Spondylodiscitis caused by viridans streptococci: three cases and a review of the literature

Candida spondylodiscitis: a systematic review and meta-analysis of seventy two studies

OBJECTIVES

Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors.

METHODS

A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed.

RESULTS

In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival.

CONCLUSION

Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.

Streptococcus gordonii finger infection: Case report and a review of the literature

RATIONALE

Streptococcus gordonii is a rare cause of finger suppurative infection. Very few cases have been reported of its treatment.

PATIENT CONCERNS

A 68-year-old male of severe finger infection. Bacterial culture of synovial fluid revealed S gordonii.According to the patient's history and auxiliary examination, the patient was diagnosed with S gordonii infection. Here, we review the diagnosis and treatment of this patient and describe the clinical and epidemiological characteristics of the patient.

DIAGNOSES

Streptococcus gordonii finger infection.Interventions: In the case of ineffective oral antibiotics, this patient chose to pursue an abscess incision, but in the course of treatment,the flexor digitorum tendon dissolved and eventually ruptured.

OUTCOMES

The infection was controlled after intravenous injection of vancomycin. The incision was sutured 2 weeks later. No recurrence of infection was found after 3 months of follow-up.

LESSONS

The treatment included antibacterial and abscess treatments. In the absence of drug sensitivity results, antibiotics can be used empirically. If empirical anti-microbial treatment fails, the antibiotic regimen should be changed in a timely manner, Vancomycin may be an antibiotic choice.

Streptococcus sanguinis Endocarditis of Bicuspid Aortic Valve Presenting as Septic Arthritis of Lumbar Facet Joint

Septic arthritis of the facet joint (SAFJ) is an uncommon etiology of low back pain that usually affects the elderly population and immunocompromised patients but is rare in immunocompetent and young patients. When such a clinical presentation occurs, it is imperative to diagnose the source of the infection. We report a case of septic arthritis of the left third and fourth lumbar vertebrae facet joint due to Streptococcus sanguinis in a young immunocompetent adult, and the source of infection was found to be subacute infective endocarditis of a bicuspid aortic valve which was undiagnosed till now. A 49-year-old male presented with new-onset palpitations, dyspnea with exertion, low back pain, night sweats, and chills. A physical exam was significant for spinal tenderness on palpation of the lumbar spine around the L3-L5 level. Blood cultures were positive for Streptococcus sanguinis, and an MRI of the lumbar spine showed left-sided L3-L4 septic arthritis with epidural abscess and posterior paravertebral cellulitis/myositis. Transesophageal echocardiography led to the diagnosis of a bicuspid aortic valve and moderate aortic insufficiency, but it was a cardiac computed tomography that showed a sub-aortic valve abscess leading to the diagnosis of infective endocarditis. He was treated with a six-week course of intravenous antibiotics with complete resolution of symptoms, followed by aortic valve replacement with a mechanical valve. This case report focuses on the importance of diagnosing occult sources in clinically atypical infections, especially when hematogenous seeding is suspected.

Rare Occurrence of Prosthetic Knee Septic Arthritis Due to Streptococcus viridans in the Background of a Dental Procedure

The American Academy of Oral Medicine, American Dental Association (ADA), in conjunction with the American Academy of Orthopedic Surgeons (AAOS) and the British Society for Antimicrobial Chemotherapy, advises against the universal use of antimicrobial prophylaxis prior to dental procedures for the prevention of prosthetic joint infection (PJI). Here, we discuss the case of a patient with PJI in the background of periodontal scaling, which was done a week prior to presentation to the hospital. The PJI occurred with Streptococcus (S.) viridans, a rare organism for PJI but a common oral commensal. As the number of prosthetic joint surgeries are increasing and more data become available, prophylactic antibiotics might be considered to prevent PJI, especially in high-risk patients.

Endocarditis associated with vertebral osteomyelitis and septic arthritis of the axial skeleton

PURPOSE

The relationship between infective endocarditis (IE) and osteoarticular infections (OAIs) are not well known. We aimed to study the characteristics of patients with IE and OAIs, and the interactions between these two infections.

METHODS

An observational study (1993-2014) which includes two cohorts: (1) patients with IE (n = 607) and (2) patients with bacteremic OAIs (n = 458; septic arthritis of peripheral and axial skeleton, and vertebral and peripheral osteomyelitis). These two cohorts were prospectively collected, and we retrospectively reviewed the clinical and microbiological variables.

RESULTS

There were 70 cases of IE with concomitant OAIs, representing 11.5% of IE cases and 15% of bacteremic OAI cases. Among cases with IE, the associated OAIs mainly involved the axial skeleton (n = 54, 77%): 43 were vertebral osteomyelitis (61%), mainly caused by "less virulent" bacteria (viridans and bovis streptococci, enterococci, and coagulase-negative staphylococci), and 15 were septic arthritis of the axial skeleton (21%), which were mainly caused by Staphylococcus aureus. OAIs with involvement of the axial skeleton were associated with IE (adjusted OR = 2.2; 95% CI 1.1-4.3) independently of age, sex, and microorganisms.

CONCLUSIONS

Among patients with IE, the associated OAIs mainly involve the axial skeleton. Transesophageal echocardiography should be carefully considered in patients presenting with these bacteremic OAIs.

Clinical case report: discitis osteomyelitis complicated by inferior vena cava venous thrombosis and septic pulmonary emboli

Viridans group streptococcus is an infrequent cause of osteomyelitis that is found in association with infective endocarditis. Only a few studies report viridans osteomyelitis in the absence of endocarditis. Vertebral pyogenic osteomyelitis can sometimes be complicated by psoas or paraspinal abscesses. These intra-abdominal and/or pelvic collections can very rarely result in venous thrombosis. A paraspinal abscess resulting in inferior vena cava (IVC) thrombosis has only been reported once in the literature. We report a case of a young female with a history of polysubstance abuse and chronic back pain, who was found to have extensive vertebral osteomyelitis and discitis with epidural, paraspinal, and psoas abscesses caused by viridans streptococci. These abscesses compressed on the IVC causing IVC thrombophlebitis extending to the iliac veins distally. Imaging also demonstrated multifocal bilateral septic pulmonary emboli and pleural effusions secondary to septic IVC thrombus; a transesophageal echocardiogram showed no evidence of infective endocarditis.

Atypical presentation of thoracic spondylodiscitis caused by Streptococcus mitis

Spondylodiscitis, which is most commonly caused by Staphylococcus aureus, is an uncommon infection in adults. The diagnosis of spondylodiscitis is often delayed by its vague and non-specific presentations. As part of the normal flora in human mouth and sinuses, Streptococcus mitis is a very rare cause of spondylodiscitis. We report a case of thoracic spondylodiscitis caused by S. mitis in a patient with chronic sinusitis. The patient atypically presented with a sharp chest pain that radiated to the back and the imaging studies were initially negative. He failed outpatient pain management and the diagnosis of spondylodiscitis was confirmed by bone biopsy 6 weeks later. Treatment with antibiotics completely alleviated the pain. Increased awareness and a high index of suspicion are essential for early diagnosis of spondylodiscitis with an atypical presentation.

Streptococcus gordonii septic arthritis: two cases and review of literature

Background

Despite advances in antimicrobial and surgical therapy, septic arthritis remains a rheumatologic emergency that can lead to rapid joint destruction and irreversible loss of function. In adults, Staphylococcus aureus is the most common microorganism isolated from native joints. Streptococcus gordonii is a prominent member of the viridans group of oral bacteria and is among the bacteria most frequently identified as being primary agent of subacute bacterial endocarditis. To the best of our knowledge, Streptococcus gordonii has not yet been described as agent of septic arthritis.

Case Presentation

We describe here two cases of septic arthritis due to Streptococcus gordonii. It gives us an opportunity to review epidemiology, diagnosis criteria and management of septic arthritis.

Conclusion

Although implication of S. gordonii as aetiologic agent of subacute endocarditis is well known, this organism is a rare cause of septic arthritis. In this case, the exclusion of associated endocarditis is warranted.

Actinobacillus endocarditis associated with hypertrophic cardiomyopathy

Infective endocarditis can be associated with complex clinical presentations, sometimes with a difficult multi-disciplinary management. Actinobacillus actinomycetemcomitans belongs to the Haemophilus species, Actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella species group, responsible for 5% to 10% of infective endocarditis in native heart valves. These organisms have slow fastidious growth pattern, often associated with negative cultures, and cause systemic embolism with abscess formation. The authors present the case of a 59-year-old man, admitted due to fever of unknown origin, with a personal history of obstructive hypertrophic cardiomyopathy and recent dental manipulation. The diagnosis of mitral valve's endocarditis was established after a transoesophageal ecocardiography, with a late isolation of A actinomycetemcomitans in blood culture. Despite the institution of antibiotic therapy, the patient suffered from multiple episodes of septic embolism: skin, mucosae, cerebral abscesses, spondylodiscitis and uveitis. He was submitted to heart surgery with miectomy and replacement of the native mitral valve by a mechanical prosthesis, while on antibiotics.

Osteoradionecrosis contains a wide variety of cultivable and non-cultivable bacteria

Background

Direct microscopy, anaerobic culture and DNA–DNA hybridization have previously demonstrated an association between microorganisms and osteoradionecrosis (ORN). The purpose of our study was to use culture independent molecular techniques to detect bacteria in necrotic bone lesions of the mandible after radiation therapy.

Design

Bacterial DNA was extracted from eight deep medullar specimens from resected mandibles (six cases), including one patient with relapse. 16S rRNA genes were PCR amplified, cloned, transformed into Escherichia coli and sequenced to determine species identity and closest relatives.

Results

From the analysis of 438 clones, 59 predominant species were detected, 27% of which have not been cultivated. The predominant species detected from radionecrotic mandibles were Campylobacter gracilis, Streptococcus intermedius, Peptostreptococcus sp. oral clone FG014, uncultured bacterium clone RL178, Fusobacterium nucleatum, and Prevotella spp. The study demonstrated intersubject variability of the bacteria present in ORN. In contrast to the diverse bacterial profile detected in primary infection, only a few members of the oral indigenous flora were identified from the relapse case.

Conclusions

Diverse bacterial profiles in specimens of ORN in marrow spaces of the mandible were detected by culture independent molecular techniques. To better understand the pathogenesis and to improve the therapy of the infection, detection of all members of the complex bacterial flora associated with ORN is necessary.

Comparison of cellular response in bovine intervertebral disc cells and articular chondrocytes: effects .of lipopolysaccharide on proteoglycan metabolism

Lipopolysaccharide (LPS) induces matrix degradation and markedly stimulates the production of several cytokines, i.e., interleukin-1beta, -6, and -10, by disc cells and chondrocytes. We performed a series of experiments to compare cellular responses of cells from the bovine intervertebral disc (nucleus pulposus and annulus fibrosus) and from bovine articular cartilage to LPS. Alginate beads containing cells isolated from bovine intervertebral discs and articular cartilage were cultured with or without LPS in the presence of 10% fetal bovine serum. The DNA content and the rate of proteoglycan synthesis and degradation were determined. In articular chondrocytes, LPS strongly suppressed cell proliferation and proteoglycan synthesis in a dose-dependent manner and stimulated proteoglycan degradation. Compared with articular chondrocytes, nucleus pulposus cells responded in a similar, although less pronounced manner. However, treatment of annulus fibrosus cells with LPS showed no significant effects on proteoglycan synthesis or degradation. A slight, but statistically significant, inhibition of cell proliferation was observed at high concentrations of LPS in annulus fibrosus cells. Thus, LPS suppressed proteoglycan synthesis and stimulated proteoglycan degradation by articular chondrocytes and nucleus pulposus cells. The effects of LPS on annulus fibrosus cells were minor compared with those on the other two cell types. The dissimilar effects of LPS on the various cell types suggest metabolic differences between these cells and may further indicate a divergence in pathways of LPS signaling and a differential sensitivity to exogenous stimuli such as LPS.

Clinical assessment and medical treatment of spine infections

Spinal infections affect the vertebral bodies, the intervertebral disks, the spinal canal, and the paravertebral soft tissues and structures. A delay in diagnosis can result in spine deformity, substantial neurologic complications, and even death. Because of this, a high level of awareness is required by physicians in order to diagnose infections of the spine promptly. Advances in medical microbiologic testing and newer imaging methods have contributed considerably to the medical treatment of these infections. Through careful followup, less invasive approaches orchestrated by a multidisciplinary team that includes a spine surgeon, an infectious diseases specialist, and a neuroradiologist may be sufficient to treat patients with these infections. Research done through multidisciplinary collaborations will further advance our knowledge for the successful treatment of spinal infections.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Acute septic arthritis due to Streptococcus sanguis

OBJECTIVE

To present a case of acute septic arthritis due to Streptococcussanguis, a member of the viridans group streptococci.

CLINICAL PRESENTATION AND INTERVENTION

A 73-year-old woman presented with fever and increasing swelling and pain of the right knee several weeks after she had been treated for severe periodontal disease. Arthrocentesis yielded purulent synovial fluid. S. sanguis was isolated in synovial fluid cultures, and the patient was treated with intravenous cefotaxime for 3 weeks and repeated aspiration of the knee joint with gradual resolution of fever, joint swelling and effusion.

CONCLUSION

Although S. sanguis is believed to be a rare cause of septic arthritis in native joints, it should be considered in the differential diagnosis of this disorder, especially in patients with recent treatment of severe dental caries and periodontal disease.

Spontaneous corynebacterium discitis in a patient with chronic renal failure

STUDY DESIGN

Case report describing spontaneous Corynebacterium diptheria discitis in a patient with chronic renal failure.

OBJECTIVES

To describe this very rare form of discitis and the results of surgical and antibiotic therapy.

SETTING

University Department of Neurosurgery, Turkey.

CASE REPORT

A 55-year-old man with chronic renal failure presented with acute low-back pain. Lumbar magnetic resonance imaging (MRI) suggested discitis and osteomyelitis at the L5-S1 level. The L5-S1 disc was operated upon and the discectomy material was sent for pathological and microbiological analysis.

RESULTS

Pathological examination revealed infection and bacterial culture grew C. diptheria. The patient was prescribed combination antibiotic therapy with vancomycin, a third-generation cephalosporin, and rifampicin. Clinical status improved after 8 weeks of therapy. Lumbar MRI revealed remission of the discitis and osteomyelitis after 10 months of follow-up.

CONCLUSION

Chronic renal failure patients with low-back pain should be investigated for spinal infection. These individuals are prone to low-grade infection in the form of discitis or osteomyelitis. Corynebacterium subspecies rarely cause spontaneous discitis. This case is interesting because of the unusual causal organism and the occurrence of discitis in the setting of chronic renal failure.

Septic arthritis due to Streptococcus sanguis

We report an unusual case of septic arthritis due to Streptococcus sanguis, a member of the viridans group of streptococci that are part of the normal flora of the mouth and upper respiratory tract. Our patient had severe underlying periodontal disease, which likely contributed to his joint sepsis through hematogenous spread. Although viridans streptococci are rare causes of septic arthritis in native joints, they should be considered in the setting of severe periodontal disease.

Questioning the Sensitivity of Magnetic Resonance Imaging in Early Septic Spondylodiscitis

Septic spondylodiscitis is an uncommon disease, but one with serious complications and potentially high morbidity and mortality. The diagnosis is sometimes delayed, particularly in those patients with an insidious mode of onset and nonspecific symptoms. Several imaging methods are available to facilitate the early diagnosis of septic spondylodiscitis, and of these methods magnetic resonance imaging (MRI) has been reported to be the most sensitive, revealing abnormalities earlier than plain x-ray, gallium scan and bone scan. We report a case of septic spondylodiscitis in which MRI did not demonstrate evidence of discitis after a symptom period of seven days. The diagnosis was later confirmed by bone scan and repeat MRI. We suggest that a negative or equivocal MRI cannot exclude infective spondylodiscitis, especially in the early stages of the disease process. In such cases, it is important to note that the addition of a short tau-inversion recovery sequence will increase the sensitivity of MRI, and, additionally, gadolinium should be administered if the magnetic resonance study is negative and a strong clinical suspicion of spondylodiscitis exists.