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.
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 earâ€“noseâ€“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.
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;39:246â€“54.
3. Rubin MM, Sanfilippo RJ, Sadoff RS. Vertebral osteomyelitis secondary to an oral infection. J Oral Maxillofac Surg 1991; 49:897â€“900