- Case Report
- Open Access
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.
- Lower Back Pain
- Infective Endocarditis
- Bicuspid Aortic Valve
- Embolic Event
- Native Valve
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.
- Habib G: Embolic risk in subacute bacterial endocarditis. Role of transesophageal echocardiography. Curr Cardiol Rep. 2003, 5: 129-36. 10.1007/s11886-003-0080-6.View ArticlePubMedGoogle Scholar
- Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, Levison M, Chambers HF, Dajani AS, Gewitz MH, Newburger JW, Gerber MA, Shulman ST, Pallasch TJ, Gage TW, Ferrieri P: Diagnosis and management of infective endocarditis and its complications. Circulation. 1998, 98: 2936-2948.View ArticlePubMedGoogle Scholar
- Cabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ, Woods CW, Reller LB, Ryan T, Fowler VG: Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med. 2002, 162: 90-4. 10.1001/archinte.162.1.90.View ArticlePubMedGoogle Scholar
- Horstkotte D, Follath F, Gutschik E, Lengyel M, Oto A, Pavie A, Soler-Soler J, Thiene G, von Graevenitz A, Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie M, Dean V, Deckers J, Fernández Burgos E, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth OA, Lekakis J, Vahanian A, Delahaye F, Parkhomenko A, Filipatos G, Aldershvile J, Vardas P, Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG): Document Reviewers. The task force on infective endocarditis of the European Society of Cardiology. Guidelines on prevention, diagnosis and treatment of infective endocarditis. Eur Heart J. 2004, 25: 267-76. 10.1016/j.ehj.2003.11.008.View ArticlePubMedGoogle Scholar
- Sanfilippo AJ, Picard MH, Newell JB, Rosas E, Davidoff R, Thomas JD, Weyman AE: Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol. 1991, 18: 1191-1199.View ArticlePubMedGoogle Scholar
- Dizdar O, Alyamac E, Onal IK, Uzun O: Group B Streptococcal Facet Joint Arthritis: Case Report. Spine. 2005, 30 (14): E414-E416. 10.1097/01.brs.0000170586.31612.25.View ArticlePubMedGoogle Scholar
- Churchill MA, Geraci JE, Hunder GG: Musculoskeletal manifestations of bacterial endocarditis. Ann Intern Med. 1977, 87: 754-9.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.