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Old 12-27-2007, 04:58 PM
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Harrison Harrison is offline
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Exclamation Spinal Diseases: Bacterial Causes

In the past year, we’ve talked about possible causes of spine disease and associated pain syndromes. I don’t always share much of what I am learning or researching, as these sciences are complicated and my understanding of the pathologies are quite iterative. My summary statement: there is simply not enough attention in the area of spinal disease diagnostics!

So, to break with the guarded position I’ve (previously) maintained, here are some abstracts found from Medline. The search strategy was based on a pathogenic cause of spinal disc disease. You will notice that many abstracts are international or simply dated. Like diseased discs, the funding for U.S. funded research on spinal disc disease appears to have dried up! Why is it that a disease that is so prevalent in America has so few research dollars behind it?! This is crazy.

The first abstract is the one that contains the proverbial “needle in a haystack.” I’ll leave this tome with you for now, and chime back in soon. Please be as candid & verbose as you can with this feedback. If it’s helpful to you all, I’ll keep digging.

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Am J Med. 1996 Jan;100(1):85-9. SPONTANEOUS INFECTIOUS DISCITIS IN ADULTS. Honan M, White GW, Eisenberg GM. Division of Rheumatology, Lutheran GeneralHospital, Park Ridge, Illinois, USA.

PURPOSE: In adults, discitis most frequently follows spinal surgery. We report 16 adult patients with spontaneously occurring infectious discitis and compare them with an additional 52 patients abstracted from the literature. Infecting organisms, predisposing factors, imaging modalities, and response to therapy are described.

PATIENTS AND METHODS: The medical records of adult patients treated for infectious discitis of a community hospital during the past 10 years were reviewed. Postoperative spine patients and patients with primary osteomyelitis were excluded. Sixteen patients were identified with spontaneous primary infection of the disc space. The particulars of comorbid conditions, infection organisms, site of culture, and response to antibiotic therapy were noted and compared to 52 additional cases of spontaneous discitis reported in the literature since 1980.

RESULTS: A wide variety of infecting organisms was identified as causing spontaneous discitis, in contrast to previous reports of both postoperative discitis and spontaneous discitis. Nine of 10 patients with positive disc cultures had negative blood cultures. Appropriate antibiotics were curative in all patients but 1, regardless of the duration of symptoms. Nuclear imaging, computed tomography, and magnetic resonance imaging were all useful, although the last appears to be the most sensitive and specific imaging modality for detecting discitis.

CONCLUSIONS: Spontaneous infectious discitis is an uncommon cause of low back pain in adults. Nevertheless, it should be considered in any patient with acute or subacute pain. Elevated acute-phase reactants with appropriate imaging modality suggest the diagnosis. Given the wide variety of infecting organisms identified, culture of blood and/or disc for the specific causative organism is critical to successful treatment outcome.
PMID: 8579092 [PubMed - indexed for MEDLINE]

Infection. 1992 Mar-Apr;20(2):97-8. LUMBAR PAIN CAUSED BY MYCOPLASMA INFECTION Kayser S, Bhend HJ.Klinik für Rheumatologie und Rehabilitation, Stadtspital Triemli, Zürich, Switzerland.

A 45-year-old woman was admitted to hospital following acute onset of lower back pain. Clinical and laboratory investigations established a lumbar paraspinal soft tissue infection with Mycoplasma hominis associated with severe spondylarthrosis at L5/S1. A relationship to a recently performed hysterectomy must be considered.
PMID: 1533852 [PubMed - indexed for MEDLINE]

Rev Neurol. 2000 Feb 16-29;30(4):326-8. SUBDURAL EMPYEMA DUE TO MYCOPLASMA HOMINIS FOLLOWING EPIDURAL ANESTHESIA[Article in Spanish] Escamilla F, Fernández MD, Espigares A, Arnal C, Ortega A, García T. Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, España. neuro2000@hvn.sas.cica.es

INTRODUCTION: In the literature there are sporadic reports of spinal epidural abscesses after epidural anaesthesia (Staphylococcus aureus in 82%), whilst subdural empyemas are more often related to ear and sinus conditions.

CLINICAL CASE: A 32 year old woman with a clinical history of migraine and symmetrical frontal atrophy on a previous cerebral CT scan, after Caesarean section under epidural anaesthesia, presented with orthostatic headache two days later. On the fourth day it had become constant and she had a high temperature which was considered to be caused by infection of the surgical wound. Neurological examination was found to be normal, the CT scan was inconclusive and the CSF showed a lymphocytic pleocytosis without consumption of glucose. In view of her worsening clinical condition on the ninth day, in the absence of a cutaneous focus and on suspicion of a para-meningeal infective focus, lumbar MR was done and found to be normal, and cerebral MR which showed images compatible with a right fronto-parietal subdural empyema. After a parietal craniotomy and culture of the surgical specimen, colonies of Mycoplasma hominis were grown, similar to those grown from the exudates of the abdomical surgical wound. Treatment was started with ciprofloxacine.

CONCLUSION: We consider that following epidural anaesthesia the patient developed hypotension of the CSF with a secondary subdural hematoma or hygroma and this became infected by hematogenous spread of Mycoplasma hominis.

Spine. 2006 Sep 15;31(20):E770-3. INFECTED VERTEBROPLASTY DUE TO UNCOMMON BACTERIA SOLVED SURGICALLY: A RARE AND THREATENING LIFE COMPLICATION OF A COMMON PROCEDURE: REPORT OF A CASE AND A REVIEW OF THE LITERATURE. Alfonso Olmos M, Silva González A, Duart Clemente J, Villas Tomé C.Department of Orthopaedic Surgery, University Clinic of Navarra, Navarra, Spain. malfonsool@unav.es

STUDY DESIGN: Case report. OBJECTIVE: The aim of this work is to describe a case of infected vertebroplasty due to uncommon bacteria solved surgically with 2 years of follow-up and to discuss 6 other cases found in literature.

SUMMARY OF BACKGROUND DATA: Vertebroplasty is a well-known and useful technique for the treatment of painful osteoporotic vertebral fractures. Complications, such as cord or root compression or pulmonary embolisms, are infrequent and are mainly related with the frequent escape of cement throughout the vertebral veins. Infection is even more rare, but when it occurs is difficult to manage and can be a life-threatening complication.

METHODS: A 63-year-old-man had a spondylitis of L2 after vertebroplasty. The patient was initially managed with antibiotics without clinical improvement. Surgical treatment by anterior debridement and anterior and posterior stabilization was done. The bacteria isolated from the intraoperative cultures were Serratia marcescens, Stenotrophomonas maltophilia, and Burkholderia cepacia. After surgery, the patient was treated with antibiotics for 3 months.

RESULTS: After 2 years of follow-up, the patient was free of pain, without signs of infection, and a correct fusion was achieved.

CONCLUSION: When facing an infected vertebroplasty, initial conservative treatment with needle biopsy culture and antibiotic administration are a rational option to start. If this treatment fails, surgical debridement is then indicated in order to remove the infected tissue and the acrylic cement and to stabilize the spine. Although this can be an effective treatment, it could be a difficult and hazardous surgical procedure.
PMID: 16985448 [PubMed - indexed for MEDLINE]

BMC Fam Pract. 2004 Oct 6;5:21. AN UNUSUAL CASE OF CHRONIC MENINGITIS. Boos C, Daneshvar C, Hinton A, Dawes M. Department of General Medicine, Portsmouth Hospitals NHS Trust, Milton Rd, Portsmouth, UK. christopherboos@hotmail.com

BACKGROUND: Chronic meningitis is defined as symptoms and signs of meningeal inflammation and persisting cerebrospinal fluid abnormalities such as elevated protein level and pleocytosis for at least one month.

CASE PRESENTATION: A 62-year-old woman, of unremarkable past medical history, was admitted to hospital for investigation of a four-week history of vomiting, malaise an associated hyponatraemia. She had a low-grade pyrexia with normal inflammatory markers. A CT brain was unremarkable and a contrast MRI brain revealed sub-acute infarction of the right frontal cortex but with no evidence of meningeal enhancement. Due to increasing confusion and patient clinical deterioration a lumbar puncture was performed at 17 days post admission. This revealed gram-negative coccobacilli in the CSF, which was identified as Neisseria meningitidis group B. The patient made a dramatic recovery with high-dose intravenous ceftriaxone antibiotic therapy for meningococcal meningitis.

CONCLUSIONS: 1) Chronic bacterial meningitis may present highly atypically, particularly in the older adult. 2) There may be an absent or reduced febrile response, without a rise in inflammatory markers, despite a very unwell patient. 3) Early lumbar puncture is to be encouraged as it is essential to confirm the diagnosis.4) Despite a delayed diagnosis appropriate antibiotic therapy can still lead to a good outcome.
PMID: 15469610 [PubMed - indexed for MEDLINE]

Enferm Infecc Microbiol Clin. 2005 Feb;23(2):71-5. SPONDYLODISCITIS AND SACROILIITIS DUE TO STREPTOCOCCUS AGALACTIAE IN ADULTS: CLINICAL CASE AND LITERATURE REVIEW. [Article in Spanish] Díaz-Gonzálvez E, Zarza B, Abreu P, Cobo J, Orte J, Dronda F. Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Ctra. Colmenar, km 9, 28034 Madrid, Spain.

INTRODUCTION: Streptococcus agalactiae is a well-known pathogen related with infection in newborns, and in women during pregnancy and the puerperium. In recent years it has been described as a causal agent in invasive disease in immunodepressed adults and those with other severe underlying pathologies.

METHODS: We describe a case of S. agalactiae spondylodiscitis and concomitant bilateral sacroiliitis in an adult with no known underlying diseases. A systematic review of the related literature was performed (MEDLINE and EMBASE, up to December 2003).

RESULTS: The literature search retrieved only 33 cases of spondylodiscitis (predominance in men, 55-70 years old) and 13 cases of sacroiliitis (higher frequency in women, 30-40 years old) due to S. agalactiae. Simultaneous involvement of both locations of the axial skeleton is unusual.

CONCLUSION: Spondylodiscitis and sacroiliitis due to S. agalactiae is uncommon. S. agalactiae is an emerging pathogen in adults outside of the gestational and perinatal period. This micro-organism produces spondylodiscitis in the adult population over 50 years old. In contrast, sacroiliac involvement is described mainly in women in the reproductive age.

Ned Tijdschr Geneeskd. 2007 Nov 10;151(45):2485-90. SPONDYLODISCITIS AS CAUSE OF UNEXPLAINED FEVER - [Article in Dutch] Van der Wal WA, Oner FC. Universitair Medisch Centrum Utrecht, Postbus 85,500, 3508 GA Utrecht.

An 83-year-old woman was admitted to hospital with complaints of fever, abdominal pain and other complaints suggesting urosepsis. Additional analyses did not reveal the cause of her complaints. After cessation of antibiotic therapy, there was a spontaneous decrease in the infection parameters and she was subsequently discharged. Two and a half months later she was presented in our hospital with low back pain with radiating to the legs. MRI showed signs ofa spondylodiscitis at the level of LIII-LIV existing for some time. Finally, a gram-positive streptococcus infection was found and she was treated with antibiotics for 13 weeks. 6 months later she was free of symptoms. A 57-year-old man was admitted to the intensive care with a double-sided olecranon bursitis and sepsis. An endocarditis caused by Staphylococcus aureus was thought to be the cause of the sepsis and the patient was treated with surgical intervention and antibiotics. Because of persistent sepsis, different CT-scans were performed, and after one and a half months an extensive spondylodiscitis with abscess formation was diagnosed and subsequently treated surgically. A delay in diagnosing spondylodiscitis is the rule rather the exception. The diagnosis should be considered in any patient with localised back pain, especially when accompanied by fever, high ESR, and the presence of risk factors such as high age, diabetes mellitus, immunosuppression, and/or rheumatoid arthritis.
PMID: 18062589 [PubMed - in process]
Pediatrics. 2001 Feb;107(2):E26.

TWO CASES OF DISKITIS ATTRIBUTABLE TO ANAEROBIC BACTERIA IN CHILDREN. Brook I. Department of Pediatrics, Georgetown UniversitySchool of Medicine, Washington, DC, USA. dribrook@yahoo.com

Diskitis, an inflammation of the intervertebral disk, is generally attributable to Staphylococcus aureus and rarely Staphylococcus epidermidis, Kingella kingae, Enterobacteriaciae, and Streptococcus pneumoniae. In many cases, no bacterial growth is obtained from infected intervertebral discs. Although anaerobic bacteria were recovered from adults with spondylodiscitis, these organisms were not reported before from children. The recovery of anaerobic bacteria in 2 children with diskitis is reported. Patient 1. A 10-year-old male presented with 6 weeks of low back pain and 2 weeks of low-grade fever and abdominal pain. Physical examination was normal except for tenderness to percussion over the spine between thoracic vertebra 11 and lumbar vertebra 2. The patient had a temperature of 104 degrees F.

Laboratory tests were within normal limits, except for erythrocyte sedimentation rate (ESR), which was 58 mm/hour. Blood culture showed no growth. Magnetic resonance imaging with gadolinium contrast revealed minimal inflammatory changes in the 12th thoracic vertebra/first lumbar vertebra disk. There was no other abnormality. A computed tomography (CT)-guided aspiration of the disk space yielded bloody material, which was sent for aerobic and anaerobic cultures.

Gram stain showed numerous white blood cells and Gram-positive cocci in chains. Cultures for anaerobic bacteria yielded heavy growth of Peptostreptococcus magnus, which was susceptible to penicillin, clindamycin, and vancomycin. The patient was treated with intravenous penicillin 600 000 units every 6 hours for 3 weeks, and then oral amoxicillin, 500 mg every 6 hours for 3 weeks. The back pain resolved within 2 weeks, and the ESR returned to normal at the end of therapy. Follow-up for 3 years showed complete resolution of the infection.

Patient 2. An 8-year-old boy presented with low back pain and low-grade fever, irritability, and general malaise for 10 days. He had had an upper respiratory tract infection with sore throat 27 days earlier, for which he received no therapy. The patient had a temperature of 102 degrees F, and physical examination was normal except for tenderness to percussion over the spine between the second and fourth lumbar vertebrae. Laboratory tests were normal, except for the ESR (42 mm/hour). Radiographs of the spine showed narrowing of the third to fourth lumbar vertebra disk space and irregularity of the margins of the vertebral endplates. A CT scan revealed a lytic bone lesion at lumbar vertebra 4, and bone scan showed an increase uptake of (99m)technetium at the third to fourth lumbar vertebra disk space. CT-guided aspiration of the disk space yielded cloudy nonfoul-smelling material, which was sent for aerobic and anaerobic cultures. Gram stain showed numerous white blood cells and fusiform Gram-negative bacilli. Anaerobic culture grew light growth of Fusobacterium nucleatum. The organism produced beta-lactamase and was susceptible to ticarcillin-clavulanate, clindamycin, metronidazole, and imipenem. Therapy with clindamycin 450 mg every 8 hours was given parenterally for 3 weeks and orally for 3 weeks. Back pain resolved within 2 weeks. A 2-year follow-up showed complete resolution and no recurrence. This report describes, for the first time, the isolation of anaerobic bacteria from children with diskitis. The lack of their recovery in previous reports and the absence of bacterial growth in over two third of these studies may be caused by the use of improper methods for their collection, transportation, and cultivation. Proper choice of antimicrobial therapy for diskitis can be accomplished only by identification of the causative organisms and its antimicrobial susceptibility. This is of particular importance in infections caused by anaerobic bacteria that are often resistant to antimicrobials used to empirically treat diskitis. This was the case in our second patient, who was infected by F nucleatum, which was resistant to beta-lactam antibiotics. The origin of the anaerobic bacteria causing the infection in our patient is probably of endogenous nature. The presence of abdominal pain in the first child may have been attributable to a subclinical abdominal pathothology. The preceding pharyngitis in the second patient may have been associated with a potential hematogenous spread of F nucleatum. P magnus has been associated with bone and joint infections. This report highlights the importance of obtaining disk space culture for aerobic and anaerobic bacteria from all children with diskitis. Future prospective studies are warranted to elucidate the role of anaerobic bacteria in diskitis in children.
PMID: 11158500 [PubMed - indexed for MEDLINE]

South Med J. 2005 Feb;98(2):144-8. ANAEROBIC SPONDYLODISCITIS: CASE SERIES AND SYSTEMATIC REVIEW. Saeed MU, Mariani P, Martin C, Smego RA Jr, Potti A, Tight R, Thiege D. Department of Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, ND 58122, USA. musabsaeed@meritcare.com

BACKGROUND: Bacterial spondylodiscitis is rarely caused by anaerobic organisms. We describe two patients with lumbar vertebral osteomyelitis and discitis caused by anaerobic bacteria, including an unusual occurrence after an endodontic procedure, and review the salient clinical features and outcomes of 31 previously reported cases. METHODS: Case reports and review of the literature.

RESULTS: Median age at presentation was 65 years, with a male-to-female ratio of 2:1. The most common presenting symptoms were back pain, fever, and neurologic deficits. The lumbar spine was most frequently involved (43%); an equal number of cases involved contiguous extension or hematogenous spread. Causative anaerobes were recovered from disk space or vertebrae (13), blood (4), and/or soft tissue abscess and included Bacteroides species (12), Propionibacterium acnes (7), Peptococcus species (4), Peptostreptococcus species and Clostridium species (3 each), Corynebacterium diphtheroides and Fusobacterium species (2 each), and unspecified anaerobes (3).

CONCLUSIONS: Apart from specific antibiotic selection, medical treatment and outcomes for anaerobic spondylodiscitis are similar to those for aerobic vertebral disk infection.
PMID: 15759942 [PubMed - indexed for MEDLINE]

QJM. 2001 Sep;94(9):465-70.A CASE ASCERTAINMENT STUDY OF SEPTIC DISCITIS: CLINICAL, MICROBIOLOGICAL AND RADIOLOGICAL FEATURES. Hopkinson N, Stevenson J, Benjamin S.
Department of Rheumatology, Royal Bournemouth and Christchurch Hospitals, Bournemouth, UK.

We studied the spectrum of septic discitis presenting to two busy district general hospitals over 2.5 years (November 1996 to April 1999), surveying the case notes of all patients attending Royal Bournemouth and PooleHospitals with probable septic discitis on magnetic resonance imaging (MRI). Twenty-two cases of septic discitis were identified, suggesting an annual incidence of 2/100 000/year. Seventy-three percent of patients were aged > or =65 years. In 91% of patients, back pain was the presenting symptom, with neurological signs evident in 45% of patients. Fever >37.5 degrees C was present in 68% of patients, and a marked elevation of erythrocyte sedimentation rate (ESR) in 91%. Diagnosis was originally by MRI in 86% of patients, with plain radiographs not diagnostic of discitis in the early stages of the infection. Staphylococcus aureus was the commonest pathogen (41%), but in 18% of patients, no organism was identified. The major predisposing factors to septic discitis were invasive procedures (41%), underlying cancer (25%) and diabetes (18%). Pre-existing degenerative spinal disease was found in 50% of patients. Four patients whose causative organism was not isolated had a poorer outcome: one death and three with increased morbidity. Our estimated incidence rate (2/100 000/year) is higher than that in previous studies and may be due to a higher detection rate with MRI and/or a genuine increase in the number of cases. Septic discitis should be considered in any patient who has severe localized pain at any spinal level, especially if accompanied by fever and elevated ESR, or in the immunosuppressed.
PMID: 11528009 [PubMed - indexed for MEDLINE]

Am J Med. 1993 Jan;94(1):21-8. Am J Med. 2001 Aug1;111(2):161.
ANAEROBIC OSTEOMYELITIS AND ARTHRITIS IN A MILITARYHOSPITAL: A 10-YEAR EXPERIENCE.

Brook I, Frazier EH.Department of Pediatrics and Infectious Diseases, Naval MedicalCenter, Bethesda, Maryland.

PURPOSE: The methods of collecting, transporting, cultivating, and identifying aerobic bacteria in bone and joint infections have improved markedly since the early 1980s. In addition, many of the anaerobes have been reclassified and renamed. The purpose of this study was to provide more current information regarding the incidence of recovery of anaerobic bacteria from clinical specimens of infected bone and joint.

MATERIALS AND METHODS: Specimens from 73 infected bone specimens and 65 infected joints inoculated on media supportive for aerobic and anaerobic bacteria showed bacterial growth.

RESULTS: One hundred fifty-seven organisms (2.2 isolates/specimen), consisting of 122 anaerobic bacteria (1.7 isolates/specimen) and 35 facultative or aerobic bacteria (0.5 isolate/specimen), were recovered from the 73 bone specimens.

Anaerobic bacteria were recovered with aerobe or facultative bacteria in 24 (33%) instances. The predominant anaerobes were Bacteroides species (49 isolates), anaerobic cocci (45), Fusobacterium species (11), Propionibacterium acnes (7), and Clostridium species (6). Conditions predisposing to bone infections were vascular disease, bites, contiguous infection, peripheral neuropathy, hematogenous spread, and trauma. Pigmented Prevotella and Porphyromonas species were mostly isolated in skull and bite infections (7 of 19), members of the Bacteroides fragilis group in hand and feet infection (12 of 16), and Fusobacterium species in skull, bite, and hematogenous long bone infections. Seventy-four organisms (1.1 isolates/specimen), consisting of 67 anaerobic bacteria (1.0 isolate/specimen) and 7 facultative or aerobic bacteria (0.1 isolate/specimen), were isolated from 65 joint specimens. The predominant anaerobes were P. acnes (24 isolates), anaerobic cocci (17), Bacteroides species (10), and Clostridium species (5). Predisposing conditions to joint infection were trauma, prior surgery, presence of a prosthetic joint, and contiguous infection. P. acnes isolates were associated with prosthetic joints, members of the B. fragilis group with hematogenous spread, and Clostridium species with trauma. The clinical presentation of these cases is discussed.

CONCLUSION: These data highlight the importance of anaerobic bacteria in bone and joint infection.
PMID: 8420297 [PubMed - indexed for MEDLINE]

Pediatr Rehabil. 2002 Jan-Mar;5(1):11-9. JOINT AND BONE INFECTIONS DUE TO ANAEROBIC BACTERIA IN CHILDREN. Brook I.

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.
PMID: 12396847 [PubMed - indexed for MEDLINE]

Br J Neurosurg. 2007 Oct;21(5):473-7. SPONDYLODISCITIS (DISC SPACE INFECTION) ASSOCIATED WITH NEGATIVE MICROBIOLOGICAL TESTS: COMPARISON OF OUTCOME OF SUSPECTED DISC SPACE INFECTIONS TO DOCUMENTED NON-TUBERCULOUS PYOGENIC DISCITIS. Bhagat S, Mathieson C, Jandhyala R, Johnston R.
Department of Neurosurgery, Institute of Neurological sciences, Southern General Hospital, Glasgow, UK. shaishav_bhagat@rediffmail.com

Discitis, an infection of the disc space, is an uncommon diagnosis that, if missed, can lead to spinal deformity and neurological deterioration, although as many as 30% of these patients will have negative microbiological cultures. It was unclear, however, whether the prognosis differed between patients who had positive or negative cultures. A retrospective case note review was carried out to assess the differences in presentation and outcome between these two groups. There were 26 and 43 patients in the negative and positive groups, respectively. Those with a positive culture were more likely to present with pyrexia, have a neurological deficit and not be independently mobile at presentation. The mean CRP recorded at the time of presentation was 96 and 157 in the negative and positive groups respectively (p = 0.004). Similarly, the mean ESR in the positive group was 88 compared with 69 in the negative group (p = 0.02). In conclusion, these patients may be at different ends of a clinical spectrum: those patients with a positive culture having a greater local and systemic inflammatory reaction to the disc space infection.
PMID: 17852101 [PubMed - in process]

A CASE OF BRUCELLA SPONDYLODISCITIS WITH EXTENDED, MULTIPLE-LEVEL INVOLVEMENT
Mehmet Ozden, MD; Kutbettin Demirdag, MD; Ahmet Kalkan, MD; Huseyin Ozdemir, MD; Pinar Yuce, MD
South Med J. 2005;98(2):229-231. ©2005 Lippincott Williams & Wilkins
Posted 03/11/2005

Brucellosis is a zoonosis that affects several organs and has a protean presentation. The authors report the case of a 61-year-old male patient with brucellar spondylodiscitis involving several vertebrae and a paravertebral abscess localized in the erector spinae muscle. Diagnosis was made by positive blood culture and MRI. No relapse was seen with a combined treatment (doxycycline/rifampin) for 3 months, followed by doxycycline alone for 6 months. Almost all radiologic findings disappeared at the end of a 1-year follow-up without any further treatment.

Introduction

Brucellosis is an endemic zoonotic disease, especially in the Middle East and Mediterranean regions. Because it affects several organs and tissues, it may present in a variety of ways.[1-4] Spondylodiscitis is a frequent and important complication of brucellosis, affecting the lumbar vertebrae, followed by thoracic and cervical involvement.[5,6]
We report the case of a male patient with brucellosis and spondylodiscitis who had a lesion at multiple levels-thoracic, lumbar, and sacral-and a paravertebral abscess localized in the erector spinae muscle.

Case Report

A 61-year-old man was admitted to our hospital with a 2-month history of fever, chills, and profuse sweating, especially at night. He complained of fatigue, lack of appetite, weight loss, and back and low back pain for the past 6 weeks. He had a 4-week history of anti-inflammatory treatment for suspected spondylolisthesis. He also had a history of consumption of unpasteurized dairy products and performed stockbreeding.
On physical examination, his body temperature was 37.5°C. Tenderness was present on thoracic and lumbar vertebrae and left lumbosacral region. No neurologic abnormality was noted. He had hepatomegaly and splenomegaly.The patient's laboratory tests included white blood cell count, 6,200/mm3; hemoglobin, 12.2 g/dL; hematocrit, 33.7%; erythrocyte sedimentation rate, 69 mm/h; C-reactive protein, 44 mg/L [normal, 0 to 6 mg/L]; and a normal blood biochemistry profile. The Rose Bengal test was positive. The Wright agglutination test and 2-mercaptoethanol test for brucella were positive at titers of 1/320 and 1/160, respectively. Brucella melitensis was isolated from the blood culture. MRI of the thoracolumbar vertebrae showed loss of height in the intravertebral disks of T12-L1, L2-L3, L4-L5, and L5-S1, signal abnormality in vertebral end plates, and corpus and intervertebral disks consistent with spondylodiscitis (Fig. 1, A and B). A paravertebral abscess extending from the S1 left transverse processus to the erector spinae muscle with epidural involvement was identified. In addition, a soft tissue abscess was observed in both psoas muscles (Fig. 1, C and D).

A and B , MRI of the lumbar spine (sagittal view). T2-weighted image shows high signal intensity of the T12-L1, L2-L3, L3-L4, and L5-S1 vertebral end plate and intervertebral disks. C , precontrast image shows abscess of paravertebral and erector spinae muscle and epidural involvement (axial view). D , postcontrast image shows peripheral enhancement of the left erector spinae muscle and paravertebral abscess. On the basis of these findings, a diagnosis of brucellar spondylodiscitis with multiple vertebral involvement was made. The patient was administered 600 mg/d rifampin and 200 mg/d doxycycline for 3 months, followed by doxycycline alone for another 6 months. The patient's condition gradually improved.

At the end of the 9-month treatment period, the back and low back pain and other symptoms disappeared, and there was no tenderness in the thoracic and lumbar vertebrae and left paravertebral muscles. Laboratory tests demonstrated that erythrocyte sedimentation rate was 7 mm/h; C-reactive protein, 6 mg/L; and Wright agglutination, 1/40. All other blood values were normal. In the thoracolumbar MRI taken 1 year after the discontinuation of the treatment for the radiologic assessment, pathologic contrast was observed to decrease significantly in T12-L1 and disappeared totally in L2-S1. Also, the paravertebral and epidural abscesses disappeared (Fig. 2, A and B). Figure 2.
A , T2-weighted sagittal image shows no high signal intensity of the T12-L1, L2-L3, L3-L4, and L5-S1 vertebral endplates and corpus. B , there is no paravertebral soft tissue and epidural involvement on T2-weighted axial image.

Discussion

Spondylitis is one of the most common and important forms of osteoarticular involvement seen in brucellosis. The most common type of involvement is lumbar vertebra, which is followed by dorsal and cervical involvement.[7,8] Lumbar vertebral involvement among brucella spondylitis cases is reported between 44 and 76%. Involvement of vertebral segments is mostly unifocal, but multifocal and multilevel involvements may also be seen, though rarely.[9,10] A study that included 35 brucellar spondylitis cases reported multifocal spinal involvement in 3 cases.[9] Cases that have both lumbar and cervical vertebral involvement are seldom reported.[11] This case of brucella spondylodiscitis had a total of seven vertebrae, thoracic (1), lumbar (5), and sacral (1), and disks at four levels, T12-L1, L2-L3, L4-L5, and L5-S1. To the best of our knowledge, no case with such an involvement has been hitherto reported.
Spondylodiscitis may be accompanied by paravertebral and/or epidural abscess, which may imitate disk herniation.[2-5,12] However, as far as we know, only one case with a paravertebral abscess in the erector spinae muscle caused by brucellosis has been reported.[13] To the best of our knowledge, this is the first brucella case that had a paravertebral abscess localized in erector spinae muscle with multiple vertebral thoracic, lumbar, and sacral involvement.

Delays in diagnosis and treatment may lead to important neurologic and vascular complications in patients.[3,7] Brucellar spondylitis may be confused with other diseases affecting vertebra, especially with tuberculosis. MRI plays a significant role in diagnosis and follow-up because it is more sensitive than other imaging methods and has an important place in the identification of paravertebral and epidural formations. In brucellar spondylodiscitis, pathologic MRI findings become apparent about 1 month after the onset of clinical symptoms.[8]
Some randomized, double-blinded studies document that in brucellar spondylitis, the doxycycline and streptomycin combination was more effective than the doxycycline/rifampin combination.[14] Other reports suggest that there are no significant differences between the treatment regimens.[9]

The duration of treatment is determined by the clinical and radiologic response. In cases of paravertebral/epidural mass, the duration may be extended up to 12 months. Some studies report treatment being continued for as long as 535 days, and one study reported a mean therapy duration of 120 days for a series of 35 cases.[9] Short-term treatments increase the risk of relapse.

Conclusion

The present case illustrates three important features: First, the multiple-level and extended vertebral involvement; second, the combined treatment for 3 months, followed by doxycycline alone for 6 months, which was not associated with a relapse; and third, nearly all radiologic findings improved at the end of 1 year.

References

1. Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21:283-290.
2. Tekkok IH, Berker M, Ozcan OE, et al. Brucellosis of the spine. Neurosurgery 1993;33:838-844.
3. Colmenero JD, Reguera JM, Martos F, et al. Complications associated with Brucella melitensis infection: a study of 530 cases. Medicine 1996;75:195-211.
4. Colmenero JD, Cisneros JM, Orjuela DL, et al. Clinical course and prognosis of Brucella spondylitis. Infection 1992;20:38-42.
5. Mousa AR, Muhtaseb SA, Almudallal DS, et al. Osteoarticular complications of brucellosis: a study of 169 cases. Rev Infect Dis 1987;9:531-543.
6. Ariza J, Gudiol F, Valverde J, et al. Brucellar spondylitis: a detailed analysis based on current findings. Rev Infect Dis 1985;7:656-664.
7. Mousa AM, Bahar RH, Araj GF, et al. Neurological complications of brucella spondylitis. Acta Neurol Scand 1990;81:16-23.
8. Khateeb MI, Araj GF, Majeed SA, et al. Brucella arthritis: a study of 96 cases in Kuwait. Ann Rheum Dis 1990;49:994-998.
9. Solera J, Lozano E, Martinez-Alfaro E, et al. Brucellar spondylitis: review of 35 cases and literature survey. Clin Infect Dis 1999;29:1440-1449.
10. Sharif HS, Aideyan OA, ClarkDC, et al. Brucellar and tuberculous spondylitis: comparative imaging features. Radiology 1989;171:419-425.
11. Zormpala A, Skopelitis E, Thanos L, et al. An unusual case of brucellar spondylitis involving both the cervical and lumbar spine. Clin Imaging 2000;24:273-275.
12. Lifeso RM, Harder E, McCorkell SJ. Spinal brucellosis. J Bone Joint Surg Br 1985;67:345-351.
13. Ozgocmen S, Ardicoglu A, Kocakoc E, et al. Paravertebral abscess formation due to brucellosis in a patient with ankylosing spondylitis. Joint Bone Spine 2001;68:521-524.
14. Ariza J, Gudiol F, Pallares R, et al. Treatment of human brucellosis with doxycycline plus rifampin or doxycycline plus streptomycin: a randomized, double-blind study. Ann Intern Med 1992;117:25-30.
Sidebar: Key Messages
· Brucellosis is a zoonosis that is commonly seen throughout the world and is endemic in Turkey. Since it affects several organs and tissues, it may appear in various clinical pictures.
· This report describes a rare case of spondylodiscitis with extended involvement at seven consecutive levels.
· No relapse was observed with a combined treatment for 3 months, followed by doxycycline alone for 6 months.
· All radiologic findings improved at the end of 1 year of follow-up without any treatment in this case.

Reprint Address
Reprint requests to Dr. Mehmet Ozden, FiratUniversity, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, TR-23119 Elazıg, Turkey. Email: ozdenm44@hotmail.com

Mehmet Ozden, MD , Kutbettin Demirdag, MD , Ahmet Kalkan, MD , Huseyin Ozdemir, MD ,and Pinar Yuce, MD , Department of Infectious Diseases and Clinical Microbiology and the Department of Radiology, FiratUniversity, Faculty of Medicine, Elazig, Turkey


Res Vet Sci. 1976 May;20(3):334-9.
PATHOGENICITY STUDIES IN POULTRY WITH AN UNDEFINED SEROTYPE OF MYCOPLASMA.
Wise DR, Fuller MK.
Pathogenicity trials in poultry are reported with an isolate of mycoplasma, designated 'W8', which is serologically unrelated to Mycoplasma gallisepticum, M synoviae or M meleagridis. W8 killed fowl and turkey embryos when injected into the yold sacs of embryonating eggs. Infection of one-day-old fowls, turkeys and pheasants by the air sac route caused marked growth depression and a high incidence of osteomyelitis of the vertebral column in all species. A large proportion of infected turkeys and a smaller proportion of infected pheasants also developed chondrodystrophic changes of the long bones similar to those of turkey syndrome '65. Infection did not cause mortality or macroscopic air sacculitis. No obvious pathological changes occurred in fowls following W8 infection by the air sac route at two weeks of age and only minimal changes when infection was given at one week. Infection did not appear to spread to in-contact controls. W8 was recovered most frequently and in greatest profusion from the air sacs, tracheas, kidneys and vertebral columns of fowls and turkeys following air sac infection at one day of age.

Infection. 2000 Jan-Feb;28(1):46-8.
RETROPERITONEAL ABSCESS AND BACTEREMIA DUE TO MYCOPLASMA HOMINIS IN A POLYTRAUMATIZED MAN.
Brunner S, Frey-Rindova P, Altwegg M, Zbinden R.
Dept. of Medical Microbiology, University of Zurich, Switzerland.
We report a case of a retroperitoneal abscess due to Mycoplasma hominis in a young polytraumatized man who developed septicemia under treatment with rifampin and flucloxacillin. M. hominis was recovered from blood cultures as well as from the abscess near the left iliac spine. After 10 days of therapy with clindamycin the patient improved, and intraoperatively taken swabs were culture negative but still positive by PCR.
PMID: 10697792 [PubMed - indexed for MEDLINE]

Acta Paediatr. 2005 Sep;94(9):1339-41.
ACUTE SEVERE SPINAL CORD DYSFUNCTION IN A CHILD WITH MENINGITIS: STREPTOCOCCUS PNEUMONIAE AND MYCOPLASMA PNEUMONIAE CO-INFECTION.
Manteau C, Liet JM, Caillon J, M'Guyen S, Quere MP, Roze JC, Gras-Le Guen C.Paediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France.

Tetraplegia developed abruptly in an 11-y-old with pneumococcal meningitis. Magnetic resonance imaging showed multiple hyperintensities at the brainstem-spinal cord junction. Serological tests were positive for Mycoplasma pneumoniae (microparticle agglutination and specific IgMs). Erythromycin and dexamethasone were started promptly, and 10 d later the patient was discharged with normal neurological function. CONCLUSION: Tetraplegia during the course of pneumococcal meningitis in an 11-y-old girl disappeared after treatment with ceftriaxone, erythromycin and dexamethasone.
PMID: 16279003 [PubMed - indexed for MEDLINE]

J Clin Neurosci. 2007 Jan;14(1):61-4. Epub 2006 Nov 7.
REVERSIBLE MYELORADICULOPATHY DUE TO MYCOPLASMA PNEUMONIAE. Hsing J, Welgampola M, Kiernan MC.
Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia.

A 22-year-old man presented with flaccid paraparesis and a thoracic sensory level in the context of a recent respiratory illness. Investigations established cerebrospinal pleocytosis with elevated protein, and subsequent serological testing confirmed raised antibody titres to Mycoplasma pneumoniae. Nerve conduction studies established that H-reflexes were prolonged and somatosensory evoked responses were delayed from the lower limbs bilaterally. Although imaging of the spinal cord revealed no abnormality, clinical and neurophysiological findings were consistent with a myeloradiculopathy. The patient was treated with pulse intravenous methylprednisone and underwent complete recovery over a 4-week period.
PMID: 17092721 [PubMed - indexed for MEDLINE]
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Old 12-27-2007, 05:20 PM
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I've having html issues, so the Word version for now for the rest of the abstracts...
________

Am J Med. 1993 Jan;94(1):21-8. Am J Med. 2001 Aug1;111(2):161.
ANAEROBIC OSTEOMYELITIS AND ARTHRITIS IN A MILITARY HOSPITAL: A 10-YEAR EXPERIENCE.
Brook I, Frazier EH.

Department of Pediatrics and Infectious Diseases, Naval Medical Center, Bethesda, Maryland.
PURPOSE: The methods of collecting, transporting, cultivating, and identifying aerobic bacteria in bone and joint infections have improved markedly since the early 1980s. In addition, many of the anaerobes have been reclassified and renamed. The purpose of this study was to provide more
obic cocci (45), Fusobacterium species (11), Propionibacterium acnes (7), and Clostridium species (6). Conditions predisposing to bone infections were vascular disease, bites, contiguous infection, peripheral neuropathy, hematogenous spread, and trauma. Pigmented Prevotella and Porphyromonas species were mostly isolated in skull and bite infections (7 of 19), members of the Bacteroides fragilis group in hand and feet infection (12 of 16), and Fusobacterium species in skull, bite, and hematogenous long bone infections. Seventy-four organisms (1.1 isolates/specimen), consisting of 67 anaerobic bacteria (1.0 isolate/specimen) and 7 facultative or aerobic bacteria (0.1 isolate/specimen), were isolated from 65 joint specimens. The predominant anaerobes were P. acnes (24 isolates), anaerobic cocci (17), Bacteroides species (10), and Clostridium species (5). Predisposing conditions to joint infection were trauma, prior surgery, presence of a prosthetic joint, and contiguous infection. P. acnes isolates were associated with prosthetic joints, members of the B. fragilis group with hematogenous spread, and Clostridium species with trauma. The clinical presentation of these cases is discussed.

CONCLUSION: These data highlight the importance of anaerobic bacteria in bone and joint infection
PMID: 8420297 [PubMed - indexed for MEDLINE]

Pediatr Rehabil. 2002 Jan-Mar;5(1):11-9.
JOINT AND BONE INFECTIONS DUE TO ANAEROBIC BACTERIA IN CHILDREN.
Brook I.

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.
PMID: 12396847 [PubMed - indexed for MEDLINE]

Br J Neurosurg. 2007 Oct;21(5):473-7.
SPONDYLODISCITIS (DISC SPACE INFECTION) ASSOCIATED WITH NEGATIVE MICROBIOLOGICAL TESTS: COMPARISON OF OUTCOME OF SUSPECTED DISC SPACE INFECTIONS TO DOCUMENTED NON-TUBERCULOUS PYOGENIC DISCITIS.
Bhagat S, Mathieson C, Jandhyala R, Johnston R.

Department of Neurosurgery, Institute of Neurological sciences, Southern General Hospital, Glasgow, UK. shaishav_bhagat@rediffmail.com

Discitis, an infection of the disc space, is an uncommon diagnosis that, if missed, can lead to spinal deformity and neurological deterioration, although as many as 30% of these patients will have negative microbiological cultures. It was unclear, however, whether the prognosis differed between patients who had positive or negative cultures. A retrospective case note review was carried out to assess the differences in presentation and outcome between these two groups. There were 26 and 43 patients in the negative and positive groups, respectively. Those with a positive culture were more likely to present with pyrexia, have a neurological deficit and not be independently mobile at presentation. The mean CRP recorded at the time of presentation was 96 and 157 in the negative and positive groups respectively (p = 0.004). Similarly, the mean ESR in the positive group was 88 compared with 69 in the negative group (p = 0.02). In conclusion, these patients may be at different ends of a clinical spectrum: those patients with a positive culture having a greater local and systemic inflammatory reaction to the disc space infection.
PMID: 17852101 [PubMed - in process]

Res Vet Sci. 1976 May;20(3):334-9.
PATHOGENICITY STUDIES IN POULTRY WITH AN UNDEFINED SEROTYPE OF MYCOPLASMA.
Wise DR, Fuller MK.

Pathogenicity trials in poultry are reported with an isolate of mycoplasma, designated 'W8', which is serologically unrelated to Mycoplasma gallisepticum, M synoviae or M meleagridis. W8 killed fowl and turkey embryos when injected into the yold sacs of embryonating eggs. Infection of one-day-old fowls, turkeys and pheasants by the air sac route caused marked growth depression and a high incidence of osteomyelitis of the vertebral column in all species. A large proportion of infected turkeys and a smaller proportion of infected pheasants also developed chondrodystrophic changes of the long bones similar to those of turkey syndrome '65. Infection did not cause mortality or macroscopic air sacculitis. No obvious pathological changes occurred in fowls following W8 infection by the air sac route at two weeks of age and only minimal changes when infection was given at one week. Infection did not appear to spread to in-contact controls. W8 was recovered most frequently and in greatest profusion from the air sacs, tracheas, kidneys and vertebral columns of fowls and turkeys following air sac infection at one day of age.
Infection. 2000 Jan-Feb;28(1):46-8.

RETROPERITONEAL ABSCESS AND BACTEREMIA DUE TO MYCOPLASMA HOMINIS IN A POLYTRAUMATIZED MAN.
Brunner S, Frey-Rindova P, Altwegg M, Zbinden R.
Dept. of Medical Microbiology, University of Zurich, Switzerland.
We report a case of a retroperitoneal abscess due to Mycoplasma hominis in a young polytraumatized man who developed septicemia under treatment with rifampin and flucloxacillin. M. hominis was recovered from blood cultures as well as from the abscess near the left iliac spine. After 10 days of therapy with clindamycin the patient improved, and intraoperatively taken swabs were culture negative but still positive by PCR.
PMID: 10697792 [PubMed - indexed for MEDLINE]
Acta Paediatr. 2005 Sep;94(9):1339-41.

ACUTE SEVERE SPINAL CORD DYSFUNCTION IN A CHILD WITH MENINGITIS: STREPTOCOCCUS PNEUMONIAE AND MYCOPLASMA PNEUMONIAE CO-INFECTION.
Manteau C, Liet JM, Caillon J, M'Guyen S, Quere MP, Roze JC, Gras-Le Guen C.
Paediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France.
Tetraplegia developed abruptly in an 11-y-old with pneumococcal meningitis. Magnetic resonance imaging showed multiple hyperintensities at the brainstem-spinal cord junction. Serological tests were positive for Mycoplasma pneumoniae (microparticle agglutination and specific IgMs). Erythromycin and dexamethasone were started promptly, and 10 d later the patient was discharged with normal neurological function. CONCLUSION: Tetraplegia during the course of pneumococcal meningitis in an 11-y-old girl disappeared after treatment with ceftriaxone, erythromycin and dexamethasone.
PMID: 16279003 [PubMed - indexed for MEDLINE]
J Clin Neurosci. 2007 Jan;14(1):61-4. Epub 2006 Nov 7.

REVERSIBLE MYELORADICULOPATHY DUE TO MYCOPLASMA PNEUMONIAE.
Hsing J, Welgampola M, Kiernan MC.
Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia.
A 22-year-old man presented with flaccid paraparesis and a thoracic sensory level in the context of a recent respiratory illness. Investigations established cerebrospinal pleocytosis with elevated protein, and subsequent serological testing confirmed raised antibody titres to Mycoplasma pneumoniae. Nerve conduction studies established that H-reflexes were prolonged and somatosensory evoked responses were delayed from the lower limbs bilaterally. Although imaging of the spinal cord revealed no abnormality, clinical and neurophysiological findings were consistent with a myeloradiculopathy. The patient was treated with pulse intravenous methylprednisone and underwent complete recovery over a 4-week period.
PMID: 17092721 [PubMed - indexed for MEDLINE]
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Old 01-01-2008, 05:56 PM
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Quote:
Nine of 10 patients with positive disc cultures had negative blood cultures.
I am new but wouold like to comment. Should i intoruce myself here? thank you
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Old 01-01-2008, 06:47 PM
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Welcome Messy Spine. You sure can introduce yourself in The Big File. Just click on the icon over to the left that says "new," then click on "discussion" and you can give your topic a title and take it away. Sometimes it takes a little experimenting to figure the forums out. Again, welcome and let us be of help to you!
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Old 01-14-2008, 09:05 AM
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Particular Form of Septic Arthritis: Septic Arthritis of Facet Joint.
Michel-Batôt C, Dintinger H, Blum A, Olivier P, Laborde F, Bettembourg-Brault I, Pourel J, Loeuille D, Chary-Valckenaere I. Rheumatology Department, Brabois Teaching Hospital, CHU Brabois, 54000 Nancy, France.

Only about 40 cases of septic arthritis of the facet joints have been reported to date. We report 6 new cases including 2 at the cervical spine, which is rarely involved. Mean age was 61.5 years; there were 5 men and 1 woman. Spinal pain and stiffness, fever, and asthenia were the presenting manifestations. Laboratory tests consistently showed inflammation. Among classical risk factors for infection, only noninsulin-dependent diabetes was noted, in a single patient. Mean time to the diagnosis was 42 days.

Discitis, a far more common condition, was considered initially, and early radiographs were of limited diagnostic assistance. Radionuclide bone scans identified the site of the infection and served to look for other foci. Magnetic resonance imaging was effective in confirming the diagnosis at an early stage and in looking for local spread (muscles, epidural space, and disk). L3-L4 was involved in 3 patients, C4-C5 in 2, and L4-L5 in 1. Direct inoculation during mesotherapy sessions was the cause in 1 patient. Cultures of blood and needle biopsy samples were positive in all 6 cases; Staphylococcus aureus was the causative agent in 3 patients. The risk of local and systemic complications governs the prognosis of facet joint infection.

Of our 6 patients, 4 experienced complications: there was 1 case each of discitis, epidural infection, endocarditis, and septic arthritis of the acromioclavicular joint. Fatal multiple organ dysfunction occurred in 1 patient. In the other 5 patients, antimicrobial therapy and protection from weight-bearing for 3 months ensured a favorable outcome.
PMID: 18093863 [PubMed - as supplied by publisher]
Rev Rhum Engl Ed. 1997 Jun;64(6):386-95.


Rev Rhum Engl Ed. 1997 Dec;64(12):859-60.
Septic Arthritis Of Lumbar Facet Joints. A Review Of Six Cases. Ergan M, Macro M, Benhamou CL, Vandermarcq P, Colin T, L'Hirondel JL, Marcelli C.Rheumatology Department, Côte de Nacre Teaching Hospital, Caen, France.

Hematogenous infection of the facet joints by pyogenic organisms is exceedingly rare. We report six cases of lumbar facet joint septic arthritis due to hematogenous spread of a pyogenic organism. A review of the literature identified ten anecdotal reports of similar cases. An analysis of these 16 cases showed that the diagnosis was based mainly on imaging study findings and that clinical data failed to discriminate between facet joint septic arthritis and infectious discitis. Increased uptake on the radionuclide bone scan was an early finding and the pattern of uptake was different from that seen in discitis.

Computed tomography was the investigation that best delineated the facet joint lesions. Magnetic resonance imaging of the lumbar spine was superior over computed tomography in demonstrating spread of the infection to the epidural space and/or soft tissues and in some instances demonstrated enhancement of the infected facet joint on T1 images after gadolinium injection. Aspiration of the facet joint under fluoroscopic guidance was required only when blood cultures were negative or when the diagnosis of the septic nature of the arthritis was in doubt. Blood cultures yielded a Staphylococcus aureus in the six cases in our series. Appropriate antimicrobial therapy was successful in most cases. In our series, four of the six patients had posterior epiduritis, pyomyositis, or an abscess in the paraspinal muscles or psoas muscle, suggesting that some epidural infections or psoas muscle abscesses believed heretofore to be primary may in fact be complications of facet joint septic arthritis. Facet joint septic arthritis is a new aspect of pyogenic spinal infections that deserves to be considered in patients with febrile spinal syndromes not explained by discitis. PMID: 9513611 [PubMed - indexed for MEDLINE]

J Spinal Disord Tech. 2003 Jun;16(3):285-7.
Delayed Presentation Of Septic Arthritis Of A Lumbar Facet Joint After Diagnostic Facet Joint Injection. Orpen NM, Birch NC.

Department of Trauma and Orthopaedics, WycombeGeneralHospital, High Wycombe, UK.

We report the case of a 46-year-old, otherwise healthy, man with chronic lower back pain and no evidence of nerve root compression who underwent diagnostic facet joint injections to assist in establishing where his pain sources were located and to try to help his spinal rehabilitation program. He presented with a facet joint infection 2 months after injection, in a manner that was indistinguishable from an acute intervertebral disc herniation. The diagnosis was confirmed on magnetic resonance imaging, and he was successfully treated with surgical debridement and antibiotics. Septic arthritis of a lumbar facet joint with an associated paraspinal abscess is a rare complication of facet joint infiltration with only two similar cases reported in the literature. We propose that this diagnosis be considered in patients who have undergone diagnostic facet joint injection who subsequently deteriorate with back and leg pain without another apparent cause.PMID: 12792344 [PubMed - indexed for MEDLINE]

Pain Med. 2006 Jan-Feb;7(1):52-6.

Septic Facet Joint Arthritis After A Corticosteroid Facet Injection.
Weingarten TN, Hooten WM, Huntoon MA. Department of Anesthesiology, MayoClinicCollege of Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota55905, USA.

Lumbar facet joint injections are commonly employed in the treatment of low back pain and are considered to be relatively safe with few known complications. We report the case of septic facet arthritis following a periarticular facet injection in a patient with recurrent urinary tract infections. The literature is reviewed to identify epidemiological and clinical features of patients in whom septic facet arthritis developed after lumbar facet injection. The diagnosis of iatrogenic septic facet arthritis is often delayed because neurologic and constitutional signs and symptoms develop slowly. Serologic nonspecific markers of infection and appropriate imaging studies may be more sensitive for the early diagnosis of septic facet arthritis. Recalcitrant or worsening back pain after facet injections should prompt an investigation to rule out infectious causes. PMID: 16533197 [PubMed - indexed for MEDLINE]

Semin Arthritis Rheum. 2006 Apr;35(5):272-83.
Spontaneous Pyogenic Facet Joint Infection.
Narváez J, Nolla JM, Narváez JA, Martinez-Carnicero L, De Lama E, Gómez-Vaquero C, Murillo O, Valverde J, Ariza J. Rheumatology Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.

OBJECTIVE: To analyze the clinical features, approaches to management, and outcome of spontaneous pyogenic facet joint infection (PFJI) in adults.

PATIENTS AND METHODS: Case series of 10 adults with microbiologically proven PFJI diagnosed during a 10-year period in a teaching hospital, plus a review of 32 additional cases previously reported (PubMed 1972 to 2003). Patients with prior spinal instrumentation or surgery and injection drug users were excluded. Only cases that were sufficiently detailed to be individually analyzed were included. These 32 cases, together with our 10 patients, form the basis of the present analysis.

RESULTS: PFJI represented nearly 20% of all spontaneous pyogenic spinal infection diagnosed in our hospital during a 10-year period. This data suggest that PFJI is more common than was previously thought. This data suggest that PFJI is more common than was previously thought. Of the 42 patients with PFJI, 26 (62%) were men and 16 (38%) were women, with ages ranging from 20 to 86 years (mean age, 59+/-15 years); 55% of patients were older than 60 years. The most common location of infections was the lumbosacral region (86%). All patients presented with severe back pain; fever was noted in 83% of the cases and neurological impairment in nearly 48%. In 38% of patients a systemic predisposing factor for infection was present; the most common conditions were diabetes mellitus, malignancies, and alcoholism.

In almost 36% of cases, one or more concomitant infectious processes due to the same microorganism was found, mainly arthritis, skin and soft-tissue infections, endocarditis, and urinary tract infections. Staphylococcus aureus was the most common etiologic microorganism (86% of cases). Bacteremia was documented in 81% of the cases. The diagnosis of PFJI was based mainly on imaging study findings. Paraspinal and/or epidural extension was frequent (81% of cases), but its presence did not indicate a worse prognosis. Medical treatment alone was usually successful. The overall prognosis of PFJI was good, with a mortality rate of only 2%. The great majority of patients were cured without functional sequelae.

CONCLUSION: Incidence data from our institution reveal that PFJI is not a rare condition, representing approximately 20% of all pyogenic spinal infections. This entity should be considered in the differential diagnosis of patients with low back pain, especially in the presence of fever, whatever the patient's immunological status. PMID: 16616150 [PubMed - indexed for MEDLINE]
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Old 01-17-2008, 04:51 PM
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A while back, I found this amazing article (attached). After reading it again today, I found more gems of intelligence that helped me connect more dots, while also validating some of my grandiose conclusions about health issues facing many patients within this community.

Following the general theme of "pathologies of spine disease," I attached an article that is now ten years old. It is not only well-researched, but it seems to be the most analytical document I’ve read that ties so many disparate pieces of pathologies and disease together – so that even patients can understand the implications of the evidence presented!

It’s not a spine-centric article, per se, but here are a few points I found interesting:

- An excerpt: “…80% of joint infections in England & Wales (1990-92) were due to mycobacteria…there is a predilection for weight bearing joints and the spine.”

- The author, Dr. Goldenberg, is based in Mass., but did not include any clinical data from the U.S. Furthermore, the paper was published in The Lancet, a UK journal.

- Note the algorithm(s) for evaluating an infected joint; which includes blood, synovial fluid AND tissue. Try getting your ortho to test all these -- most will not except in very rare circumstances.


I am sure there are many other points that patients will find valuable and interesting. Please read it a few times, share it with someone and talk about it. Then read it again in a few weeks!

Again, I find it amazing that this was written a decade ago – with so few other like this published since then. Why is that?!

We are still very much in the dark on these important issues. I hope that helps others connect the dots too! There are many...
Attached Files
File Type: pdf Septic_Arthritis.pdf (86.9 KB, 20 views)
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Old 02-05-2008, 04:53 PM
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Oops...almost forgot this eight-year-old article! As I've lamented earlier -- all the studies & article specific to joint disease originate from other countries. You do the math!
______________________________________

J Clin Microbiol. 2000 January; 38(1): 90–93. American Society for Microbiology

Identification of Mycoplasma fermentans in Synovial Fluid Samples from Arthritis Patients with Inflammatory Disease

Sheena Johnson,* David Sidebottom, Felix Bruckner, and David Collins†
St. George's Hospital and Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom
*Corresponding author. Biochemistry Department, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom. Phone: 44 181 725 5779. Fax: 44 181 725 2992. E-mail: sjohnson@sghms.ac.uk.

†Present address: Princess Margaret Hospital, Swindon SN1 4JU, United Kingdom.
Received July 13, 1999; Revisions requested August 26, 1999; Accepted September 22, 1999.
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Abstract

Since 1970 Mycoplasma fermentans has been suspected of being associated with rheumatoid arthritis. However, this association has been difficult to prove, and this has been our goal. The distribution of M. fermentans was studied in the synovial fluid of patients suffering from different arthritides. Samples of synovial fluid were taken from patients with well-defined disease and a clear diagnosis. After removal of the inflammatory cells and hyaluran, they were treated with proteinase K and tested by a single or fully nested PCR with primers directed against part of the two 16S rRNA genes of M. fermentans.

The product was sequenced automatically, by using an ALF Express automatic sequencer, to confirm the mycoplasma species and to identify the strain since the two genes were usually found to be polymorphic. This was also true of the type strain, strain PG18. M. fermentans was detected in 23 of 26 (88%) rheumatoid arthritis patients, and four different strains were found. It was also found in 7 of 8 (88%) of the nonrheumatoid inflammatory arthritis patient group, which consisted of one patient with reactive arthritis, one patient with pauciarticular juvenile chronic arthritis, two patients with gout, two patients with ankylosing spondylitis, and two patients with psoriatic arthritis, only one of whom was infected with M. fermentans. It was not detected in any of the 10 osteoarthritis patients. M. fermentans was therefore found to be a variable and very common organism in arthritic patients with inflammatory joint exudates and may well prove to be important in the etiology of the diseases.

Full article at:

http://www.pubmedcentral.nih.gov/art...gi?artid=86027
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Fell on my ***winter 2003, Canceled fusion April 6 2004
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Old 02-25-2008, 06:31 PM
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Harrison Harrison is offline
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A patient who recently had 2 level cervical ADR sent me this article. He also tested positive for Lyme disease, erlichiosis and bartonella. It's an old article, but it is worth repeating since these diseases are so rampant. Many spine patients from our community are from New York, New Jersey and Connecticut!
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Sciatica, disk herniation, and neuroborreliosis. A report of four cases Sciatica, disk herniation, and neuroborreliosis. A report of four cases

Arnaud Dupeyron , , a, Jehan Lecocqa, Benoît Jaulhacb, Marie-Eve Isner-Horobetia, Philippe Vautraversa, Julien Cohen-Solalc, Christelle Sordetc and Jean-Louis Kuntzc
a Physical Medicine and Rehabilitation Unit, Strasbourg Teaching Hospitals, Avenue Molière, 67098, Strasbourg cedex, France
b School of Medicine, Bacteriology Institute, Louis Pasteur University and Strasbourg Teaching Hospitals, 67000, Strasbourg, France
c Rheumatology and Clinical Immunology Department, Strasbourg Teaching Hospitals, Avenue Molière, 67098, Strasbourg cedex, France

Available online 25 September 2003. Abstract

We report four cases of sciatica in patients with same-level disk herniation confirmed by computed tomography and a final diagnosis of acute radiculitis caused by Borrelia burgdorferi, with a favorable response to ceftriaxone therapy. The neurological manifestations of Lyme disease are protean, and a potential contribution of concomitant disk disease to sciatica can lead to diagnostic wanderings. Disk lesions and infectious conditions that can cause sciatica are discussed. Whether a favorable response to antibiotic therapy should be taken as proof of B. burgdorferi radiculitis deserves discussion. In practice, in a patient with clinical manifestations suggesting disk-related nerve root pain and residing or having traveled to an endemic area, B. burgdorferi infection should be looked for, as both etiologies can coexist.
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
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Old 02-26-2008, 06:51 AM
Don Don is offline
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I was wondering how many disks that are removed for fusion or ADR are ever investigated, so the cause of the degeneration is known and can be used as a treatment. I bet nearly zero% are ever studied. It a pitiful shame that medicine treats symptoms, not causes. Every doctor will matter of factly claim they don't know what causes these diseases, but do they investigate them to find a cause?

If or when I have surgery, I will ask if they are going to do anything with the disks.

Thanks for the articles Harrison.
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3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
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Old 02-26-2008, 08:15 AM
Nairek Nairek is offline
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Rich,
When I finish my project for tomorrow night's class, I'll read thru what you have here & comment. I caught something about osteomyelitis which hits home.
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Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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