Disseminated actinomycosis with spinal cord compression: report of two cases

Post-traumatic osteomyelitis with spinal epidural abscess of cervical spine in a young man with no predisposing factor

Spinal osteomyelitis with epidural abscess is a rare disease. Most patients have 1 or more predisposing factors, such as impaired immune system secondary to diabetes mellitus, chemotherapy for cancer, immunological compromised disease, and chronic renal or hepatic impairment. We present a case of a physically steady young man without any predisposing risk factor who suffered from cervical osteomyelitis with epidural abscess after neck blunt injury. This patient recovered well after one-stage anterior surgical debridement with implant instrumentation and proper antibiotics treatment. The initial accurate diagnosis rate of spinal epidural abscess is low, even in patients with predisposing factor(s). We present this case to raise the attention of medical staff to this disease in patients with or without any predisposing factor(s) in order to establish early diagnosis and treatment. Our case report also indicates that with adequate debridement and antibiotic coverage, one-stage surgery is a safe and efficacious method to treat patients with cervical spinal epidural abscess.

Thoracic vertebral actinomycosis: Actinomyces israelii and Fusobacterium nucleatum

Actinomyces spp. are considered rare pathogens in today's medicine, especially with thoracic vertebral involvement. Classic actinomycosis (50%) presents as an oral-cervicofacial ("lumpy jaw") infection. This report describes a case of spinal cord compression caused by Actinomyces israelii with the coisolation of Fusobacterium nucleatum. There are limited numbers of similar cases.

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.

[Pelvic pseudotumoral actinomycosis with multisegmental lumbosacral root failure. A case report]

We report a case of pseudotumoral pelvic actinomycosis with lumbosacral spinal involvement in a 21 year-old woman. The radiological work-up showed a pseudotumoral left ovarian lesion extended to sacral spine, which involved the fifth lumbar vertebra. Diagnosis of actinomycosis was established in histopathological examination of the tubo-ovarian mass under laparotomy. After four months of treatment with ofloxacin and rifampicin evolution was marked by improvement of general health and infection, associated to a progressive recovery of motricity of the lower limbs. Early diagnosis of pelvic actinomycosis may prevent the occurrence of rare but severe neurological complications of this disease.

Cervical epidural actinomycosis. Case report

Cervical actinomycosis causing spinal cord compression is a rare clinical entity. In a review of the literature, the authors found only 13 cases with actinomycosis-related spinal neurological deficit. The authors describe the case of a 26-year-old man who presented with neck pain and partial paresis of the upper limbs. Magnetic resonance imaging revealed a long cervical epidural enhancing lesion that extended from C-1 to T-2. The radiological findings resembled metastasis and other epidural infections. The patient was treated medically with penicillin and amoxicillin for 7 months and recovered neurologically. The authors conclude that although cervical epidural actinomycosis is a rare clinical entity resembling metastasis and other infections in this region, it should be considered so that this unique infection can be diagnosed in the least invasive fashion and, whenever possible, unnecessary surgery can be avoided.

[Vertebral actinomycosis with spinal cord compression. A case report]

INTRODUCTION

Vertebral involvement of actinomycosis is extremely rare and associated spinal cord compression is unusual.

EXEGESIS

We report a case of a 31-year-old man with vertebral actinomycosis presenting with spinal cord compression. Magnetic resonance imaging demonstrated a paravertebral abscess and lytic areas on the vertebral body of C5 requiring emergency surgery and antibiotic treatment. The patient was still asymptomatic after 12 months of follow-up.

CONCLUSION

Clinical aspects of this unusual localization are reviewed. Treatment may be particularly difficult.

Cervical actinomycosis causing spinal cord compression and multisegmental root failure: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Epidural invasion and the resulting cord compression are clinical entities not usually associated with actinomycosis, and we found only 11 reported cases of cord compression caused by Actinomyces infection in the literature. Only one reported case was described as actinomycosis with epidural granuloma (14, 16), whereas in the other cases, epidural macroabscess (phlegm) formation caused the symptoms. Histopathological demonstration of the inflammatory granulation tissue and gram-positive sulfur-containing filamentous bacteria are important for the diagnosis of actinomycosis, because the clinical and microbiological studies cannot always demonstrate the causative microorganism and primary infection source.

CLINICAL PRESENTATION

In this article, a case of Actinomyces infection causing cervical cord compression is presented. Precise diagnosis was accomplished using specific histopathological studies of the surgical specimens; such a precise diagnosis cannot always be achieved using preoperative investigations and microbiological studies. The treatment modalities and the patient's outcome are also discussed.

CONCLUSION

As shown by hematoxylin and eosin stain, in contrast to the Nocardia species, Actinomyces filaments histopathologically are basophilic in nature and terminate in eosinophilic clubs as a predictive feature. The clinical and radiological findings closely resemble metastatic tumors and other infectious processes. A differential diagnosis is also emphasized in this article, along with a review of the literature.

Spinal intrathecal actinomycosis: a case report

BACKGROUND

Actinomycosis of the central nervous system is a rare disease that most frequently forms cerebral abscesses. In the present report, we describe an extremely rare case of spinal intrathecal actinomycosis.

CASE PRESENTATION

A 33-year-old man presented with high fever followed by back pain and paraparesis. Magnetic resonance imaging (MRI) with gadolinium-diethylene-triamine penta-acetic acid (Gd-DTPA) enhancement (Gd-MRI) displayed an irregularly enhanced mass lesion at the thoraco-lumbar junction that mimicked an intramedullary tumor with exophytic growth. Surgical exploration 7 months after the onset of the high fever revealed intrathecal granulation tissue with small abscess formation. Another surgical exploration was carried out 2 months after the first operation because the patient developed progressive paraparesis and showed an intrathecal ring-like enhancement that was detected with Gd-MRI. Actinomyces organisms were finally identified histologically in the surgical specimen.

CONCLUSIONS

The clinical course and serial changes of Gd-MRI findings are important considerations when this rare and infectious spinal lesion is suspected.

Spinal abscess and spondylitis due to actinomycosis

STUDY DESIGN

Report of a rare case of spinal actinomycosis in a young immunocompetent woman.

OBJECTIVE

To show the difficulties in diagnosing spinal actinomycosis.

SUMMARY OF BACKGROUND DATA

Spinal actinomycosis is rare and usually occurs as a result of a contiguous (abdominal, pelvic, or thoracic) spread of the infection. This localization represents less than 5% of the infectious sites and was mainly, before the penicillin era, a postmortem discovery.

METHODS

A case is reported of a 34-year-old Algerian woman who had fever, persistent cough, right-side thoracic pain, and progressive severe back pain. Radiographs, computed tomographic scan, and magnetic resonance imaging demonstrated lytic areas on the vertebral bodies of T11 and T12 and a paravertebral mass, without disk involvement. A surgical biopsy of T12 and the paravertebral abscess was performed.

RESULTS

Presence of characteristic sulfur granules and gram-positive filamentous bacteria in surgical biopsy tissues and isolation of Actinobacillus actinomycetemcomitans in cultures led to the diagnosis of vertebral actinomycosis. The patient was virtually free of pain and fever after a 3-month regimen of ofloxacin and rifampicin (Rifadine, Marion-Merell, France) and was without recurrence after 18 months of follow-up.

CONCLUSIONS

Actinomycosis of the spine, caused by the spread of a paraspinal abscess, is extremely rare. The previously poor prognosis has been transformed by antibiotics.

Actinomycosis as a cause of spinal cord compression: a case report and review

A case is presented of a 40-year-old man with rapidly progressing symptoms of thoracic medullary compression, initially thought to be caused by metastatic pulmonary malignancy. Further investigations, however, revealed thoracic actinomycosis spreading to the vertebral column and an actinomycotic epidural granuloma was causing medullary compression. After decompression by laminectomy and antibiotic treatment with penicillin there was some neurological improvement. The condition is rare, and some of the diagnostic difficulties are discussed.

Spinal intrathecal empyema due to Actinomyces israelii

The authors report a case of a spinal intrathecal empyema caused by Actinomyces israelii in a patient who had been diagnosed, four years previously, of a left petrous apex abscess due to an unknown microorganism. The clinical course is outlined and the possibility of both lesions being related is discussed.

Thoracic, abdominal, and vertebral actinomycosis. Diagnosis and long-term therapy in three dogs

The clinical, laboratory, radiographic, and histologic features and the response to therapy in three dogs with actinomycosis are reported. One dog (dog 1) had a 12-cm nonresectable mass extending from the ventrolateral chest wall into the left ventricular myocardium. Another dog (dog 2) had a diffuse peritonitis with "sulfur granules" and two large masses. One of these masses was nonresectable involving adjacent abdominal structures. A third dog (dog 3) had a subvertebral mass at T1-3 producing quadraplegia. Two dogs had periosteal reactions involving adjacent sternebrae (dog 1) or ribs and vertebral bodies (dog 3) that are characteristic of Actinomyces spp infections. In dogs 1 and 2 the diagnosis was based on the morphologic and tinctorial properties of free sulfur granules and/or tissue granules. Culture results were variable. Tissue from dog 1 yielded no growth, while polymicrobial infections, which included Actinomyces spp, were identified in dogs 2 and 3. Actinomyces odontolyticus was isolated from dog 3. Although the actinomycotic granulomas were either not excised or only partially excised from dogs 1 and 2, both animals were cured by the oral administration of high doses of penicillin G for 19 and 6 months, respectively. Dog 3 responded dramatically to the same antibiotic therapy given for 5 months. However, within 4 months of discontinuing treatment an abscess and draining fistulous tracts developed in the left axillary region. Two surgical fistulectomies and additional penicillin therapy were required to cure this animal. These cases and the current veterinary and human literature on actinomycosis are used to propose a rational approach to the treatment of actinomycosis in the dog.

Cervical cord extradural haematoma with familial cutaneous haemangiomas

This case report confirms the link between familial cutaneous haemangiomas and haemangiomas of the spinal extradural space. Haemorrhage from a cervical extradural haemangioma may cause a haematoma resulting in an anterior cord syndrome. Recovery is possible with early diagnosis and surgical decompression at the involved level. If the diagnosis is not made the patient may die from this extradural cervical compression. Diagnosis involves myelography with spinal angiography to confirm the site and extent of both haemangioma and extradural haematoma.

Actinomycotic osteomyelitis of the skull and atlas with late dissemination. A case of transient neurosurgical syndrome

Actinomycosis of the skull and/or the vertebral column is extremely rare in previously healthy children and its diagnosis is difficult. A case is reported here involving the occipital bone and the atlas. The disease had started 4 years before diagnosis and presented as a neurosurgical affection in a 13-year-old-girl. The disease spread towards the retropharyngeal space and probably disseminated to the liver and the lung. Actinomyces israeli grew from cultures. Antibiotic treatment was successful.

Spontaneous spinal epidural hematoma

Spontaneous spinal epidural hemorrhage is a rare emergency. It is characterized by back pain with radicular radiation in the chest and extremities followed by progressive signs of cord compression. The exact etiology is unknown. Presented here is the case of a 34-year-old man who arrived in the emergency department with back pain, followed 20 minutes later by acute paralysis of both legs. Emergency laminectomy revealed an epidural hematoma with compression of the spinal cord. The man was discharged from the hospital seven days post-evacuation of the hematoma with a slightly unsteady but improving gait. The presenting symptoms, etiology, pathophysiology, differential diagnosis, and treatment of this unusual lesion are reviewed.