Spondylodiscitis caused by Prevotella intermedia: A case report and literature review

Spondylodiscitis caused by Prevotella intermedia: A case report and literature review

Accepted Manuscript Spondylodiscitis caused by Prevotella intermedia: A case report and literature review Michael Opoku-Darko, W. Bradley Jacobs PII:...

1MB Sizes 0 Downloads 18 Views

Accepted Manuscript Spondylodiscitis caused by Prevotella intermedia: A case report and literature review

Michael Opoku-Darko, W. Bradley Jacobs PII: DOI: Reference:

S2214-7519(17)30124-X doi: 10.1016/j.inat.2017.07.003 INAT 223

To appear in:

Interdisciplinary Neurosurgery: Advanced Techniques and Case Management

Received date: Revised date: Accepted date:

28 June 2017 ###REVISEDDATE### 8 July 2017

Please cite this article as: Michael Opoku-Darko, W. Bradley Jacobs , Spondylodiscitis caused by Prevotella intermedia: A case report and literature review, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management (2017), doi: 10.1016/ j.inat.2017.07.003

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Spondylodiscitis caused by Prevotella intermedia: a case report and literature review. Michael Opoku-Darko1, W. Bradley Jacobs1 Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.

CE

M

PT

ED

(Corresponding author) W. Bradley Jacobs MD. Foothills Medical Centre, 12th Floor 1403-29 Street NW Calgary, AB CANADA T2N2T9 email: [email protected] Phone: +1(403)9443406

AN

US

CR

IP

T

1

fusion.

AC

Keywords: Spondylodiscitis; Prevotella intermedia; Low virulent spinal infection; Instrumented

ACCEPTED MANUSCRIPT Spondylodiscitis caused by Prevotella intermedia: a case report and literature review. Michael Opoku-Darko1, W. Bradley Jacobs1 Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.

T

1

CR

IP

Abstract

BACKGROUND: Spondylodiscitis is commonly caused by Staphylococcus aureus. Anaerobic

US

organisms are the causative agents in only 3-4% of cases. Diagnosis of anaerobic spondylodiscitis can be challenging due to their low virulence nature.

AN

CASE DESCRIPTION: We describe a rare case of spondylodiscitis caused by Prevotella

M

intermedia managed with antibiotics and spinal instrumentation and highlight the challenges in diagnosis in such cases.

ED

CONCLUSION: Low virulent anaerobic spondylodiscitis can be difficult to diagnose. A high

PT

degree of suspicion is necessary and multiple attempts at pathogen identification, including possible open surgical biopsy may be required for diagnosis. A good prognosis is possible in

AC

CE

appropriately managed cases.

ACCEPTED MANUSCRIPT Abbreviation list: AFB: acid fast bacilli, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, PMR: polymyalgia rheumatic, MGUS: monoclonal gammopathy of

AC

CE

PT

ED

M

AN

US

CR

IP

T

undetermined significance.

ACCEPTED MANUSCRIPT INTRODUCTION Spondylodiscitis is an infection of the intervertebral disc and adjacent vertebral body. The incidence is reported to range from 0.2 – 2.4 per 100,000 per year in developed counties.1–3 This incidence is increasing, likely secondary to a combination of an increasing life expectancy,

T

increased prevalence of chronic debilitating disease and IV drug abuse.4,5 Anaerobic organisms

IP

are responsible for 3-4% of all spinal infections with Bacteroides, Peptostreptococcus and

CR

Propionibacteriium acnes accounting for the majority of cases.6–8 Hematogenous spread is the usual route of infection from sources such as the skin, respiratory tract, genitourinary tract,

US

gastrointestinal tract and oral cavity. Blood cultures in cases of anaerobic spondylodiscitis, as

AN

reported of osteomyelitis in general, are rarely positive.9,10 We report a rare, biopsy proven case

M

of cervicothoracic spondylodiscitis caused by Prevotella intermedia.

ED

CASE REPORT Case History and Examination

PT

A 70-year-old female, with a history of polymyalgia rheumatica (PMR), was referred to the spine

CE

service at our institution by her rheumatologist for evaluation and management of progressive neck pain and intrinsic hand muscle wasting/weakness. Her symptoms started approximately 4

AC

months earlier and had progressively worsened despite treatment with analgesics and corticosteroids for a presumed flare of PMR. Pain was localised to the lower neck and intrascapular region. It was sharp, constant in nature and worse when upright or with ambulation. She also complained of paresthesias and weakness to both hands. Review of systems was significant for shortness of breath on exertion, fatigue, anorexia and night sweats but no fevers or chills.

ACCEPTED MANUSCRIPT In addition to PMR her past medical history included monoclonal gammopathy of undetermined significance (MGUS), alcoholic cirrhosis (Child-Pugh Class B), hypothyroidism and chronic sinusitis. On physical examination, vital signs were within normal limits. Motor exam revealed mild

IP

T

atrophy of the intrinsic hand muscles with 3/5 motor power in abductor digiti minimi, 4/5 finger flexion and 4+/5 elbow extension bilaterally. Other myotomes of both upper and lower

CR

extremities were strong. Deep tendon reflex was 1+ in the upper and lower limbs.

US

Investigations and Imaging

Laboratory data showed WBC count of 12,300µ/L (predominantly neutrophils). C-reactive

AN

protein (CRP) and erythrocyte sedimentation rate (ESR) levels were 87.8 mg/L [normal:

M

0-8.0mg/L] and 97mm/hr [normal: 2-20mm/hr] respectively. Alkaline phosphate was 157 U/L

ED

and GGT was 115U/L. Urine and serum protein electrophoresis detected no monoclonal protein. Leukemia/lymphoma immunophenotyping detected no abnormal phenotypes. Blood culture and

PT

sputum acid fast bacilli were negative.

CE

MR showed an enhancing infiltrative lesion involving C7-T2 vertebrae and both the C7-T1 and T1-2 disc spaces with extension into the mediastinum and lung apices bilaterally (Figure 1). CT

AC

showed mixed lytic sclerotic destruction of C7, T1 and T2 vertebrae (Figure 2). Intervention

All investigations by post admission day 6 were negative or inconclusive as to the etiology of the spinal lesion. As such, the patient underwent a CT guided biopsy targeting the T1 lesion with core samples sent for bacterial, fungal and AFB cultures as well as histopathologic analysis. CT guided biopsy specimen analysis was also inconclusive as to specific etiology, and, as such, she

ACCEPTED MANUSCRIPT was taken to the operating room for an open surgical biopsy through an anterior cervical approach. Histopathology of the surgical biopsy specimen noted evidence of an acute pyogenic and chronic inflammatory process with no evidence of neoplasia. The patient was empirically treated with

T

Cefazolin 2gIV Q8 and Flagyl 500mg PO BID while speciation and sensitivities were pending.

IP

Final cultures were positive for Prevotella intermedia (with susceptibility to Clindamycin,

CR

Imipenem, Metronidazole, Piperacillin-tazobactam and resistance to Penicillin) and hence, antibiotics was changed to IV Piperacillin-tazobactam. Despite the initiation of antibiotics, the

US

patient continued to have worsening mechanical axial neck pain with radiologic progression of

AN

T1 vertebra body osseous destruction and kyphosis (Figure 3). For this reason, the patient underwent a C6-T2 posterior decompression and C4-T4 instrumented fusion.

M

Postoperative Course

ED

The patient developed a left C5 nerve palsy that resolved within two weeks. Her neck pain improved and she was transferred to a rehabilitation facility to expedite recovery. She remained

PT

on antibiotics for a total of 3 months. At her 1 year clinic visit, the patient reported no significant

CE

neck pain and had almost normal motor function except for the right abductor digiti minimi which was 4/5. C-spine radiograph demonstrates maintained alignment and stability on

AC

flexion/extension views (Figure 4). DISCUSSION

We present a rare bacterial infection causing spondylodiscitis. Prevotella intermedia is a gramnegative rod shaped anaerobe found in the mucosal lining of the oral cavity, gastrointestinal and genitourinary tracts.11 Common infections caused by this bacterium include periodontal disease,

ACCEPTED MANUSCRIPT pneumonia, brain, tubo-ovarian and intraabdominal abscesses.11,12 It was previously described as a Bacteriodes species and reclassified under the new genus Prevotella by Shah and colleagues.13 Our review of the English literature via PubMed and MedLine OVID database with search words “Spondylodiscitis” or “Vertebral osteomyelitis” or “Spinal disease” or “Spinal infection” and

T

“Prevotella” yielded only 10 cases of vertebral osteomyelitis caused by Prevotella species with

IP

only 2 of these specifically secondary to Prevotella intermedia (Table 1).14–21 Back pain was the

CR

most common presenting symptom. Interestingly, the cervical spine was the least affected site of infection considering Prevotella spp. resides in the oral cavity and its prevalence in osteomyelitis

US

of the skull and human bite infections.22 Blood cultures were negative in almost all cases

AN

signifying the low virulence nature of these organisms as previously reported23 and the common need for fine needle or open surgical biopsy to facilitate diagnosis. All cases except for one

ED

M

responded well to antibiotic treatment and made full recovery.

Our report showcases a rather atypical presentation of a pyogenic spondylodiscitis. In our

PT

patient, the source of infection was unclear but the long-term use of steroids was potentially a

CE

predisposing factor. The spondylodiscitis involved the cervicothoracic junction with extension into the mediastinum mimicking tuberculosis or a neoplastic process. This was further

AC

corroborated by the progressive lysis of the T1 vertebra. In accordance with the 2015 Infectious Disease Society of America (IDSA) Clinical practice guidelines, the patient was treated with 6 weeks of IV Piperacillin-tazobactam. Surgery (posterior instrumentation and fusion) was necessitated secondary to mechanical instability even in the setting of appropriate medical therapy, as demonstrated by decreasing CRP and ESR levels.

ACCEPTED MANUSCRIPT This case highlights the importance of considering low virulent organisms such as Prevotella intermedia when dealing with indolent, slow growing spine lesions. Blood cultures may be negative as illustrated in our case report as well as in the literature and a biopsy may be warranted. Although patients generally respond well to antibiotics, there remains a role for

IP

T

surgery in cases of mechanical instability, as with our patient.

CR

CONCLUSIONS

This case highlights the importance of recognising atypical indolent species such as Prevotella

US

intermedia as a potential cause of spondylodiscitis and may require fine needle or open surgical

AN

biopsy to make the diagnosis. Prompt diagnosis and appropriate treatment with antimicrobial

AC

CE

PT

ED

M

agents result in excellent outcome.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

ACCEPTED MANUSCRIPT References 1.

Quinones-Hinojosa A, Jun P, Jacobs R, Rosenberg WS, Weinstein PR. General principles in the medical and surgical management of spinal infections: a multidisciplinary approach. Neurosurg Focus. 2004;17(6):E1. Cheung WY, Luk KD. Pyogenic spondylitis. Int Orthop. 2012;36(2):397-404.

3.

Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and

IP

T

2.

Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a

US

4.

CR

management. J Antimicrob Chemother. 2010;65 Suppl 3:iii11-24.

retrospective study of patients during 1990-95. Scand J Infect Dis. 2001;33(7):527-532. Krogsgaard MR, Wagn P, Bengtsson J. Epidemiology of acute vertebral osteomyelitis in

AN

5.

M

Denmark: 137 cases in Denmark 1978-1982, compared to cases reported to the National Patient Register 1991-1993. Acta Orthop Scand. 1998;69(5):513-517. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for

ED

6.

7.

PT

253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002;34(10):1342-1350. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and

Carragee EJ. Pyogenic vertebral osteomyelitis. J bone Jt surgeryAmerican Vol.

AC

8.

CE

review of the literature. Rev Infect Dis. 1979;1(5):754-776.

1997;79(6):874-880. 9.

Raff MJ, Melo JC. Anaerobic osteomyelitis. Medicine (Baltimore). 1978;57(1):83-103.

10.

Lewis RP, Sutter VL, Finegold SM. Bone infections involving anaerobic bacteria. Medicine (Baltimore). 1978;57(4):279-305.

11.

Hillier SL, Lau RJ. Vaginal microflora in postmenopausal women who have not received estrogen replacement therapy. Clin Infect Dis. 1997;25 Suppl 2:S123-6.

ACCEPTED MANUSCRIPT 12.

Salliot C, Lavie F, Azria A, Clerc D, Miquel A, Mariette X. Retroperitoneal fibrosis secondary to spondylodiscitis after infection with Prevotella. J Rheumatol. 2005;32(5):957-958.

13.

Shah HN, Collins DM. Prevotella, a new genus to include Bacteroides melaninogenicus

T

and related species formerly classified in the genus Bacteroides. Int J Syst Bacteriol.

Karatay M, Koktekir E, Celik H, Erdem Y, Sertbas I, Bayar MA. Spinal intradural abscess

CR

14.

IP

1990;40(2):205-208.

caused by hematogenous spread of Prevotella oralis in a 3-year-old child with an

de Moreuil C, Surgers L, Miquel A, Girard P-M. Prevotella is not so kind. Joint, Bone, Spine Rev du Rhum. 2013;80(3):338.

Goyal H, Arora S, Mishra S, Jamil S, Shah U. Vertebral osteomyelitis and epidural

M

16.

AN

15.

US

asymptomatic congenital spinal abnormality. Spinal Cord. 2015;53(Suppl 1):S13-5.

2012;16(6):594-596.

Huang C-R, Lu C-H, Chuang Y-C, et al. Clinical characteristics and therapeutic outcome

PT

17.

ED

abscesses caused by Prevotella oralis: a case report. Brazilian J Infect Dis.

CE

of Gram-negative bacterial spinal epidural abscess in adults. J Clin Neurosci Off J Neurosurg Soc Australas. 2011;18(2):213-217. Purushothaman B, Lakshmanan P, Gatehouse S, Fender D. Spondylodiscitis due to

AC

18.

Prevotella associated with ovarian mass--a rare case report and review of literature. World Neurosurg. 2010;73(2):119-122. 19.

Mukhopadhyay S, Rose F, Frechette V. Vertebral osteomyelitis caused by Prevotella (Bacteroides) melaninogenicus. South Med J. 2005;98(2):226-228.

20.

Frat J-P, Godet C, Grollier G, Blanc J-L, Robert R. Cervical spinal epidural abscess and

ACCEPTED MANUSCRIPT meningitis due to Prevotella oris and Peptostreptococcus micros after retropharyngeal surgery. Intensive Care Med. 2004;30(8):1695. 21.

Schober W, Horger M, Niehues D, Claussen CD, Duda SH. One case of gram-negative anaerobic spondylodiscitis with Prevotella intermedia. Arch Orthop Trauma Surg.

Brook I, Frazier EH. Anaerobic osteomyelitis and arthritis in a military hospital: a 10-year

IP

22.

T

2003;123(8):436-438.

Schofferman L, Schofferman J, Zucherman J, et al. Occult infections causing persistent

CE

PT

ED

M

AN

US

low-back pain. Spine (Phila Pa 1976). 1989;14(4):417-419.

AC

23.

CR

experience. Am J Med. 1993;94(1):21-28.

ACCEPTED MANUSCRIPT Figure 1. MR+gadolilium of the c-spine. A. Infiltrative mass lesion involving C7-T2 vertebrae and T1-2 disc space. B,C. Lesion avidly enhances with gadolinium. D. Extension of the

IP

T

enhancing mass into the mediastinum and lung apices.

US

CR

Figure 2. Sagittal (A) and axial (B) CT c-spine showing lytic destruction of the T1 vertebra.

AN

Figure 3. Sagittal CT c-spine demonstrating further lytic destruction of T1 vertebra and focal

ED

M

kyphosis.

PT

Figure 4. Anteroposterior (A), Flexion(B) and Extension (C) c-spine radiologic films showing

AC

CE

posterior instrumentation from C4 to T4 6months post operatively.

PT

ED

M

AN

US

CR

IP

T

ACCEPTED MANUSCRIPT

AC

CE

Fig. 1

US

CR

IP

T

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

AN

Fig. 2

ED

M

AN

US

CR

IP

T

ACCEPTED MANUSCRIPT

AC

CE

PT

Fig. 3

CR

IP

T

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

AN

US

Fig. 4

ACCEPTED MANUSCRIPT Table 1. Clinical characteristics of patients with vertebral osteomyelitis caused by Provetella spp. Manuscript – author (year)

Age

Sex

Prevotella species

Site of infection

Risk factor

Onset

Clinical manifestation

Blood cultures

Biopsy/ Other

Treatment, duration

Outcome

Spinal intradural abscess caused by hematogenous spread of Prevotella oralis in a 3-year-old child with an asymptomatic congenital spinal abnormality - Karatay et al. (2015)16 Prevotella is not so kind - de Moreuil et al. (2013)17

3

F

Prevotella oralis

L4-5

UTI, Dermal sinus tract, Epidermoid cyst

Subacute

Back pain, leg weakness, urinary difficulty, fever

N/A

Aspirate

L3-5 laminectomy and duroplasty + IV Vancomycin and Metronidazole, 6weeks

Full recovery

32

M

Prevotella disiens

L5-S1

None

Subacute

Back pain

Negative

Fine needle aspiration

Surgery(laminectomy)+ IV Metronidazole and Amoxicillin-clavulanic acid, 3months

Full recovery

Vertebral osteomyelitis and epidural abscesses caused by Prevotella oralis: a case report - Goyal et.al. (2012)18

68

F

Prevotella oralis

T5-8

Esophageal submucosal cyst necrosis

Subacute

Back pain, fever

Fine needle aspiration

IV Ampicillin-sulbactam and Metronidazole, 2months

Full recovery

Clinical characteristics and therapeutic outcome of Gram-negative bacterial spinal epidural abscess in adults - Huang et al. (2011)19 Spondylodiscitis due to Prevotella associated with ovarian mass--a rare case report and review of literature - Purushothaman et al. (2009)20 Vertebral osteomyelitis caused by Prevotella (Bacteroides) melaninogenicus Mukhopadhyay et al. (2005)21 Retroperitoneal fibrosis secondary to spondylodiscitis after infection with Prevotella Salliot et al. (2005)12 Cervical spinal epidural abscess and meningitis due to Prevotella oris and Peptostreptococcus micros after retropharyngeal surgery - Frat et al. (2004)22

73

F

Prevotella melaninogenica

T12-L3

Diabetes

Subacute

Surgery+ IV Flomoxef,1month

Died

74

F

Prevotella spp.

L3-4

35

F

Prevotella melaninogenica

62

M

61

M

T P

D E Ovarian cancer

I R

C S

U N

T P

Positive

Back pain, paresthesias

Positive

Subacute

Back pain, constitutional symptoms

Negative

Image guided biopsy

IV Metronidazole, 6weeks followed by PO Metronidazole, 6weeks

Full recovery

A

M

S1

Dental procedure

Subacute

Back pain, fever

Negative

Open surgical biopsy

IV Piperacillin-tazobactam

Full recovery

Prevotella spp.

L5-S1

Steroids

Chronic

Back pain

Negative

Biopsy

Full recovery

Prevotella oris

C1-7

Diabetes, retropharyngeal surgery

Subacute

Meningoencephalitis

N/A

Aspirate

IV Ceftriaxone and Metronidazole, 3weeks followed by PO Amoxicillin-clavulanic acid, 3 months Laminectomy+ IV fosfomycine, ceftriaxone and metronidazole, 3 weeks, followed by Metronidazole PO, 8weeks

E C

C A

Full recovery

ACCEPTED MANUSCRIPT One case of gram-negative anaerobic spondylodiscitis with Prevotella intermedia – Schöber et al. (2003)23 Pyogenic vertebral osteomyelitis cased by Prevotella intermedia Fukuoka et.al. (2002)24

45

F

Prevotella intermedia

L1-2

Pneumonia

Subacute

Back pain, fever

N/A

Pus from abscess drain

IV Imipenem,2weeks

Full recovery

60

M

Prevotella intermedia

T7-8

None

Chronic

Back pain, fever and paresthesias

Negative

Open biopsy

T7-8 discectomy+IV Ampicillin-sulbactam and Clindamycin, 4weeks followed by Tosufloxacin PO, 2months

Full recovery

T P

I R

N/A=not reported, C=Cervical, T=Thoracic, L=Lumbar, S=Sacral, spp.=unspecified species, IV=Intravenous, PO=oral

C S

A

U N

D E

T P

C A

E C

M

ACCEPTED MANUSCRIPT Highlights  Low virulent organisms such as Prevotella intermedia are a potential cause of spondylodiscitis.  Biopsy may be key to establishing a diagnosis.

T

 Prompt diagnosis and appropriate treatment with antimicrobials and/or instrumentation

AC

CE

PT

ED

M

AN

US

CR

IP

where there is instability result in good outcome.