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VERTEBRAL OSTEOMYELITIS 22nd ECCMID, April 1, 2012, LONDON
Werner Zimmerli, Basel University Medical Clinic Liestal
• Classification of vertebral osteomyelitis • Epidemiology, microorganisms • Clinical characteristics • Diagnostic work-up • Differential diagnosis of MRI • Treatment • Conclusions
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TYPE OF VERTEBRAL OSTEOMYELITIS
• Acute haematogenous vertebral osteomyelitis: < 30 days of duration (pyogenic)
• Subacute or chronic haematogenous VO: >30 days of duration (tb, brucellosis)
• Exogenous VO without implant: mainly after disk surgery (rare)
• Exogenous implant-associated VO: mainly after internal stabilisation for scoliosis
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EPIDEMIOLOGY
[Grammatico L et al. Epidemiol Infect 136:653-660, 2008]
Incidence: 2.4 cases per 100,000 population Clear age-dependence, i.e. infection of the elderly: - 0.3 cases/100,000 <20 years of age - 2.4 cases/100,000 >70 years of age
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VERTEBRAL OSTEOMYELITIS CAUSED BY S. AUREUS: AGE DEPENDENCE
[Jensen et al. Arch Intern Med 1998]
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MICROORGANISMS IN 255 EPISODES
Number of Microorganism episodes
S. aureus 123 (48.3 %) Coagulase-neg. staphylococci 17 (6.7 %) Gram-negative bacilli 59 (23.1%) Streptococci 24 (9.4 %) Polymicrobial 20 (7.8 %) Micellaneous 12 (4.7 %)
[M.C. McHenry et al. Clin Infect Dis 2002]
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LOCALISATION
• Cervical 10.6 % • Cervico-thoracal 0.4 % • Thoracal 23.9 % • Thoracolumbal 6.3 % • Lumbal 43.1 % • Lumbosacral 15.3 % • Sacral 0.4%
[M.C. McHenry et al. Clin Infect Dis 24:1342, 2002]
Data from 255 episodes of vertebral osteomyelitis in the USA from 1950-94
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CLINICAL CHARACTERISTICS
SYMPTOMS: Back pain 86% (528/608) Fever 60% (481/800) CLINICAL SIGNS: Neurologic impairment* 34% (310/901)
(*Sensory loss, weakness, radiculopathy)
Tenderness on percussion 17.5% (7/40) Paraspinal muscle spasm 7.5% (3/40)
[Mylona E et al.: Semin Arthritis Rheum 39:10-7,2009 Priest&Peacock: South Med J 98:854-62,2005]
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LABORATORY WORK-UP
• Leukocytosis and neutrophilia have a low sensitivity (65% and 40%, respectively)
• Increased ESR and CRP have a high sensitivity (98% and 100%, respectively)
• Blood cultures: 58% positive (30-78%)
• CT-guided or open biopsy: 77% (535/693) positive (47-100%)
[Zimmerli W, NEJM 2010 and Mylona E, Sem Arthritis Rheum 2009]
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IMAGING WORK-UP
• Technetium-99 methylene diphosphonate → positive within a few days: non-specific
• Anti-granulocyte antibodies and labeled leukocyte scan → difficult interpretation
• CT-scan → useful for CT-guided biopsy
• MRI: early positive (bone marrow edema): 90% accuracy (gold standard)
• PET-scanning with 18-fluoro-deoxyglucose, similar to MRI, may be better in case of metallic implants
[Palestro CJ et al., Best Pract Res Clin Rheumatol 2006]
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3-PHASE TECHNETIUM AND ANTI-GRANULOCYTE SCAN
99mTc-MDP 99mTc-anti-NCA-90Fab
Vertebral osteomyelitis Th6/7 in a man with growth of Streptococcus bovis in blood cultures
Hot spot Cold spot
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MRI in a 62-y-old woman with group B Streptococcus vertebral osteomyelitis Th10/11
T1 w/o gadolinium T1 with gadolinium T2
Edema in vertebrae, disk and prevertebral
Gadolinium enhancement in vertebrae,disk and prevertebral
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MRI - DIFFERENTIAL DIAGNOSIS
• Case 1: 71-y-old woman with increasing lumbar pain and high CRP
• Case 2: 85-y-old man with lumbar back and flank pain and arthritis
• Case 3: 84-y-old man with lumbar pain and high CRP
• Case 4: 20-y-old man returning from a trip to Ecuador with back pain and remitting fever
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DIFFERENTIAL DIAGNOSIS: Case 1 71-y-old woman R.V-A.,25.03.1937,f
Signs and symptoms Temp. 36.9°C, lumbosacral pain since many
years, however increasing since a couple of days.
Lab work-up Hb 143 g/L, Lc 14’000/µl with 8% band forms,
Tc 391‘000/µl, CRP 132 mg/L, 2 x 2 blood cultures without growth.
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MRI: 71-y-old woman (case 1)
T2 29/9/08 T1 29/9/08 T1fs 29/9/08 gadolinium
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MRI: 71-y-old woman (case 1)
T1/GAD Sept 2007 T1/Gad Sept 2008
No change during 1 year
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T1/GAD Sept 2007 T1/Gad Sept 2008
Erosive osteochondrosis
MRI: 71-y-old woman (case 1)
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DIFFERENTIAL DIAGNOSIS: Case 2 85-y-old man
Case history:
Chronic back pain, chronic renal insufficiency, gouty arthritis.
Clinical findings:
Intense tender lumbar back pain and pain in right flank, swelling and redness of the right index
Lab work-up:
Leukocytes 25.3G/L, CRP 349 mg/L, uric acid 513 µmol/L [Rufener J. et al. Lancet in press]
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MRI: 85-y-old man (case 2)
Erosion L1/L2 Gadolinium enhancement M. psoas
Courtesy: Parham Sendi Lancet in press 2012
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Work-up: 85-y-old man (case 2)
Microbiology:
• Blood cultures: No growth
• CT-guided biopsy of vertebra and psoas abscess: No growth in cultures, eubacterial PCR (16-S-RNA): negative
Which laboratory exam revealed the diagnosis?
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Work-up: 85-y-old man (case 2)
Polarized light microscopy showed needle-shaped uric acid cristals in the specimen of the psoas muscle:
Gouty tophus involving the spine and mimicking spondylodiscitis with psoas abscess
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DIFFERENTIAL DIAGNOSIS: Case 3 84-y-old man h. hermann,17.12.1926
Case history: Lumbar pain since 4 days before hospitalisation. Pain only during mobilisation, not in horizontal position. Steroid therapy for chronic obstructive lung disease since several years. Clinical findings: Tenderness on percussion in the lumbar spine Lab work-up: CRP 75 mg/L, Leukocytes 12‘000/µl
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MRI: 84-y-old man (case 3)
1.4.10 T1 14.4.10 T1 14.4.10 T1 Gad
Low signal intensity = „fluid sign“ in L4
Air in L4 Prevertebral mass
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DIFFERENTIAL DIAGNOSIS: Case 3 84-y-old man
1.4.10 T1 14.4.10 T1 14.4.10 T1 Gad
Fluid in L4 Air in L4 Prevertebral mass (bleeding?)
Intravertebral fluid in conjunction with air is typical for osteonecrosis (M. Calvé = aseptic bone necrosis) [Yu CW et al., Am J Neuroradiol 28:42-7,2007]
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DIFFERENTIAL DIAGNOSIS: Case 4 20-y-old man s. luzius,6.7.91
Case history: 05.1.12: Trip to Ecuador. 15.1.12: 1-day episode of diarrhea. 31.1.12: rapidly progressing back pain. 4.2.12 remitting fever responding to ibuprofen. Early flight back to Switzerland because of severe back pain and fever. Clinical findings (16.2.12): 20-y-old man with 37.8°C, BP 120/78 mm Hg, HF 88/min, Lumbar paraspinal muscle spasm on the right side. Lab work-up: Lc 10‘400/ul, Hb 142 g/L, SR 39 mm, CRP 61 mg/L MRI and blood cultures performed.
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MRI: 20-y-old man (case 4)
16.2.12 T2 16.2.12 T1 Gad
Minimal edema in Th12/L1 Gadolinium enhancement
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DIFFERENTIAL DIAGNOSIS: Case 4 20-y-old man
Blood cultures: In 4/4 blood cultures growth of Salmonella enterica subsp. enterica Tennessee Final diagnosis: Spondylitis due to Salmonella enterica Comment: No gadolinium enhancement in the discus. Nevertheless, clear vertebral osteomyelitis
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PRINCIPLES OF ANTIMICROBIAL THERAPY OF VERTEBRAL OSTEOMYELITIS
• Start antibiotics only when the infecting agent is known (positive blood cultures or positive biopsy).
• Most patients need 6 weeks of therapy, longer is not better. [Roblot et al. Semin Arthritis Rheum 2007]
• Longer treatment in case of undrained abscesses or implants. [Kowalski et al. CID 2007]
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PRINCIPLES OF SURGICAL THERAPY OF VERTEBRAL OSTEOMYELITIS
• Acute haematogenous osteomyelitis does not require surgery, except for diagnosis (biopsy).
• Most abscesses can be drained with the use of a CT-guided catheter, except for large epidural abscesses with neurologic deficit.
• A minority with large defects needs stabilisation
• Early (<30d) implant-associated infection can be treated with débridement and retention. Late infection requires removal or suppressive therapy. [Zimmerli, NEJM 2010, Kowalski et al. CID 2007]
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IS FOLLOW-UP MRI NEEDED IN ORDER TO DEFINE THE DURATION OF THERAPY?
49-y-old man with GBS-vertebral osteomyelitis.
T 0 (at dg) T 12 days T 52 days Would you stop therapy at day 52 based
on the MRI control?
Courtesy: Univ Hosp Geneva
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Study with 79 patients having 2 MRI at diagnosis and 4-8 weeks therapy
MRI follow-up Percentage without failure Better 100% (27/27) Equal 89% (34/38) Worse 56% (9/14) Clinical follow-up better at 2nd MRI: 94% (49/52)* * 2 with failure had still increased CRP and in one patient it has not been tested. [Kowalski TJ et al. CID 43:172-9, 2006]
IS CONTROL MRI NEEDED AND USEFUL?
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IN CASE OF EPIDURAL ABSCESS, MRI-CONTROL MAY BE USEFUL
57-y-old man with E. coli ESBL VO and epidural abscess
T1/GAD 21.7.09 T1/Gad 18.5.09
Based on the disapperance of the epidural abscess antibiotics could be stopped despite clear worsening of the bone deminera-lisation.
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COMPLICATONS AND OUTCOME
[Mylona et al. Semin Arthritis Rheum 39:10-7, 2009, Zimmerli W., N Engl J Med 362:1022-1029,2010]
Abscesses: paravertebral, epidural and M.psoas: • Paravertebral abscess: 26% • Disk abscess: 5% • Epidural abscess: 17%
Relapse: 8% (especially frequent with concomitant endocarditis)
Mortality: 6%
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VERTEBRAL OSTEOMYELITIS: CONCLUSIONS
• No specific signs or symptoms
• Only 40% have fever
• Nuclear medicine is not helpful
• MRI is gold standard, however differential diagnosis has to be considered
• No antibiotic treatment before culture result
• 6-week-therapy is enough
• Surgical therapy is almost never needed
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