Yaeeun Suh1 Shahzad Ilyas1 Nithin K Bejjanki2, Shafic S Al-Nammari2
1St Thomas’ Hospital, London, 2York District Hospital
Corresponding Author Mr Shafic S Al-Nammari e-mail: shafic2@hotmail.com
SMJ 2007 52(4): 53
We
report on the first case of pyogenic spondylodiscitis caused by otitis externa,
which arose by haematogenous spread. Pyogenic spondylodiscitis is a serious
condition and it is imperative to have a high index of suspicion for this
condition in any patient that has back or neck pain, systemic upset and raised
inflammatory markers.
Keywords: otitis externa, pyogenic
spondylodiscitis
Pyogenic
spondylodiscitis is a rare condition although its incidence is increasing.1
It is imperative to have a high index of suspicion for this condition in
any patient that has back pain, systemic upset and raised inflammatory markers.
We report here on the first case of pyogenic spondylodiscitis as a complication
of otitis externa.
Case
Report
A
sixty-six year old lady presented to her GP with a one week history of left
sided otalgia, otorrhoea and decreased hearing. Her only past medical history consisted of mild asthma for
which she was on salbutamol and becatide inhalers and osteoarthritis of her
knees and wrists. She was noted to
have a normal tympanic membrane on examination by her GP and was diagnosed with
otitis externa. The ear was swabbed
and she was commenced on empirical oral amoxicillin and gentamycin eardrops.
Malignant otitis externa, which is an osteomyelitis of the skull base
typically, caused by Pseudomonas aeruginosa, which carries a high morbidity, and
mortality was thought unlikely as it tends to occur only in elderly diabetics
and immunosuppressed individuals. Furthermore
the patient’s ear symptoms resolved entirely
within two weeks and the swab grew Streptococcus agalactiae.
However the patient did notice a gradual onset of neck pain radiating to
both shoulders that was exacerbated by movement but with no neurological
symptoms, systemic upset or history of trauma.
She was seen by her GP who felt that taking into account her known
osteoarthritis, the patients’ current symptoms most likely represented new
onset cervical spondylosis and the patient was started on ibuprofen.
This had minimal effect and two weeks later she was brought in to our
Hospital with an non-steroidal anti-inflammatory drug induced upper
gastrointestinal haemorrhage secondary to multiple gastric and duodenal
erosions.
During
her admission the patient complained of persistent and worsening neck pain.
She was referred to the rheumatologists who noted that her symptoms now
included occipital headache, jaw claudication and malaise.
Examination at that time revealed that she was afebrile with point
tenderness over C5 and C6 with a decreased range of neck movement and no
neurology. She was also tender over
her temporal arteries; although the pulses were palpable.
Bloods showed a White Cell Count (WCC) of 12.4x10-9/L,
Erythrocyte Sedimentation Rate (ESR) of 116 mm/hr and a C-reactive Protein (CRP)
of 197 mg/dL and a negative myeloma screen. At this stage the differential diagnosis consisted of giant
cell arteritis, polymyalgia rheumatica and spinal sepsis. She was started on empirical prednisolone and sent for urgent
plain X-ray of her cervical spine and temporal artery biopsy.
Plain X- Ray’s showed severe degenerative changes at C4/5 and temporal
artery biopsy was subsequently found to be normal.
Her inflammatory markers remained elevated despite an improvement of her
symptoms following the introduction of corticosteroids and on the seventh day of
admission she spiked a Temperature of 39.2C.
Three sets of blood cultures grew Streptococcus agalactiae, which were
fully sensitive to penicillin. There
were no other identifiable focuses of infection other than the spine.
MRI C-spine was performed and showed odontoid destruction, in keeping
with osteomyelitis, with mild posterior odontoid peg thecal impingement and a
C4/5 spondylodiscitis. At this
point steroids were stopped, the Spinal Team was contacted and the patient was
started on intravenous penicillin. This
was continued for one month at which point her symptoms had improved and her
inflammatory markers had normalised. Oral
penicillin was continued for a further two months.
At follow up at two years she was complaining only of occasional
occipital neck stiffness with headaches. Examination
revealed a mild torticollis with her head tilting to the right a decreased range
of motion throughout the cervical spine without neurology.
MRI showed burned out spondylodiscitis with fusion of C5/6 and widening
of the odontoid processes.
Discussion
Pyogenic
spondylodiscitis is rare especially in otherwise well individuals; although its
incidence is increasing.1 It is a serious infection which had a death
rate ranging from 40% to 70% in the pre-antibiotic era.2
Spondylodiscitis occurs by three routes haematogenous spread, contiguous
spread and direct inoculation.3
Haematogenous spread and direct inoculation are the two most common
routes while contiguous spread is rare. The
most common causative organism of spondylodiscitis is Staphylococcus aureus,
which accounts for about 45% of cases.4
Streptococcus agalactiae is traditionally considered to be a rare cause
of any infection in adults other than urinary tract infection in pregnant women.
However its incidence is increasing as the causative agent in a range of
conditions including urinary tract infection, respiratory tract infections, soft
tissue infection and osteomyelitis. In
the neonatal period bone and joint infections caused by this organism are well
documented.5 Spondylodiscitis
caused by Streptococcus agalactiae is normally associated with a very good
outcome. It most commonly occurs in
the lumbar and thoracic spine and is commonly associated with diabetes mellitus,
alcoholism,
intravenous drug abuse and steroids. This
is the only reported case of Streptococcus agalactiae spondylodiscitis resulting
in chronic pain and spinal instability as is common in other causes of
spondylodiscitis and vertebral osteomyelitis6 and it occurred in an
unusual location in a patient without risk factors.
This is the first reported case of spondylodiscitis secondary to otitis
externa and serves to highlight the importance of having a high index of
suspicion for this condition in anyone presenting with new onset neck or back
pain, systemic upset and raised inflammatory markers.
References:
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Wood GW. Infections of the spine. In: Crenshaw AH, ed. Campbell's
operative orthopedics, vol. 4. St. Louis: Mosby; 1987: 3323–45.
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