-2 :: Case - 14169 :: - Vertebral osteomyelitis and diskitis with presacral abscess
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Tx and Followup:
She was initially treated with broad spectrum antibiotics which consisted of Ciprofloxacin 400mg IV q12 Vancomycin 1000mg q12 Metronidazole 500mg IV q6. She had drainage and culture of the abscess by Interventional Radiology, were they removed 60 ml of purulent fluid. Pt culture grew Fusobacterium species so her antibiotics were switched to ertapenem 1gm IV daily.

She was discharged from the hospital with a PICC line to continue IV antibiotics for 6 weeks; and, with a drain tube in place per IR recommendation. The drain was removed two weeks later. Pt also had a TEE because of her new murmur, which was negative.

Additional Discussion:
This case is unique because of the bacterial cause of her osteomyelitis. Patients abscess was cultured and shown to grow Fusobacterium spp. Fusobacterium is a Gram-negative, nonmotile non-sporeforming, obligate anaerobic rods belonging to the family Bacteroidacecae. According to some journals there has been only 12 cases of Fusobacteria causing diskitis in medical literature. Factors associated with fusobacterial infection include disruption of the normal cutaneous and mucocutaneous barriers, tissue injury, and impaired blood supply leading to hypoxia. A previous ear–nose–throat (ENT) infection or maxillofacial problem was found in the majority of the patients (n=8, 73%) without any other identified portal of entry. This pt did not have any oral associated procedures or infection but she did have shoulder surgery which during anesthesia may have disrupted normal mucocutaneous barrier. Pt did also complain of mild back pain before her shoulder surgery. The clinical and radiological presentations for osteomyletis caused by Fusobacterium include localized pain and classical signs of vertebral osteomyelitis. Back pain and fever were present for a majority of patients (n=10, 91%). Back pain was present in our pt and at least one episode of fever along with radicular pain. Thirty years ago, almost all Fusobacteria were susceptible to metronidazole, penicillin G, clindamycin, cefoxitin, chloramphenicol but were resistant to vancomycin, aminoglycosid and erythromycin. Recently, increasing numbers of strains have been found to be resistant to some of these drugs, in particular to B-lactam by enzymatic production. Fusobacteria vertebral osteomylitis does not seem to increase the length of antiobiotic treatment. Fusobacteria species causing vertebral osteomyelitis seems to be extremely uncommon. Nevertheless the diagnosis might be underestimated because of difficulties to isolate these bacteria. These bacteria should be considered when the infection does not respond to standard therapy.

Reference:

1.   Le Moal G, Juhel L, Grollier G, Godet C, Azais I, Roblot F. Vertebral osteomyelitis due to Fusobacterium species: report of three cases and review of the literature. Journal of Infection. 2005 Aug;51(2):E5-9.

2.   Bennett KW, Eley A. Fusobacteria: new taxonomy and related diseases. J Med Microbiol 1993;39:246–54.

3.   Rubin MM, Sanfilippo RJ, Sadoff RS. Vertebral osteomyelitis secondary to an oral infection. J Oral Maxillofac Surg 1991; 49:897–900

Discussion Author: Pil Kang

Diskitis is an inflammatory process of the intervertebral disk that is more common in children than in adults. There is a bimodal age distribution, with peaks at 0.5-4.0 years and 10-14years. There is a 2:1 predominance in girls. Lumbar spine is the most commonly affected area.

The pathogenesis is not completely understood, however this entity is thought to be due to the different vascularity of the intervertebral disk space and the vertebral bodies that children have in comparison with the adults. The additional vascular channels connecting the vertebral metaphyses and the intervertebral disks allow infectious and inflammatory processes to spread more readily.

Patients usually present with low-grade fever, back pain, and unable/refusal to bear weight. White blood cell count and erythrocyte sedimentation rate may be elevated. Most common organism is S. aureus; however, blood cultures and biopsy cultures are positive in only 50-60% of the time.

Plain radiographs may be entirely normal or demonstrate subtle paravertebral soft tissue swelling in the first few days. Disk space narrowing may be seen in 7-10 days. After weeks, erosion and destruction of the vertebral end plates may be seen, along with new bone formation. At this stage, the diskitis has firmly converted into an osteomyelitis of the surrounding vertebral bodies.

Bone scintigraphy alone or combined with either indium-111 or gallium-67 imaging has the advantage of being positive earlier in the course of the disease. The characteristic finding is the increased in radiotracer uptake in the disk space and either the surrounding end plates or the entire adjacent vertebral body in both flow, blood pool, and delayed phases, with corresponding increase in activity in the In-111 or the Ga-67 images.

MR imaging is the modality of choice, with sensitivity and specificity of 96% and 93% respectively. Decreased disk space height is seen on all sequences. On T1-weighted images, the affected vertebral body and disk demonstrate low signal intensity with loss of distinction at their margins. On T2/STIR images, the affected disks appear hypointense and flattened, with increased signal at the adjacent vertebral body end plate. With gadolinium administration T1 images, areas of active inflammation in both the vertebral body and disk show enhancement. MR has another advantage in that the presence of any epidural and/or paraspinal abscess can be assessed.

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