain Reaction identification of Koch's bacillus was performed, resulting positive, confirming the diagnosis of miliar tuberculosis and Pott's disease. Once antituberculosis treatment was finished, a new column's CT was requested to decided surgical conduct. Discussion: Is important to actively suspect of tuberculosis ethiology in presence of spondylodiscitis and psoas abscess, despite it's low frequency. The early treatment start may modify the progresion of an infección that can be invalidating and even mortal.

Espondilodiscitis: análisis de 19 casos internados en un hospital de tercer nivel / Spondylodiscitis: analiysis of 19 inpatients at a referral hospital in Rosario, Argentina

Introducción: la espondilitis representa un desafío diagnóstico, ya que el dolor lumbar, su principal manifestación clínica, constituyeun motivo de consulta muy frecuente en la práctica cotidiana y carece de especificidad. Por lo tanto, resulta indispensablemantener una elevada sospecha clínica. Objetivo: Analizar las características clínicas, analíticas, microbiológicas e imagenológicas,el tratamiento, la evolución y los factores pronósticos de pacientes internados por espondilodiscitis en el Hospital Provincial delCentenario, desde enero de 2011 a marzo de 2015, excluyéndose los casos postquirúrquicos. Resultados: Se analizaron 19 pacientescon una edad media 48±11 años, 63% varones. Se identificaron como comorbilidades: diabetes (37%), obesidad (16%), etilismo(21%), insuficiencia renal crónica en hemodiálisis (16%), HIV (11%), adicción EV (11%). Los gérmenes más frecuentes fueron losestafilococos (52%). Al ingreso el 94% presentó dolor, 73% fiebre y 36% foco neurológico. La media de tiempo de evolución desíntomas hasta ingreso fue 62±80 días (rango 4-360 días). La velocidad de eritrosedimentación fue elevada en todos los pacientes,y sólo 37% presentaban leucocitosis. La vancomicina fue el antibiótico más utilizado. El 37% de los pacientes presentaba infeccióndiseminada. La mortalidad fue del 26%. Los pacientes que tuvieron un tiempo de evolución al ingreso mayor a 25 días presentaronpeor evolución (colecciones, foco neurológico o muerte) (p<0,05). Conclusiones: en esta serie, la asociación de la consulta tardíacon la mala evolución destaca la importancia de considerar las pautas de alarma en centros de atención primaria para posibilitar undiagnóstico más temprano.

Introduction: Spondylodiscitis represents a diagnostic challenge since the main clinical manifestation, low back pain, is very frequent andnonspecific, and often impedes a timely diagnosis. Clinical suspicion is essential. Objective: to analyze the clinical, analytical, microbiological,and radiological features, as well as outcome and prognostics factors, in patients with spondylodiscitis admitted to the Hospital Provincialdel Centenario (Rosario, Argentina), from January 2011 to March 2015. Postsurgical cases were excluded. Results: Nineteen patients wereincluded. Mean age was 48±11 years, 63% were males. We identified the following comorbid diseases: diabetes (37%), obesity (16%),alcoholism (21%), hemodialysis-dependent chronic kidney disease (16%), HIV (11%), intravenous drug abuse (11%). The most frequentcausative organism was Staphylococcus sp. (52%). Upon admission 94% of patients presented pain, 73% fever, and 36% neurologicalinvolvement. The average time from the onset of symptoms to diagnosis was 62±80 days (range 4-360). The erythrocyte sedimentation ratewas raised in all the patients, and only 37% had leukocytosis. Vancomycin was the most frequently prescribed antibiotic. Disseminatedinfection was present in 37% of patients. The mortality rate was 26%. Patients with a time lag to diagnosis higher than 25 days had worseoutcome (suppurative collections, neurological involvement, or death) compared to those with earlier diagnosis (p <0.05). Conclusions:The association of late consultation with poor outcome in this study emphasizes the importance of educating the general population toencourage attendance to medical centers. Physicians in primary care settings must be trained to identify pain pattern, and incorporateclinical perspectives capable of recognizing a defined syndrome at first contact, in other to achieve a better outcome.Key words: Spondylodiscitis, comorbid conditions, diagnostic delay, outcome.

Espondilodiscite espontânea – sempre uma dificuldade etiológica / Spontaneous spondylodiscitis - always an etiological Struggle

Espondilodiscite é uma enfermidade incomum no adulto 1-6, associada ao risco aumentado de morbidade e mortalidadedevido à dificuldade diagnóstica, com aumento de incidência na infância e na fase adulta, representando de 2 a 4% dos casos deosteomielite2-4 e até 15% de todos os casos de infecção da coluna vertebral. Insuficiência renal crônica em paciente realizandohemodiálise, diabetes melitus, obesidade (principalmente IMC >30), etilismo crônico, uso de drogas injetáveis, neoplasias ouqualquer outro fator imunossupressor aumentam os riscos de desenvolver a doença. Entre os principais patógenos piogênicos,o Staphilococos aureus é o mais frequente. Nas formas de apresentação granulomatosa, o Mycobacterium tuberculosis é omais frequente, seguido de Brucella millitensis (em regiões endêmicas), espiroquetas e fungos2,4. Os exames de imagem ajudamna formulação do diagnóstico etiológico2,3,4, sendo a ressonância nuclear magnética o exame mais sensível. Antibioticoterapiadirecionada ao patógeno encontrado é o tratamento de escolha. Relatamos o caso de um paciente internado com quadro deparaparesia crural (FMG II) secundária a discite D7/D8 que foi submetido à descompressão cirúrgica da medula e artrodeseantero-lateral. Houve controle da doença com uso de esquema antibiótico clindamicina/ciprofloxacino por 12 semanas.

Espondilodiscite e endocardite bacteriana: relato de caso / Spondylodiscytis and bacterial endocarditis: case report

JUSTIFICATIVA E OBJETIVOS: A espondilodiscite é uma entidade clínica de difícil diagnóstico devido à clínica inespecífica e sinais radiológicos tardios. O objetivo deste estudo foi relatar um caso de espondilodiscite secundária à endocardite bacteriana por Staphylococcus aureus, adquirido na comunidade. RELATO DO CASO: Paciente do sexo feminino, 79 anos, branca, casada, procedente de Santa Cruz do Sul, RS, em tratamento regular de diabetes mellitus tipo 2 e hipertensão arterial sistêmica. Iniciou com piora de dor lombar crônica e dificuldade para deambular. Os exames de imagem demonstravam lesão lítica de vértebras lombares que após investigação foi definida como espondilodiscite decorrente de endocardite bacteriana. CONCLUSÃO: A endocardite infecciosa, em consequência da gravidade, deverá fazer parte do diagnóstico diferencial de doenças causadas por provável disseminação hematogênica, especialmente, em pacientes que apresentam condições que aumentam o risco de endocardite, como prolapso de valva mitral, doença valvar degenerativa e uso de fármacos por via venosa.

BACKGROUND AND OBJECTIVES: Spondylodiscitis is a clinical entity difficult to diagnose because of nonspecific clinical and radiologics signs late. The aim was to report a case of spondylodiscitis secondary to bacterial endocarditis caused by Staphylococcus aureus, community-acquired. CASE REPORT: Female patient, 79 years old, white, married, resident of Santa Cruz do Sul, RS, regular treatment of type 2 diabetes mellitus and hypertension. Began with worsening of chronicback pain and difficulty in walking. Imaging tests showed osteolytic lesion of the lumbar vertebrae that after investigation it was defined to be due to complication of bacterial endocarditis. CONCLUSION: Infective endocarditis should be part of the differential diagnosis of disease caused by probable hematogenous dissemination, especially in patients who have conditions increase the risk of endocarditis, such as mitral valve prolapsed,valve heart disease degenerative and intravenous drug use.