- Email: [email protected]
Atypical presentation of spontaneous discitis: case report
Infection
Atypical Presentation of Spontaneous Discitis: Case Report Lei Han, M.D.,* M. Altaf Keiserrudin, M.D.,* and Paul L. Jensen, M. D.† *Wausau Family Practice Center and †Wausau Spine & Neurosciences, Wausau, Wisconsin
Han L, Keiserrudin MA, Jensen PL. Atypical presentation of spontaneous discitis: case report. Surg Neurol 2004;61:142– 4. BACKGROUND
Spontaneous discitis is primarily a pediatric illness. Adult patients usually present at an average age of 69 years with a history of diabetes or with a systemic infection. The lumbar spine is the most frequent site of infection (54%), and the cervical is the least at 10%. The causative organisms are most commonly Staphylococcus aureus and -hemolytic streptococcus species. Intravenous antibiotics are the mainstays of treatment, and surgical intervention is usually not required. CASE PRESENTATION
A single case observation with an unusual presentation from the statistically typical criterion of discitis is described. CONCLUSIONS
Atypical discitis needs to be considered in the differential diagnoses in the middle-aged and healthy population. © 2004 Elsevier Inc. All rights reserved. KEY WORDS
Atypical spontaneous discitis, Streptococcus mitis, spontaneous discitis, atypical, adult, middle aged, dental cleaning, human, English.
pontaneous discitis is primarily a pediatric illness. Adult patients usually present at an average age of 69 years with diabetes or with a systemic infection [2]. The lumbar spine is the most frequent site of infection (54%), and the cervical is the least at 10% [3]. The causative organisms are most commonly Staphylococcus aureus and -hemolytic Streptococcus species [4]. Intravenous antibiotics are the mainstays of treatment, and surgical intervention is usually not required. This case involved a 47-year-old, previously healthy female with an acute onset of constant neck pain that radiated to her face and followed with numbness and tingling over both shoulders without weakness. Narcotic analgesics alleviated symp-
S
Address reprint requests to: Lei Han, M.D., Wausau Family Practice Center, 995 Campus Dr., Wausau, WI 54401. Received March 31, 2003; accepted May 8, 2003. 0090-3019/04/$–see front matter doi:10.1016/S0090-3019(03)00421-X
toms, and chiropractic manipulations aggravated the pain. A cervical spine X-ray film revealed lytic lesions in C4 and C5, exaggerated kyphosis, decreased intervertebral disc space, and increased soft tissue shadows. A follow-up magnetic resonance imaging (MRI) study showed erosion of the end plates, epidural phlegmons, and a marked gibbous deformity (Figures 1 and 2). The patient was admitted to the intensive care unit (ICU), and surgery was performed the following day because of instability of her cervical spine. The initial approach was anterior; purulent material with a foul odor was collected from a paraspinal abscess, which later identified as Streptococcus mitis. The C4 and C5 vertebrae and the intercalated disc were debrided, and an anterior-superior iliac crest autograft was harvested and implanted into the gap between C4 and C5. Because of the concern of the infection, anterior hardware was avoided. The next day, the fusion was instrumented posteriorly with lateral mass plates. Postoperatively, nafcillin and vancomycin were initiated. Erythromycin was added at ICU. When the gram staining and culture of the cervical spine specimen identified the organism as ␣-hemolytic Streptococcus, the antibiotic regimen was changed to IV penicillin G and erythromycin with a single dose of Gentamycin. The patient was discharged home 1 week postoperatively with ceftriaxone, 2 g IV per day, for duration of 5 weeks with a PICC line placed. Follow-up X-rays showed stable spinal structures. Further follow-ups indicated no further complications or sequelae. Interestingly, further query of history detail revealed possible precipitating factors. The patient was involved in a motor vehicle accident approximately 20 years earlier resulting in chronic neck and shoulder pain. Then, about 1 month before onset of this neck pain, the patient underwent a routine dental cleaning. It is highly unusual for S. mitis found in normal oral flora [1] to cause an infectious process in the © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Atypical Spontaneous Discitis
1
Demonstrates the distraction of the vertebrates and the disc.
central nervous system. In this case, the recent dental procedure may have produced a bacteremia, which perhaps seeded in a susceptible site caused by the previous motor vehicle accident. Throughout the course of the discitis, the patient remained systemically asymptomatic. She was afebrile with a normal white blood count (WBC) count. HIV and hepatitis testing were negative; blood and urine cultures were also negative; immunoglobulin (IgG, IgM, and IgE) levels were normal; and a 2-D echocardiogram was negative for endocarditis. The case reported here is atypical in several aspects. The patient did not fit in the classic bimodal age distribution; she did not have any chronic medical problems; the area of involvement was in the least common, the cervical spine; she did not have any preceding systemic infectious processes; and finally, surgical intervention was required. We would like to acknowledge James S. Collinson, M.D., for his radiology expertise.
Surg Neurol 143 2004;61:142– 4
2
Indicates the abscesses and fluid collections at anterior and posterior spaces of the spinal column.
REFERENCES 1. Barsotti O, Decoret D, Renaud FN. Identification of streptococcus mitis group species by RFLP of the polymerase chain reaction-amplified 16S-23S rDNA intergenic spacer. Res Microbiol 2002;153:10:687–91. 2. DeSouza L. Disc space infection in children, late adolescents, and adults. Minn Med 1980;63:314 –20. 3. Kemp H, Jackson JW, Jeremiah JD, Hall AJ. Pyogenic infections occurring primarily in intervertebral discs. J Bone Joint Surg 1973;55(B):698 –714. 4. Wiley A, Trueta J. The vascular anatomy of the spine and its relationship to pyogenic vertebral osteomyelitis. J Bone Joint Surg 1959;41B:796 –809. COMMENTARY
This case report of cervical discitis and osteomyelitis with epidural abscess formation is unusual from two standpoints. First, the patient had no associated illness that is ordinarily found in adult patients with this disease, and second, the organism is unusual since S. mitis, a streptococcas viridans organism normally residing in the mouth, was the microbiologic cause. While S. mitis is a
Atypical Presentation of Spontaneous Discitis: Case Report Lei Han, M.D.,* M. Altaf Keiserrudin, M.D.,* and Paul L. Jensen, M. D.† *Wausau Family Practice Center and †Wausau Spine & Neurosciences, Wausau, Wisconsin
Han L, Keiserrudin MA, Jensen PL. Atypical presentation of spontaneous discitis: case report. Surg Neurol 2004;61:142– 4. BACKGROUND
Spontaneous discitis is primarily a pediatric illness. Adult patients usually present at an average age of 69 years with a history of diabetes or with a systemic infection. The lumbar spine is the most frequent site of infection (54%), and the cervical is the least at 10%. The causative organisms are most commonly Staphylococcus aureus and -hemolytic streptococcus species. Intravenous antibiotics are the mainstays of treatment, and surgical intervention is usually not required. CASE PRESENTATION
A single case observation with an unusual presentation from the statistically typical criterion of discitis is described. CONCLUSIONS
Atypical discitis needs to be considered in the differential diagnoses in the middle-aged and healthy population. © 2004 Elsevier Inc. All rights reserved. KEY WORDS
Atypical spontaneous discitis, Streptococcus mitis, spontaneous discitis, atypical, adult, middle aged, dental cleaning, human, English.
pontaneous discitis is primarily a pediatric illness. Adult patients usually present at an average age of 69 years with diabetes or with a systemic infection [2]. The lumbar spine is the most frequent site of infection (54%), and the cervical is the least at 10% [3]. The causative organisms are most commonly Staphylococcus aureus and -hemolytic Streptococcus species [4]. Intravenous antibiotics are the mainstays of treatment, and surgical intervention is usually not required. This case involved a 47-year-old, previously healthy female with an acute onset of constant neck pain that radiated to her face and followed with numbness and tingling over both shoulders without weakness. Narcotic analgesics alleviated symp-
S
Address reprint requests to: Lei Han, M.D., Wausau Family Practice Center, 995 Campus Dr., Wausau, WI 54401. Received March 31, 2003; accepted May 8, 2003. 0090-3019/04/$–see front matter doi:10.1016/S0090-3019(03)00421-X
toms, and chiropractic manipulations aggravated the pain. A cervical spine X-ray film revealed lytic lesions in C4 and C5, exaggerated kyphosis, decreased intervertebral disc space, and increased soft tissue shadows. A follow-up magnetic resonance imaging (MRI) study showed erosion of the end plates, epidural phlegmons, and a marked gibbous deformity (Figures 1 and 2). The patient was admitted to the intensive care unit (ICU), and surgery was performed the following day because of instability of her cervical spine. The initial approach was anterior; purulent material with a foul odor was collected from a paraspinal abscess, which later identified as Streptococcus mitis. The C4 and C5 vertebrae and the intercalated disc were debrided, and an anterior-superior iliac crest autograft was harvested and implanted into the gap between C4 and C5. Because of the concern of the infection, anterior hardware was avoided. The next day, the fusion was instrumented posteriorly with lateral mass plates. Postoperatively, nafcillin and vancomycin were initiated. Erythromycin was added at ICU. When the gram staining and culture of the cervical spine specimen identified the organism as ␣-hemolytic Streptococcus, the antibiotic regimen was changed to IV penicillin G and erythromycin with a single dose of Gentamycin. The patient was discharged home 1 week postoperatively with ceftriaxone, 2 g IV per day, for duration of 5 weeks with a PICC line placed. Follow-up X-rays showed stable spinal structures. Further follow-ups indicated no further complications or sequelae. Interestingly, further query of history detail revealed possible precipitating factors. The patient was involved in a motor vehicle accident approximately 20 years earlier resulting in chronic neck and shoulder pain. Then, about 1 month before onset of this neck pain, the patient underwent a routine dental cleaning. It is highly unusual for S. mitis found in normal oral flora [1] to cause an infectious process in the © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Atypical Spontaneous Discitis
1
Demonstrates the distraction of the vertebrates and the disc.
central nervous system. In this case, the recent dental procedure may have produced a bacteremia, which perhaps seeded in a susceptible site caused by the previous motor vehicle accident. Throughout the course of the discitis, the patient remained systemically asymptomatic. She was afebrile with a normal white blood count (WBC) count. HIV and hepatitis testing were negative; blood and urine cultures were also negative; immunoglobulin (IgG, IgM, and IgE) levels were normal; and a 2-D echocardiogram was negative for endocarditis. The case reported here is atypical in several aspects. The patient did not fit in the classic bimodal age distribution; she did not have any chronic medical problems; the area of involvement was in the least common, the cervical spine; she did not have any preceding systemic infectious processes; and finally, surgical intervention was required. We would like to acknowledge James S. Collinson, M.D., for his radiology expertise.
Surg Neurol 143 2004;61:142– 4
2
Indicates the abscesses and fluid collections at anterior and posterior spaces of the spinal column.
REFERENCES 1. Barsotti O, Decoret D, Renaud FN. Identification of streptococcus mitis group species by RFLP of the polymerase chain reaction-amplified 16S-23S rDNA intergenic spacer. Res Microbiol 2002;153:10:687–91. 2. DeSouza L. Disc space infection in children, late adolescents, and adults. Minn Med 1980;63:314 –20. 3. Kemp H, Jackson JW, Jeremiah JD, Hall AJ. Pyogenic infections occurring primarily in intervertebral discs. J Bone Joint Surg 1973;55(B):698 –714. 4. Wiley A, Trueta J. The vascular anatomy of the spine and its relationship to pyogenic vertebral osteomyelitis. J Bone Joint Surg 1959;41B:796 –809. COMMENTARY
This case report of cervical discitis and osteomyelitis with epidural abscess formation is unusual from two standpoints. First, the patient had no associated illness that is ordinarily found in adult patients with this disease, and second, the organism is unusual since S. mitis, a streptococcas viridans organism normally residing in the mouth, was the microbiologic cause. While S. mitis is a