Scandinavian Journal of Infectious Diseases

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Gas-forming vertebral osteomyelitis in diabetic patients Chan-Wei Chen, Chi-Jack Yang, Jeng-Jong Huang, Yin-Ching Chuang & Chenden Young To cite this article: Chan-Wei Chen, Chi-Jack Yang, Jeng-Jong Huang, Yin-Ching Chuang & Chenden Young (1991) Gas-forming vertebral osteomyelitis in diabetic patients, Scandinavian Journal of Infectious Diseases, 23:2, 263-265, DOI: 10.3109/00365549109023410 To link to this article:

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Date: 22 April 2016, At: 20:16

Scand J Infect Dis 23: 263-265, 1991


Gas-forming Vertebral Osteomyelitis in Diabetic Patients CHAN-WE1 CHEN, CHI-JACK YANG, JENG-JONG HUANG, YIN-CHING CHUANG and CHENDEN YOUNG

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From ihe Section of Injeciious Diteases Departmen/ 01 Internal Medic in 150 mm/h. Blood culture obtained o n admission grew Escherichia coli the next day. Computed tomography (CT) revealed destruction of the third lumbar vertebra with increased sclerosis and there was gas over intraosseous, intradiscal, intraspinal areas and bilateral psoas muscles (Fig. I ) . Parenteral antibiotics with cefamandole and tobramycin were started after admission. Cefamandole was replaced with cefoxitin on the third day after gas-forming infection was found. Her blood pressure turned normal 1 day later. However, severe thrombocytopenia ( i20x 109/1)persisted. Surgical intervention was considered inappropriate due to widespread involvement and persistent thrombocytopenia. Her consciousness deteriorated gradually 3 days after admission. Brain CT was normal. No focal neurological deficit was found. Her family refused CT-guided biopsy and drainage. She was discharged against advice on the fifth day. Blood culture taken just before discharge yielded E. coli again. She died 2 days later. Case 2

A 50-year-old man was admitted to our medical intensive care unit in January 1990 with a I-month history of low back pain and 2-weeks of fever and chill. He became progressively dyspneic 3 days before admission. Hypertension was known for 3 years without treatment and diabetes mellitus was diagnosed recently without regular treatment.

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264 C.-W. Chen et al.

Scand J Infect Dis 23 (1991)

Fig. 1. Computed tomogram shows gas bubbles within vertebral body, spinal canal and bilateral psoas muscles (arrows). Sclerotic changes in the vertebral body are also seen. Fig. 2. Computed tomogram shows gas bubbles in the vertebral body. Psoas abscess is not clearly shown in this plane. Upon admission, he appeared acutely ill-looking. The body temperature was 38.6"C, the pulse rate was 120/min, the blood pressure was 160/100 mmHg, the respiratory rate was 30/min. Physical examination revealed a mildly anemic conjunctiva and slightly icteric sclera. Diffuse inspiratory crackles and tine wheezing were heard upon auscultation. There was no murmur or gallop. Healed herpes zoster lesion was noted over the right flank and there was low back tenderness corresponding to L2-L3 vertebral level. Chest X-ray showed diffuse alveolar lesions with normal heart size. Laboratory data included a WBC count of 1 2 . 6 109/1 ~ with 91 'Yo neutrophils, hemoglobin level 82 g/l, platelet count 1 2 x 109/l.Prothrombin time and partial thromboplastin time were normal, blood sugar was 22 mmoUl (3.58-6.05 mmol/l), blood urea nitrogen 19.3 mmol/l and serum creatinine 123.8 pnolll. Abdominal echogram was performed due to abnormal liver function test. A 3.5x3.5 cm liver abscess was noted over the right lobe. CT scan performed subsequently showed destruction of the second lumbar vertebra and gas over the vertebral body and both psoas muscles (Fig. 2). He was treated with cefotaxime and tobramycin after hospitalization. Blood culture and echo-guided aspirates from right psoas abscess grew Klebsiella pneumoniae. His condition did not improve after parenteral antibiotic therapy and pigtail drainage for liver abscess failed. He was intended for surgical drainage for both liver abscess and psoas abscess 4 days later. Unfortunately, he became comatose before operation and his family refused further invasive procedure. He died 9 days after admission.

COMMENT The diagnosis of pyogenic vertebral osteomyelitis requires a compatible clinical picture, radiological confirmation and bacteriological proof, which could be obtained by needle aspiration, bone biopsy, direct surgical approach or at least 2 positive blood cultures (2). The combination of spinal infection and gas production is documented in the literature in only a few case reports (3). The causative microorganisms include clostridia, mycobacteria, brucella, E. coli, streptococcus and bacteroides. The associated medical conditions include alcoholism, steroid usage and malignancy (3). Although diabetes mellitus has been cited as a probable predisposing factor to vertebral osteomyelitis (2) and a variety of gas-forming infections are associated with diabetes (4), the combination of gas-forming vertebral osteomyelitis with diabetes mellitus has, to our knowledge, never been reported. The presence of gas in vertebral infection may implicate a severe necrotizing process (4), for which parenteral antibiotics may not be enough. Vertebral osteomyelitis is always a diagnostic pitfall to clinicians ( 5 ) . The accuracy of the primary diagnosis is compromised by the prevalence of back pain, a low index of suspicion and lack of systemic manifestation. Given the

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Vertebral osteornyelitis in diabetics 265

insidious nature of vertebral osteomyelitis and the possible ominous outcome of delayed prolonged back pain in a high-risk patient (e.g. diabetes mellitus with elevated diagnosis (3, ESR) should never be ignored. An early radionuclide scan may be helpful ( 5 ) . Once a gas-forming vertebral infection is further confirmed, surgical intervention is recommended without delay.

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REFERENCES 1. Ryan MD, Taylor TKF. Septic discitis-a misnomer. Med J Aust 147: 415, 1987. 2. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis. Report of nine cases and review of the literature. Rev Infect Dis 1: 754-776, 1979. 3. Bielecki DK, Sartoris D, Resnick D, Lom KV, Fierer J, Haghighi P.Gas in spinal infection. Am J Radio1 147: 83-86, 1986. 4. Wheat LJ. infection and diabetes mellitus. Diabetes Care 3: 187-197, 1980. 5. Waldvogel FA, Vasey H. Osteomyelitis: the past decade. N Engl J Med 303: 360-370, 1980.

Gas-forming vertebral osteomyelitis in diabetic patients.

We report 2 cases of gas-forming vertebral osteomyelitis in diabetic patients. Both were caused by gram-negative bacilli, Escherichia coli and Klebsie...
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