A rare case of embolic spondylo-discitis after treatment of aortic valve endocarditis
© Beri et al; licensee BioMed Central Ltd. 2008
Received: 01 September 2008
Accepted: 22 October 2008
Published: 22 October 2008
Infective Endocarditis is associated with a high incidence of embolic events, commonly involving the central nervous system, spleen, kidney, lungs, heart and eyes.
We report a case of infective endocarditis with late embolization to the L5/S1 region of the spine leading to spondylo-discitis. The disc space infection presented ten days after completion of antibiotic therapy based on blood culture and antibiotic sensitivity.
This is the first reported case of acute infective spondylo-discitis demonstrated on MR imaging following completion of appropriate antibiotic therapy.
Infective Endocarditis (IE) is associated with a high incidence of embolic events, ranging from 10–49% . Common sites include the central nervous system, spleen, kidney, lungs, heart and the eyes . We report a case of infective endocarditis with embolization to the L5/S1 region of the spine, despite appropriate intravenous antibiotic therapy.
The incidence of IE remains high at 1.7–6.2 per 100 000 person years in the US and Europe . It is associated with high in-hospital mortality ranging from 16–25% . There is a lot of morbidity and mortality due to destructive valvular lesions causing valve regurgitation and heart failure, and a high incidence of embolic events. Predisposing factors include damaged native valves, prosthetic heart valves and intravenous drug use. Most patients can be successfully treated with intravenous antibiotics for 4–6 weeks based on blood cultures and organism sensitivity . Surgery is performed when there is intractable congestive heart failure, recurrent embolization and local abscess formation .
Emboli often involve major arterial beds, including central nervous system (65%), spleen (49%), kidneys (22%), lungs (16%), extremities (13%) and coronary arteries (2%) . More than 90% of central nervous system emboli lodge in the distribution of the middle cerebral artery. These emboli are associated with a high mortality rate. Most emboli occur within the first 2 to 4 weeks of diagnosis. The rate of embolic events drops significantly during the first 2 weeks of successful antibiotic therapy, from 13 to < 1.2 embolic events per 1000 patient-days . The type of organism, size and number of vegetations, the number of valves involved, and vegetation characteristics (e.g. lack of calcification) predict embolic complications [2, 5].
Dizdar et al reported the case of Group B Streptococcal endocarditis leading to arthritis in the left L5/S1 facet joint in a patient who presented as lower back pain and bacteremia. On investigation, the site of infection was found to be mitral valve endocarditis .
Churchill et al had studied 192 of IE. Five cases out of these who presented with lower back pain were found to have lumbar disc space infection. In all these patients, the symptoms of IE appeared after the back pain . However, this series was performed in the pre-MRI era where this diagnosis was clinical. The diagnosis and treatment of infective endocarditis has undergone a lot of change since then. It is also not confirmed whether the valves or the spine was the primary source of bacteremia.
Ours is a rare case of spondylo-discitis following appropriate treatment of IE. He had IE due to NHS in a congenitally bicuspid aortic valve with small size vegetation at the outset. He had none of the above-mentioned high-risk characteristics that are thought to be predictors of an embolic event and was treated with intravenous antibiotics based on culture sensitivity for four weeks. Despite this, the vegetations persisted and he suffered an embolic episode.
This case shows that IE can present with late embolic episodes, even after the completion of appropriate antibiotic therapy. Lower back pain in patients of IE should not be ignored as this can be due to disc space infection. Our report shows that spondylo-discitis can be a source of bacteremia for endocarditis  as well as the result of embolization from infected valves to the spine as in the present case.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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