A Rare Case of Vertebral Osteomyelitis Caused by Mycobacterium farcinogenes in an Immunocompetent Host.

The aim of this study was to evaluate the roles of 67Ga-citrate and 99Tcm-methylene diphosphonate (99Tcm-MDP) planar and single photon emission tomographic (SPET) imaging in patients with vertebral osteomyelitis. Thirty patients (22 females, 8 males) aged 62.7 +/- 16.4 years (mean +/- s) were enrolled prospectively between May 1995 and May 1998. The patients had been on antibiotics for 7 +/- 4 weeks prior to the study. Histology was available for all but nine patients with mild infections, who were evaluated by a combination of magnetic resonance imaging (MRI), clinical and laboratory tests. 67Ga-citrate (185 MBq) and three-phase bone (555 MBq 99Tcm-MDP) planar and SPET imaging were performed in all patients, together with MRI as a comparison. In total, 67 infectious foci were detected. Based on histology, there were four cases of severe, 13 cases of moderate and four cases of mild osteomyelitis; nine mild infections were also classified by the combination of MRI, clinical and laboratory results. Combined MRI and 67Ga-citrate SPET correctly classified all patients; MRI detected all 67 infectious foci, whereas 67Ga-citrate SPET identified 54 only. False-negative results were seen with all other modalities, especially in cases of mild and moderate infection. 67Ga-citrate SPET identified unsuspected cases of endocarditis (n = 2), paravertebral abscess (n = 1), subaxillary soft tissue abscess (n = 1) and rib osteomyelitis (n = 1). For 67Ga-citrate SPET, the target-to-background ratio was 2.24 +/- 0.31, 1.76 +/- 0.07 and 1.30 +/- 0.18 for severe, moderate and mild osteomyelitis, respectively. Significant differences were noted between severe and moderate infection (P = 0.0051) and between severe and mild infection (P < 0.0001); that between moderate and mild infection was non-significant. For 99Tcm-MDP planar and SPET imaging, and for planar 67Ga-citrate imaging, there was no correlation with severity. We conclude that 67Ga-citrate SPET is able to identify vertebral osteomyelitis and detect additional sites of infection. It can also aid in determining the severity of infection and, potentially, the response to therapy.

Imaging of Spinal Infections in Children

We report what we believe is the first case of vertebral osteomyelitis caused by Roseomonas species. The diagnosis of vertebral osteomyelitis can be difficult. The case illustrates the importance of the establishment of an etiologic diagnosis in vertebral osteomyelitis. The features of Roseomonas species and the evaluation of cases of vertebral osteomyelitis are reviewed.

To evaluate the safety and cost-effectiveness of a totally tubeless percutaneous nephrolithotomy (PCNL) by comparing the clinical outcomes and cost analysis between standard PCNL and totally tubeless PCNL for renal stones. From June 2012 to September 2013, a total of 121 patients with renal stones who underwent totally tubeless or standard PCNL by two experienced surgeons were retrospectively evaluated by group. According to the surgeon's preference for the nephrostomy tube and/or ureteral stent, the present study was designed to be divided into Group 1 and Group 2. Group 1 was performed by one surgeon (H.J. Cho) who preferred a totally tubeless PCNL and Group 2 was performed by the other surgeon (S.H. Hong) who preferred a standard PCNL. We excluded bilateral renal stones, multiple approach, whole staghorn calculi, and previous renal surgery. Patient and stone characteristics, intraoperative and postoperative parameters, and cost analysis were compared between the two groups. There were no significant differences in the patient demographics between groups. Mean stone burden was 501.5±361.1 mm(2) in Group 1 v 535.2±353.1 mm(2) in Group 2 (P=0.651). Length of hospital stay (1.72±0.58 v 4.10±1.88 days, P<0.001), postoperative pain scores using a visual analog scale (day 0: P<0.001, day 1: P=0.002), and analgesia requirements (33.2±21.3 v 45.2±19.5 mg, P=0.005) for Group 1 v Group 2 showed significant differences. The stone-free rate was 86.4% v 89.8% in Group 1 and Group 2, respectively (P=0.609). There were no significant differences in overall complications between groups (P=0.213). Mean total medical treatment costs in Groups 1 and 2 were 2398.22±549.1 USD and 2845.70±824.2 USD, respectively (P=0.002). Many clinical outcomes in the totally tubeless PCNL showed comparable or better results than standard PCNL. We believe that totally tubeless PCNL is an acceptable, safe, and cost-effective alternative to standard PCNL for the treatment of renal stones.

Utility of the Guy's Stone Score Based on Computed Tomographic Scan Findings for Predicting Percutaneous Nephrolithotomy Outcomes

Economic Outcomes of Treatment for Ureteral and Renal Stones: A Systematic Literature Review

To the Editors: A healthy 15-year-old male presented with a 6-month history of thoracic pain most prominent in the lower ribcage near the right midaxillary line. The patient associated the onset of pain with a muscle strain sustained while weightlifting 6 months earlier. The pain was cramping, intermittent, nonradiating, and worse in the mornings, during exercise, and when flexing to the right side. He denied fever, weight loss, night sweats, respiratory, or gastrointestinal symptoms, and had no neurologic symptoms. His personal and family medical histories were unremarkable. The physical examination was normal except for tenderness to palpation halfway between the vertebral column and the right midaxillary line at the T9 to T10 levels, without localized swelling, erythema, or fluctuance. There was no tenderness and there were no step-offs of his spinous processes. He rotated his trunk hesitantly and slowly and reported 5/10 pain when flexing or extending his back and when bending to either side. The complete blood count and comprehensive metabolic panel were normal with the exception of an alkaline phosphatase of 305 IU/L (normal 70-260 IU/L). The erythrocyte sedimentation rate was 29 mm/h (normal 0–20 mm/h) and the C-reactive protein was 1.9 mg/L (normal 0–10 mg/L). Magnetic resonance imaging revealed T9–T10 discitis and osteomyelitis with a mild compression fracture of the superior endplate of T10. Also seen was a paraspinal phlegmon without epidural abscess or intrathecal extension. Biopsies of the T9–T10 intervertebral disc and the T9 and T10 endplates were performed under fluoroscopic guidance. Pathologic examination of these specimens was consistent with discitis-osteomyelitis. Routine aerobic cultures of disc and bone both yielded Streptococcusagalactiae (also known as Group B Streptococcus or GBS). Anaerobic, fungal, and AFB cultures were negative, as was PCR for Bartonella. A tuberculin skin test and serum Bartonella antibodies were negative. Because GBS was unexpected from this site in a patient this age, a screen of the patient's immune status was undertaken. The HIV antibody was negative; serum immunoglobulins, total hemolytic complement, and neutrophil oxidative burst were normal; serum antibody values were consistent with an appropriate response to routine immunizations. The patient was placed in a thoracolumbosacral orthosis and he was treated with 8 weeks of intravenous antibiotics. The rate of GBS infection in neonates has decreased since the institution of universal screening of pregnant women.1 Invasive GBS disease remains a significant cause of morbidity and mortality in nonpregnant adults, almost exclusively in those with underlying immunocompromising conditions.1,2 Although uncommon, discitis and vertebral osteomyelitis caused by GBS have been described, primary in elderly or immunocompromised patients.3–5 Our search of the literature did not reveal any cases of GBS discitis or vertebral osteomyelitis in children outside of the neonatal period. The isolation of GBS in our healthy adolescent patient from both the vertebral body and intervertebral disc makes his unusual presentation of discitis even more remarkable. Clinicians should be aware of the possibility of GBS as a pathogen in discitis and vertebral osteomyelitis, especially, although not exclusively, in immunocompromised patients. Indi Trehan, MD, MPH, DTM&H Stephanie A. Fritz, MD, MSCI Department of Pediatrics Washington University St. Louis, MO

An unexpectedly large number of elderly patients with chronic illnesses such as diabetes, rheumatoid arthritis, renal insufficiency, or malignant disease may also suffer from severe vertebral osteomyelitis and never know it, according to a report presented at the recent annual meeting of the American Academy of Orthopaedic Surgeons in Atlanta. The report, made by Thomas N. Walinski, MD, associate clinical professor of orthopedics at the John A. Burns School of Medicine at the University of Hawaii, Honolulu, described the condition—vertebral osteomyelitis—as "the great masquerader." The classic symptoms—spinal pain, fever, chills, and general malaise—are often confused with chronic illnesses commonly found in the elderly, he said. The orthopedist may be quick to associate the classic symptoms with the condition, but few such patients see an orthopod first, making early diagnosis much less likely. In his study of patients with the disease, Walinski confirmed earlier findings that many cases of vertebral osteomyelitis

Enterococcus raffinosus is a rare isolate in clinical specimens. A case of vertebral osteomyelitis caused by E. raffinosus in an elderly patient is described and confirms this organism to be an opportunistic human pathogen.

The Unique Clinical Features and Outcome of Infectious Endocarditis and Vertebral Osteomyelitis Co-infection

Spontaneous pyogenic vertebral osteomyelitis and endocarditis: Incidence, risk factors, and outcome

Sixty-one cases of bacterial vertebral osteomyelitis from July 1969 to July 1979 were analyzed. The ages of the 49 men and 12 women ranged from 21 to 66 years. The portal of entry was hematogenous in 58 cases, gunshot wounds in two cases, and and adjacent retroperitoneal abscess in one case. Biopsy was performed in 60 patients. There were 15 complications related to the disease. Gram-negative rods were the predominant bacteria isolated. Blood culture was positive in 13 of the 26 (50%) patients tested. Eleven of the 13 (85%) organisms isolated from the blood cultures correlated with organisms recovered from biopsy specimens. Eleven of the patients had more than one disk level involved. Of the 61 patients, 29 went on to spontaneous fusion, 17 were lost to follow-up study, 11 failed to fuse, three had surgical fusion, and one patient died. Recommendations for diagnosis included the collection of blood cultures and radionuclide bone scans. Management recommendations included systemic antibiotics for at least three weeks and immobilization with either bed rest or spinal orthoses. Surgery was indicated if an abscess was present, neurologic complications occurred, instability became a factor, or the medical treatment failed.

Two cases of vertebral osteomyelitis and discitis in the cervical spine are presented, both having arisen from hematogenous spread to the spine. Bacteriologic diagnosis was established in 1 patient, but the infection had subsided in the other. Both patients were treated with anterior debridement and fusion, and a supplemental posterior wiring and fusion was performed in the second case to reduce kyphotic angulation. In the second case, both the anterior and posterior surgery were performed while the patient was under the same anesthetic. Satisfactory results were achieved in both cases.

Mycobacterium bovis Bacillus Calmette-Guérin (BCG) instillations are used in bladder cancer treatment. Adverse effects can occur. Osteoarticular complications are mainly reactive arthritis, but true infections have been described, such as vertebral osteomyelitis. We made a review of M. bovis BCG vertebral osteomyelitis after instillations for bladder cancer using PubMed search. We added three new French cases. Twenty-seven cases of BCG vertebral osteomyelitis had been reported on PubMed. Of the 30 cases, all were male, averaging 73.4 ± 8.7years old. Median time between diagnosis and first and last instillation was 22.5 and 14months respectively. Half of vertebral osteomyelitis was thoracic and lumbar in the other half. Sensitivo-motor deficit was present at diagnosis in 42% of cases. Other infectious locations were common, mainly infectious abdominal aortic aneurysms (20%). Rifampicin, ethambutol and isoniazid were the usual therapy. Poor outcomes were reported with 50% of one or more spine surgery. M. bovis BCG vertebral osteomyelitis following bladder instillation for bladder cancer is a rare complication. However, the late onset of back pain after instillations differentiates them from reactive arthritis. Concomitant septic location such as infectious abdominal aortic aneurysms must be known.

Osteomielitis vertebral por Candida spp.