A travel-loving woman in her eighties with lower back pain and weight loss

BACKGROUND

This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding.

CASE PRESENTATION

A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis.

INTERPRETATION

An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

Is the discopathy associated with Modic changes an infectious process? Results from a prospective monocenter study

BACKGROUND

The local infectious origin and the putative role of Cutibacterium acnes (CA) of a particular subtype of discopathy (Modic 1) are still debated.

PURPOSE

To establish the association of CA in intervertebral disc (IVD) and Modic 1 discopathy in patients with low back pain.

METHODS

The prevalence of bacteria in IVD samples obtained by anterior approach in patient with chronic low back pain harboring Modic type 1, 2 or no Modic changes was compared to that measured in IVD samples obtained by posterior approach for sciatica. From 45 patients included in the study, 77 discs samples were obtained: 58 by anterior approach (32 Modic 1/2 changes, 26 without Modic change) and 19 by posterior approach. Conventional microbial cultures, universal 16S rRNA molecular detection and a CA specific PCR were performed.

RESULTS

12 /77 (15.6%) disc samples were culture positive. Among the 10 CA positive cultures, 5 out of 58 (8.6%) were identified from specimens obtained by anterior approach and 5/19 (26.3%) from posterior approach (p = 0.046). Moreover, the percentage of CA culture positive sample was statistically no different between the patient with or without Modic changes. The CA prevalence was lower through molecular, culture-free approaches: the universal 16S rRNA PCR was positive for 6 specimens, including one CA positive sample and the CA specific PCR was positive for one specimen obtained by posterior approach.

CONCLUSIONS

In spine surgery the prevalence of CA in culture was significantly higher in IVD samples collected through a posterior approach compared to an anterior approach, suggesting a contamination process. This study did not support the CA related local infectious origin of Modic 1 discopathy.

Unilateral Septic Arthritis of a Lumbar Facet Joint Secondary to Acupuncture Treatment - a Case Report

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.

Importance of Propionibacterium acnes hemolytic activity in human intervertebral discs: A microbiological study

Most patients with chronic lower back pain (CLBP) exhibit degenerative disc disease. Disc specimens obtained during initial therapeutic discectomies are often infected/colonized with Propionibacterium acnes, a Gram-positive commensal of the human skin. Although pain associated with infection is typically ascribed to the body's inflammatory response, the Gram-positive bacterium Staphylococcus aureus was recently observed to directly activate nociceptors by secreting pore-forming α-hemolysins that disrupt neuronal cell membranes. The hemolytic activity of P. acnes in cultured disc specimens obtained during routine therapeutic discectomies was assessed through incubation on sheep-blood agar. The β-hemolysis pattern displayed by P. acnes on sheep-blood agar was variable and phylogroup-dependent. Their molecular phylogroups were correlated with their hemolytic patterns. Our findings raise the possibility that pore-forming proteins contribute to the pathogenesis and/or symptomology of chronic P. acnes disc infections and CLBP, at least in a subset of cases.

Propionibacterium acnes induces discogenic low back pain via stimulating nucleus pulposus cells to secrete pro-algesic factor of IL-8/CINC-1 through TLR2-NF-κB p65 pathway

Latent infection of Propionibacterium acnes was considered as a new pathogeny for low back pain (LBP); however, there is no credible animal evidence or mechanism hypothesis. This study proved that P. acnes is a causative pathogen of bacteria-induced LBP and investigated its underlying mechanism. For this, P. acnes was firstly identified in patients' degenerated intervertebral disc (IVDs) samples. The results of patients' Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Japanese Orthopaedic Association (JOA), and Oswestry Disability Index (ODI) scores indicated that P. acnes-positive patients showed more severe LBP and physical disability. Then, a P. acnes-inoculated lumbar IVDs model was established in rats. The results of paw/foot withdrawal threshold and qRT-PCR indicated that P. acnes-inoculated rats had obvious LBP in behavioral evaluation and over-expression of substance P (SP) and calcitonin gene-related peptide (CGRP) in IVDs. Subsequently, enzyme-linked immunosorbent assay (ELISA) results demonstrated that increased expression of IL-8 or CINC-1 (the homolog of IL-8 in rats) in the P. acnes-positive IVDs of human and rats. The CINC-1 injected animal model proved that the cytokines were able to induce LBP. Finally, the co-culture experiments showed that nucleus pulposus cells (NPCs) were able to respond to P. acnes and secreted IL-8/CINC-1 via TLR-2/NF-κB p65 pathway. In conclusion, P. acnes had strong association with LBP by stimulating NPCs to secrete pro-algesic factor of IL-8/CINC-1 via TLR2/NF-κBp65 pathway. The finding may provide a promising alternative therapy strategy for LBP in clinical. KEY MESSAGES: Patients with P. acnes-positive IVDs tended to have more severe LBP, physical disability, and increased IL-8 expressions. P. acnes can induce LBP via IL-8/CINC-1 in IVDs. P. acnes stimulate the NPCs to secrete pro-algesic factor of IL-8/CINC-1 via TLR2/NF-κBp65 pathway.

Vertebral Osteomyelitis Caused by Helicobacter cinaedi Identified Using Broad-range Polymerase Chain Reaction with Sequencing of the Biopsied Specimen

A 65-year-old man presented with gradually exacerbating low back pain. Magnetic resonance imaging revealed vertebral osteomyelitis in the Th11-L2 vertebral bodies and discs. The patient showed negative findings on conventional cultures. Direct broad-range polymerase chain reaction (PCR) with sequencing of the biopsied specimen had the highest similarity to the 16S rRNA gene of Helicobacter cinaedi. This case suggests that direct broad-range PCR with sequencing should be considered when conventional cultures cannot identify the causative organism of vertebral osteomyelitis, and that this method may be particularly useful when the pathogen is a fastidious organism, such as H. cinaedi.

Subclinical Propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID): protocol for a prospective cohort

INTRODUCTION

Low back pain and vertebral endplate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably challenging from a clinical perspective. Progressive infection of the intervertebral disc has been extensively associated with increasing low back pain, with Propionibacterium acnes specifically implicated with in relation to sciatica. The main purpose of this study is to identify if the presence of an infective pathogen within the intervertebral disc is primary or is a result of intraoperative contamination, and whether this correlates to low back pain.

METHODS AND ANALYSIS

An open prospective cohort study will be performed. Subjects included within the study will be between the ages of 18 and 65 years and have a diagnosis of lumbar disc herniation requiring open decompression surgery. Excised herniated disc fragments, muscle and ligamentum flavum samples will be collected during surgery and sent to microbiology for tissue culture and pathogen identification. Score questionnaires for pain, functionality and quality of life will be given preoperatively and at 1, 3, 6 and 12 months postoperatively. A MRI will be performed 12 months after surgery for analysis of Modic changes and baseline comparison. The primary endpoint is the rate of disc infection in patients with symptomatic degenerative disc disease. The secondary endpoints will be performance scores, Modic incidence and volume.

ETHICS AND DISSEMINATION

This study was approved by our Institutional Review Board and was only initiated after it (CAAE 65102617.2.0000.0071). Patients agreeing to participate will sign an informed consent form before entering the study. Results will be published in a peer reviewed medical journal irrespective of study findings. If shown to be the case, this would have profound effects on the way physicians treat chronic low back pain, even impacting health costs.

TRIALS REGISTRATION NUMBER

NCT0315876; Pre-results.

Clinical Features and Drug-Resistance Profile of Urinary Tuberculosis in South-Western China: A Cross-sectional Study

To investigate the epidemiology, clinical features, and drug-resistance profile of urinary tuberculosis (UTB) in south-western China to improve UTB diagnostics.After the screening of 1036 cases of suspected UTB, 193 patients with UTB were enrolled during 2009 to 2014. Urine samples were collected for routine urinalysis, smear, tuberculosis DNA (TB-DNA) detection, and drug-resistant analysis, whereas blood samples were collected for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and renal function evaluation. Clinical features (such as symptoms and outcome) and imageology results (such as B ultrasonic, computerized tomography, intravenous pyelography, and renography) were also collected and analyzed to investigate the epidemiology, clinical features, and drug-resistance profile.The most common presenting symptoms were urinary irritation (61.1%) and lumbago (49.2%). High proportions of microscopic hematuria (63.2%) and microscopic proteinuria (45.6%) were also observed. The positive rate for TB-DNA was 66.3%. The positive rate for culture was 13.1% and for smear it was 9.8%. The abnormal outcome rates of the computerized tomography, ultrasonography, intravenous pyelography, and the nephrogram were 76.9%, 70.1%, 29.8%, and 37.0%, respectively. The total rate of drug-resistant TB (resistant to at least 1 drug) was 39.7%, of which 20.7% was multidrug-resistance TB. The most prevalent mutation sites were katG S315T1, rpoB S531L, and gyrA D94G.We observed a serious epidemic of drug-resistant UTB and a substantial number of new UTB cases with multidrug resistance TB. Molecular diagnostics is crucial in the definite diagnosis of UTB, and our finding is a supplement and further confirmation of polymerase chain reaction usage for TB diagnosis. We recommend real-time polymerase chain reaction for TB-DNA identification instead of culture, and GenoType tests (MTBDRplus and MTBDRsl assay) for drug resistance as routine assays for patients with suspected UTB.

Discovery of the drivers of inflammation induced chronic low back pain: from bacteria to diabetes

The intervertebral disc is a unique avascular organ that supports axial skeleton flexion and rotation. The high proteoglycan content of the nucleus pulposus tissue, present at the center of the disc, is pivotal for its mechanical function, distribution of compressive loads. Chronic low back pain, a prevalent and costly condition, is strongly associated with disc degeneration. Degenerated discs exhibit high levels of inflammatory cytokines, matrix catabolizing enzymes, and an overall reduction in proteoglycan content. Although the cytokine profile of diseased discs has been widely studied, little is known of what initiates and drives inflammation and subsequent low back pain. Recent studies have shown that anaerobic bacteria are present in a high percentage of painful, herniated discs and long-term treatment with antibiotics resolves symptoms associated with chronic low back pain. It is thought that these anaerobic bacteria in the disc may stimulate inflammation through toll-like receptors to further exacerbate disc degeneration. Despite the promise and novelty of this theory, there are other possible inflammatory mediators that need careful consideration. The metabolic environment associated with diabetes and atypical matrix degradation products also have the ability to activate many of the same inflammatory pathways as seen during microbial infection. It is therefore imperative that the research community must investigate the contribution of all possible drivers of inflammation to address the wide spread problem of discogenic chronic low back pain.

Psoas abscess in an immunocompetent host

We present a case of iliopsoas abscess in an immunocompetent patient. She experienced three weeks of worsening right hip pain, which was initially misdiagnosed as degenerative joint disease. This led to admission to the Intensive Care Unit for severe sepsis. The patient improved with intravenous antibiotics and percutaneous abscess drainage.

A special case of lower back pain in a 3-year-old girl

We describe the case of a 3-year-old girl with a 15-day clinical history of lower back pain. We diagnosed a spondylodiscitis of vertebral bodies L5-S1 caused by Salmonella species group B that totally recovered with appropriate antibiotic therapy. Spondylodiscitis in children is a rare condition and Salmonella infection is one of the rarest aetiology. A high index of suspicion is needed for prompt diagnosis to ensure better long-term outcome. Microbiological diagnosis is essential for the appropriate choice of antibiotic treatment.

Escherichia coli septic arthritis of a lumbar facet joint following urinary tract infection

Septic arthritis of a lumbar facet joint is a rare condition. We report the case of a 77-year-old diabetic woman who developed fever and back pain 15 days after she had been diagnosed with a genitourinary infection for which she had received ciprofloxacin. Physical examination showed fever (38°C) and pain on pressure over the lower lumbar spinous vertebral apophyses and over the lower left paraspinal musculature. Investigations showed a white cell count of 8.4×10⁹/l, neutrophils 85.3%, erythrocyte sedimentation rate of 125 mm/h, and C-reactive protein of ≥9 mg/dl. Two blood cultures were both positive for Escherichia coli resistant to ciprofloxacin. There was no growth of pathogens from the urine cultures. Scintigraphy with gallium citrate Ga⁶⁷ showed vertical lower lumbar (L4-L5) radionuclide uptake lateralized to the left. Magnetic resonance imaging of the lumbar spine demonstrated signal changes and alteration of the structure at the left interapophyseal L4-L5 joint, an adjacent small collection of 1cm in diameter, and infiltration of the surrounding soft tissues, which extended to the epidural area, left conjunction hole, and paraspinal muscles. The patient was treated with intravenous cefotaxime and gentamicin and bed rest for 21 days, and recovered. This is the first report of interapophyseal arthritis caused by E. coli.

Minimally invasive dorsal percutaneous spondylodesis for the treatment of adult pyogenic spondylodiscitis

BACKGROUND

Most adult patients with pyogenic lumbar or thoracic spondylodiscitis are treated with an external orthosis and antimicrobial therapy for several weeks to months. If surgical intervention is required, a combined anterior and posterior approach for debridement and fusion with autologous bone graft or titanium mesh cage is usually performed.

METHOD

We here report on our experience with the use of a minimally invasive percutaneous dorsal pedicle screw-rod spondylodesis in adult patients with pyogenic lumbar or thoracic spondylodiscitis.

FINDINGS

Eight patients with lumbar, one with thoracolumbar and three with thoracic pyogenic spondylodiscitis with a mean back pain of 9/10 on the visual analog scale (VAS) and without corresponding neurological deficits were treated. Immediately after the operation, we calculated a significant reduction of the back pain on the VAS to 1.7, of leukocyte counts and C-reactive protein levels. After a mean of 61 days of continuous antimicrobial therapy during full mobilization, all patients were pain free, and leukocyte counts as well as C-reactive protein levels were normalized.

CONCLUSIONS

We conclude that minimally invasive percutaneous fixation is a feasible and effective technique to achieve immediate pain release, avoid long-term immobilization and overcome the disadvantages of a dorsoventral procedure. However, surgical complications and possible follow-up procedures supplement the patients' risks of adverse reactions of the disease.

Aspergillus spondylodiscitis after multivisceral transplantation

BACKGROUND

Although spondylodiscitis is rare, it is increasingly described in patients with compromised immunity due to malignancy, chemotherapy or immunosuppression. Typical pathogens are staphylococcus aureus and enterobacteria; fungal spondylodiscitis is uncommon.

CASE REPORT

We present a case of aspergillus spondylodiscitis following pulmonary aspergillosis in a patient with multivisceral and kidney transplantation. Due to irreversible disc destruction, surgical restoration by autologous iliac crest graft was required in addition to intravenous antifungal therapy, which consisted of voriconazole, caspofungin and liposomal amphotericin B.

CONCLUSIONS

Aspergillus spondylodiscitis is a diagnostic and therapeutic challenge, a combination of surgical debridement and antifungal therapy is inevitable to prevent rapid progression of invasive aspergillosis and neurological damage.

Pyogenic sacroiliitis a comparison between paediatric and adult patients

BACKGROUND

Pyogenic sacroiliitis is a rare cause of hip pain and fever. We aim to report a series of 33 patients with pyogenic sacroiliitis and to investigate the differences among paediatric and adult cases.

METHODS

Clinical and laboratory data of 33 cases who were admitted to the emergency department with a confirmed discharge diagnosis of pyogenic sacroiliitis between 1996 and 2005 were assessed. All patients were divided into paediatric and adult groups by the age of 15 yr. The features of pyogenic sacroiliitis and clinical outcome were compared among the two groups. Several factors were analysed including gender, age, clinical signs and symptoms, laboratory tests, radiological examinations and scintigraphy.

RESULTS

Among the all included patients, females were attacked more frequently than males (3: 1). One-third of patients had concurrent infections, of which urinary tract infections were the most common (41.6%). Compared with adult patients, paediatric patients tend to have fewer comorbid immunocompromized conditions, fewer concurrent infections, more equality in gender distribution and more presentations of weight bearing difficulty. Staphylococcus aureus was the main blood culture isolate from paediatric patients (80%), but only accounted for half of those from adult patients. Group B streptococcus and Salmonella spp. were not uncommon in the adult patients. Scintigraphic bone scan has the highest sensitivity (93.3%) and remains the image modality of choice. When local abscess formation is suspected, computed tomography or magnetic resonance imaging may be the preferred method used for examination.

CONCLUSION

This case series should alert the physicians to the possibility of pyogenic sacroiliitis and the difference between paediatric and adult patients.

Septic Arthritis of Lumbar Facet Joints Without Predisposing Infection

Septic arthritis of a lumbar facet joint is a rare clinical entity and most articles have reported a single case. There have been few studies that have evaluated the clinical and imaging features of septic arthritis of lumbar facet joints. The clinical data of 5 patients diagnosed with septic arthritis of lumbar facet joints were retrospectively studied. The average age of 5 patients was 73.6 years. All patients had elevated temperature at admission (37.7 degrees C). Leukocyte count was tested in all 5 patients and was elevated in only 2 patients. Erythrocyte sedimentation rate and C-reactive protein were examined and were elevated in all 5 cases. Magnetic resonance imaging was accurate in identifying the septic joint and associated abscess formation. All patients were treated with bed rest and received intravenous antibiotics for an average of 33.3 days. Four of 5 patients had positive outcomes with full recoveries and no evidence of recurrent infections. One patient exhibited evidence of recurrent infection and required open facet arthrotomy and paraspinal muscle debridement after intravenous administration of antibiotics. Septic arthritis of the lumbar facet joint is a rare cause of low back pain. It is important to ascertain the diagnosis at the earliest possible stage and to start intravenous antibiotics therapy as soon as possible. Magnetic resonance imaging is quite a sensitive modality for identifying infection of the lumbar facet joint. Familiarity with its clinical symptoms and radiographic features is necessary to avoid misdiagnosis of this condition.

Pyogenic intradural abscess: a case report

STUDY DESIGN

A case report of pyogenic intradural abscess is described.

OBJECTIVES

The rarity of the presentation and its successful management are discussed.

SUMMARY OF BACKGROUND DATA

Intradural abscesses are exceptionally rare.

METHOD

The abscess was drained by performing a posterior midline lumbar durotomy, and intravenous antibiotics were initiated.

RESULT

At the 1 year follow-up, the patient has made significant neurologic recovery.

CONCLUSION

Intradural pyogenic abscess secondary to chronic pyogenic spondylodiscitis is a rare manifestation. MRI is a vital component in diagnosis, which revealed key pathologic features within the dural sac as well as in the vertebral column. An emergency decompression and appropriate antibiotic regimen is the solution for a favorable outcome.

Unusual Presentation of Isolated Sacral Tuberculosis

Tuberculosis is as old as mankind. Vertebral tuberculosis is fairly common form of bone and joint tuberculosis. However, isolated sacral tuberculosis is rare. It may present as an atypical sacral lesion having epidural granuloma without destruction of sacrum on MRI and plain X-rays. This atypical presentation may lead to delay in diagnosis and treatment. This case report intends to emphasize that spinal tuberculosis should be the first and foremost differential diagnosis in the presence of atypical clinical and radiological features of a sacral lesion particularly in developing countries. Early diagnosis and treatment can prevent or minimize the neurological morbidity in such cases.

"My back is killing me"

This is a case of a rare cause of back pain that presented to several clinicians before the diagnosis became obvious and the correct management was initiated. Lemierre's syndrome was confirmed at post mortem examination. We conclude that thoracic back pain should not be assumed to have a simple mechanical cause and that efforts should be made to discover the underlying aetiology.

Spondylodiscitis and Streptoccus viridans endocarditis

Infective endocarditis in association with spondylodiscitis is rarely observed. It is sometimes difficult to distinguish between rheumatologic diseases and infective endocarditis. We reported a 61-year-old male with Streptococcus viridans endocarditis suffering from low-back pain as initial symptom. Infective endocarditis was diagnosed according to Duke Criteria. L4-5 spondylodiscitis was revealed on the lumbar magnetic resonance imaging. He responded to antibiotic treatment. Infective endocarditis should be considered in patients with fever and low-back pain due to spondylodiscitis.

Postoperative discitis due to Propionibacterium acnes: a case report and review of the literature

BACKGROUND

No previous report has described a progressive, destructive postoperative discitis requiring operative stabilization due to Propionibacterium acnes. The clinical and radiographic features and treatment options associated with discitis due to P acnes are presented in a retrospective case study, as well as a review of the current literature.

CASE DESCRIPTION

Seven weeks after a routine lumbar discectomy, the patient presented with clinical findings and radiographic imaging consistent with discitis. Intraoperative cultures obtained from irrigation and debridement of the disc space revealed P acnes, and appropriate intravenous antibiotic treatment was instituted. Approximately 2 months later, the patient showed progression to a destructive osteomyelitis requiring operative stabilization. Nine weeks after stabilization, the patient continued to have lower back pain without radiculopathy. Laboratory values had normalized. Radiographic imaging revealed good instrumentation positioning and adequate fusion. The patient was ambulatory with bilateral articulating ankle foot orthoses and a walker.

CONCLUSION

The reported case adds to the literature on postoperative discitis due to P acnes and demonstrates that this organism can occasionally be the cause of progressive, destructive osteomyelitis. In addition, we review the incidence, risk factors, and clinical course of discitis due to P acnes.

Multifocal discitis caused by Staphylococcus warneri

Staphylococcus warneri is a coagulase-negative staphylococcus that is a normal inhabitant of the skin but occasionally causes septicemia and endocarditis. We report a case of multifocal discitis caused by S. warneri in an immunocompetent patient. Only three cases of spinal S. warneri infections have been reported in the literature. They illustrate the atypical clinical presentation, with chronic pain of increasing severity in the thoracic or lumbar spine instead of the abrupt onset that characterizes S. aureus discitis. In our patient, despite the multifocal distribution of the lesions, heretofore unreported, clinical presentation suggested common low back pain. This presentation may be ascribable to the unique bacteriological characteristics of S. warneri. The case reported here illustrates the diagnostic challenges sometime raised by discitis due to coagulase-negative staphylococci.

Unusual cause of infective discitis in an adolescent

The first case of infective discitis caused by Eikenella corrodens in an adolescent is presented. The need for anaerobic cultures when dealing with infective pathology in the spine is stressed. A 14 year old boy presented with acute exacerbation of back pain, which showed characteristics of infective discitis after magnetic resonance imaging. Computed tomography guided biopsy grew E corrodens in anaerobic cultures that was sensitive to ampicillin, co-amoxiclav, cefadroxil, and cefotaxime. This patient responded well to co-amoxiclav and recovered without any surgical intervention.

Vertebral osteomyelitis combined streptococcal viridans endocarditis

Endocarditis may be difficult to diagnose in patients with osteomyelitis in an early stage because they usually are treated for fever, bone pain and stiffness in the outpatient department. Herein we report an uncommon patient who developed severe lower back pain sustained for 2 months, and streptococcal viridans infected vertebral osteomyelitis combined endocarditis were diagnosed and cured.

A man with backache and renal failure

Backache, a common symptom, is rarely caused by infection of the lumbar discs. The authors present the case of a 60-year-old man with a Staphylococcus aureus septicemia and associated lumbar discitis in whom a pauci immune crescentic glomerulonephritis and renal failure developed. Treatment with antibiotics and not immunosuppressive agents resulted in improved renal function with a discharge creatinine level of 1.87 mg/dL (165 micromol/L). This case highlights an association of pauci-immune crescentic glomerulonephritis with discitis that responded to antibiotic therapy alone.

[Centro-somatic staged tuberculous vertebral osteitis: a case report]

Centro-somatic tuberculous vertebral osteitis is defined as tuberculous infection of the vertebral body with preserved integrity of the adjacent intervertabral disk. Other types of vertebral tuberculosis include Pott's spondylodiscitis and exceptional lesions of the posterior arch. We report a case of centro-somatic tuberculous vertebral osteitis in a 14-year-old boy who developed staged lesions of the L2 to S1 bodies, associated with a posterior epidural collection but without any deterioration of the intervertebral disk on plain x-rays and computed tomography. This atypical aspect of the lesions required a surgical biopsy which yielded a yellow-whitish fibro-oleagenous, friable product more suggestive of neoplasm than infection, but histology rectified the diagnosis, showing typical caseo-follicular tuberculosis. A 6-month anti-tuberculosis regimen was rapidly followed by symptom improvement. We emphasize the importance of modern imaging techniques for the diagnosis of vertebral lesions and for guided biopsy or drainage.

Low back pain at presentation in a newly diagnosed diabetic

Insulin dependent diabetes mellitus predisposes to a range of different and unusual infections, including epidural and psoas abscesses. However, they occur mainly in adults with longstanding diabetes. We report the case of a 12 year old boy who presented with diabetic ketoacidosis and low back pain, and was subsequently diagnosed with both a left psoas abscess and an extensive thoracolumbar spinal epidural abscess measuring 20 cm in length. This case report highlights the need to maintain a high index of suspicion for epidural abscesses in children presenting with fever and localised back pain. Early diagnosis with appropriate imaging and aggressive management can prevent development of permanent neurological damage as was the case in our patient.

Bacteroides fragilis vertebral osteomyelitis secondary to anal dilatation

STUDY DESIGN

A case report of anaerobic vertebral osteomyelitis after anal dilatation.

OBJECTIVES

To present a patient with monomicrobial anaerobic vertebral osteomyelitis secondary to a previously undescribed source of infection.

SUMMARY OF BACKGROUND DATA

A 17-year-old boy presented with low back pain 3 months after anal dilatation.

METHODS

Physical examination, technetium-99m bone scan, plain radiograph, CT, and MRI studies of the lumbar spine were used to clinically diagnose lumbar osteomyelitis. Culture material from the involved disc was positive for Bacteroides fragilis.

RESULTS

The patient recovered after 8 weeks of treatment with oral metronidazole.

CONCLUSIONS

Bacteroides fragilis hematogenous osteomyelitis is a rare entity. This is the first reported case of such disease after anal dilatation.

Isolated septic arthritis of a lumbar facet joint

This is a report of an isolated septic arthritis of a lumbar facet joint where the infectious agent was Bacteroides sp. and where an early diagnosis was made using MRI.

[Septic arthritis of a lumbar facet joint. A case report]

Septic arthritis of the posterior lumbar joints is extremely rare in comparison with spondylodiscitis which is much more common. We report a case of an 86-year-old women with septic arthritis of the left L4-L5 lumbar facet joint associated with endocarditis. Arthritis diagnosis was made on CT scan and MRI, infection by Staphyloccocus aureus was proved by blood cultures. Heart growth was seen by echocardiography. Twenty-three cases were reported in the literature. Clinical and biological data failed to discriminate between facet joint septic arthritis and spondylodicitis. Diagnosis is established on imaging findings, computed tomography and magnetic resonance imaging, completed by blood cultures and, if they are negative, by aspiration-biopsy. Appropriate antimicrobial therapy is usually successful. Some back pain generally persists. In conclusion, lumbar pain with fever without spondylodiscitis is suggestive of septic arthritis of a lumbar facet joint. Epiduritis associated in 60% patients requires rapid treatment.

Septic arthritis of a lumbar facet joint due to pyonex

We present a case of septic arthritis of a lumbar facet joint with an associated epidural abscess. A 13-year-old boy was hospitalized with acute severe back pain and fever after pyonex was done. The infection was precisely localized with magnetic resonance imaging, bone and gallium scintigraphy. He responded to antibiotic therapy. We suppose that the infection was caused by pyonex because the blood cultures were negative, and the patient had an abrupt onset of severe pain and fever 24 h after the acupuncture.

Musculoskeletal manifestations of bacterial endocarditis

CONTEXT

The incidence of staphylococcal infection has been increasing during the last 20 years.

OBJECTIVE

Report a case of staphylococcal endocarditis preceded by musculoskeletal manifestations, which is a rare form of clinical presentation.

DESIGN

Case report.

CASE REPORT

A 45-year-old-man, without addictions and without known previous cardiopathy, was diagnosed as having definitive acute bacterial endocarditis due to Staphylococcus aureus. Its etiology was community-acquired, arising from a non-apparent primary focus. In addition, the musculoskeletal symptoms preceded the infective endocarditis (IE) by about 1 month, which occurred together with other symptoms, e.g. mycotic aneurysms and petechiae. Later, the patient showed perforation of the mitral valve and moderate mitral insufficiency with clinical control.

Infective discitis as an uncommon but important cause of back pain in older people

CASE REPORTS

two elderly patients (aged 70 and 80 years) presented with severe back pain and restriction of spinal movements. Inflammatory markers were raised and in each case computed tomography findings confirmed infective discitis. One patient improved with antibiotics but the second developed paraplegia, a recognized complication of discitis.

CONCLUSION

the association of back pain, restricted spinal movements and raised inflammatory markers should act as 'red flags', alerting the clinician to the presence of serious, but potentially treatable pathology.

Enterobacter agglomerans spondylodiscitis: a possible, unrecognized complication of tetracycline therapy

STUDY DESIGN

This case report describes infection in a lumbar disc in a healthy young man with an organism of low pathogenicity. The patient was taking a prolonged course of antibiotics at the time the infection occurred.

OBJECTIVE

To describe this unique case of infective spondylodiscitis.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, spinal infection with Enterobacter agglomeranshas never been reported. This organism is a transient gut colonizer, and may have established itself secondary to the patient's prolonged ingestion of tetracycline for acne.

METHODS

This 22-year-old farmer had spontaneous lumbar back pain. Radiologic investigations showed an abnormality in the L4-L5 disc region, and together with other investigations, were suggestive of infection. The diagnosis was confirmed by surgical aspiration.

RESULTS

Antibiotic therapy was administered, and the patient made a complete recovery. Follow-up radiographs showed a complete loss of the L4-L5 disc space with only minimal bone destruction.

CONCLUSION

A unique cause of infective lumbar discitis is presented. Several features of this case are unusual. The magnetic resonance findings were not readily diagnostic. The cultured organism is usually nonpathogenic. The infection may have been secondary to prolonged tetracycline therapy.

Psoas abscess secondary to discitis: a case report of conservative management

We report a case of secondary psoas abscess in a 37-year-old man with a 3-week history of severe low backache managed conservatively without surgical drainage. Apart from bilaterally restricted straight leg raising (<70 degrees), his neurologic examination was within normal limits. Magnetic resonance imaging showed discitis of the L3-L4 space and a left-sided secondary psoas abscess. Aspiration biopsy of the abscess material under radiologic control isolated Staphylococcus aureus, which responded to appropriate antibiotic therapy with complete resolution. A high index of suspicion is necessary for diagnosis of psoas abscess, which should be considered in patients with pyrexia and backache with a neurologic examination that is otherwise normal. We discuss the recommendations for surgical and nonsurgical approaches.

Acute brucella sacroiliitis: clinical features

Although back pain is very common, the differential diagnosis may sometimes be very difficult. Both inflammation and infections of spinal or sacroiliac joints are examples of such causes. We report three cases of brucella sacroiliitis resembling acute low back pain or lumbar disc herniation. All patients had had a recent infection and were referred complaining of acute back pain with a suspicion of lumbar disc herniation. The complaints of all patients reduced dramatically after proper medication. Radiographs of all patients and bone scans of two patients revealed sacroiliitis. One of the patients was positive for HLA-B27; in the other two patients HLA-B27 could not be determined.

Paraspinal abscess associated with epidural in labour

A 24-year-old presented in labour requesting an epidural. She had been diagnosed as having "pelvic arthropathy" at 37 weeks. After an uneventful epidural and instrumental delivery, she discharged herself home. She re-presented 19 days later with left hip pain and abnormal neurological signs in the lower limbs. On MRI, there was a large paraspinal abscess with an epidural granulation mass compressing her spinal cord. She had an urgent surgical decompression. In hindsight, it is likely that the paraspinal mass was present at the time of epidural insertion. The discussion highlights that complications are sometimes not what they seem.

Unusual aetiology of persistent back pain in a patient with multiple myeloma: infectious discitis

A 47 year old man with multiple myeloma presented with persistent back pain caused by infectious discitis. Aspiration of the affected vertebral disc space was carried out, guided by computed tomography, and microbiological examination of the aspirate revealed Staphylococcus aureus and Mycobacterium tuberculosis. Antituberculous and antistaphylococcal antibiotic treatment resulted in a dramatic clinical response with complete resolution of the vertebral abscess. Detailed radiological and microbiological investigations are necessary to diagnose unusual causes of chronic bone pain such as discitis or infectious bone disease in patients with multiple myeloma.