Annals of the Rheumatic Diseases, 1988; 47, 333-336

Case report

Acute vertebral osteomyelitis complicatingStreptococcus sanguis endocarditisCHRISTINE DEMERS, MICHEL TREMBLAY, AND YVES LACOURCIERE

From the Departments of Medicine, Pathology and Nuclear Medicine, Le Centre Hospitalier de l'UniversiteLaval, Quebec, Canada GIV 4G2

SUMMARY The first well documented case of acute pyogenic vertebral osteomyelitis presentingas the initial manifestation of Streptococcus sanguis endocarditis is reported. The importance ofsuspecting vertebral osteomyelitis in the presence of disc infection and the diagnostic value ofimaging procedures are underlined.

Although low back pain accounts for 25-33% ofmusculoskeletal manifestations of bacterial endo-carditis, the finding of pyoenic vertebral osteo-myelitis is extremely rare.'-As highly sensitive screening procedures designed

for infectious bone disease enhance the diagnosticcapabilities of the clinician, and most patients withthis condition respond well to antibiotic therapy,very few cases have been confirmed either by biopsyor at necropsy.We report the first case recorded at necropsy of a

patient who presented with vertebral osteomyelitisas the primary manifestation of S sanguis endo-carditis.

Case report

A 64 year old man with no significant previousillnesses and no history of recent injury or dentalmanipulation was admitted to hospital in August1985 with a four week history of severe low backpain exaggerated by standing and motion and onlypartially relieved by recumbency. Neurologicalsymptoms were absent. One month previously hehad developed chills, sweating, fatigue, anorexia,and a 15 pound weight loss. On examination thepatient was pale and prostrated. His temperaturewas 38-7°C. Mouth examination showed no

Acccpted for publication 15 June 1987.Correspondencc to Dr Yvcs Lacourcicrc, Department of Medi-cine, Lc Centrc Hospitalier dc l'Universitc Laval, 2705, boulevardLaurier, Ste-Foy, Qu6bcc, Canada GIV 4G2.

evidence of dental caries or gingivitis. Pertinentcardiac findings included supine blood pressure150/70 mmHg, pulse 88/min, and a grade 3/6 systolicejection murmur along the left sternal borderradiating to the neck. There was no peripheraloedema and the lung bases were clear. Examinationof the lower back showed exquisite tenderness onpalpation and percussion of L2, L3, L4, spasm of theparavertebral musculature, and moderate limitationof back motion in all directions. Neurologicalexamination was unremarkable.

INVESTIGATIONSInvestigations showed haemoglobin 94 g/l, white cellcount 10-7x 109/l with a normal differential, platelets198x 109/l, erythrocyte sedimentation rate 50 mm/h.Renal function was normal, but there was a mild

derangement of the liver enzymes. Chest x ray wasnormal and the electrocardiogram showed leftventricular hypertrophy. Lumbar spine x ray find-ings were consistent with degenerative disc diseaseand computed tomography suggested discitis of L3,L4. Increased uptake in the area of L2, L3, L4compatible with osteomyelitis was observed on bothtechnetium-99m labelled methylene diphosphonate("Tc MDP) and gallium-67 (17Ga) scans (Fig. 1).An alpha-haemolytic streptococcus identified asS sanguis type I was isolated from the aerobic bottlesof six blood cultures taken at intervals of 60 minutesover a two day period.An echocardiogram disclosed left ventricular

hypertrophy and vegetations on the aortic valve.333

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334 Demers, Tremblay, Lacourciere

Fig. I Tlhe ""'Tc MDPscan shows i,creased uiptake inthe second, third, and fouirtivertebra. The "7Ga scatialso demonstrates enhanceduptake in the area.

COURSE OF DISEASE

Therapy was instituted with penicilline G, 24 millionunits a day intravenously and gentamicin 240 mg aday intravenously. Rapid defervescence andamelioration of back pain was noted. Twelve daysafter initiation of antibiotics the patient developedleft ventricular failure with bilateral pleural effusionwhich responded temporarily to medical treatment.Aortic valve replacement was considered, but he

died two days later of intractable acute pulmonaryoedema.

N ECROPSYThe heart showed typical lesions of infectiveendocarditis with both mitral and aortic valvesshowing vegetations and ulcerations affecting themargins of mitral valve and the cusps of aortic valve(Fig. 2). Gross findings in the lumbar vertebrae (L2,

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Vertebral osteomyelitis cotniplicating S sanguis endocarditis 335

Fig. 3a Fig. 3b

Fig. 3 (a) Lotngitudinial section oJ luimbar vertebrae with irregular cavitv destro ving the bone; (b) hzigh mnagnzificationshowing granullationi tissue andti necrosis wit/h irregulalr bony traibecldla.

L3, L4) showed a 5 cm cavity surrounded withfriable and necrotic bone (Fig. 3a). Histologyshowed subacute osteomyelitis (Fig. 3b). Bacterialcultures of the specimens were negative.

Discussion

This is the first case recorded at necropsy of Ssanguis endocarditis in a patient who presented withacute lumbar vertebral osteomyelitis. We identified49 cases in the world published reports of vertebralosteomyelitis during the course of endocarditis' 4I(0and found that only one (which involved S aureus)had been fully documented at necropsy. ' Thefailure to culture the causative agent in valvular andbone specimens in our patient is not surprising as hehad received antibiotic therapy for 15 days. Bothmacroscopic and histological findings, however,were compatible with the diagnosis of endocarditisand osteomyelitis. Many features of this case aresimilar to those of previously published reports. In

fact low back pain antedating the diagnosis ofendocarditis by one month, weight loss, characteristicphysical findings, and rapid improvement afterinstitution of antibiotic therapy are consistent withprevious descriptions. -

Discitis and osteomyelitis are usually consideredin the literature as separate complications ofbacterial endocarditis. In a review of bacterialendocarditis disc space infection was thought to bepresent in five of 84 (6%) patients with musculo-skeletal manifestation and osteomyelitis in none.3As the vascular supply of the intervertebral disc islost with aging it seems reasonable to suggest thatpyogenic infection of this structure occurs afterosteomyelitis has spread beyond the vertebrae. Thusdisc space narrowing or discitis, or both, disclosedby radiological studies in the course of bacterialendocarditis may suggest the presence of anassociated vertebral osteomyelitis.

Pyogenic vertebral osteomyelitis must be recog-nised rapidly because delays in diagnosis and

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336 Deniers, Tremblay, Lacourciere

treatment can result in unnecessary surgery, seriousneurological complications, and a high mortality. 12 13Spine x rays are usually consistent with the diagnosisin 50% of cases with abnormalities such as narrow-ing of the disc space, sclerosis, or erosion of the endplates and destruction of the vertebral body. Fiftyper cent of patients' x rays are normal, however,or consistent with degenerative arthritis, as in ourpatient. In the early stage of the disease, computedtomography may be negative or disclose disc hypo-density, an early sign of vertebral osteomyelitis.'4The diagnostic value of radionuclide bone imaginghas been well established, with a sensitivity of 100%for a 99mTc MDP bone scan. '5 A positive 67Ga scanincreases the specificity when pyogenic vertebralosteomyelitis is suspected in the course of bacterialendocarditis.The authors thank Dr S Carettc for a helpful review of themanuscript and Martine Perron for secretarial assistance.

References

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2 Meycrs 0 L. Commerford P J. Musculoskcletal manifestationsof bactcrial endocarditis. Annt1 Rheu,n Dis 1977; 36: 517-9.

3 Churchill M A. Geraci J E. Hunder G G. Musculoskeletalmanifestations of bactcrial cndocarditis. Anni1 Inttertn Med 1977;87: 754-9.

4 Ninet J, Gayet J L, Etienne J, et al. Bacterial endocarditispresenting as acute vertebral osteomyelitis: 14 cases. Eur HeartJ 1984; 5 (suppl c): 101-5.

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10 Harkonen M, Olin P E, Wennstrom J. Severe back pain aspresenting sign of bacterial endocarditis. Acta Med Scand 1981;210: 329-31.

11 Case records of the Massachusetts General Hospital (case31-1978). N Engl J Med 1968; 279: 260-6.

12 Elliott J. Vertebral osteomyelitis often goes undiagnosed.JAMA 1980; 243: 1410.

13 Freehafer A A, Furey J G, Pierce D S. Pyogenic osteomyclitisof the spine resulting in spinal paralysis. J Bone Joint Surg /Aml1962; 44A: 710-6.

14 Larde D, Mathieu D, Frija J, Gaston A, Vasile N. Vertebralosteomyelitis: disk hypodensity on CT. AJR 1982; 139: 963-7.

15 Adatepe M H, Powell 0 M, Isaacr G H, Nichols K, Cefola R.Hematogenous pyogenic vertebral osteomyelitis: diagnosticvalue of radionuclide bone imaging. J Nucl Med 1986; 11:1680-5.

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