ID Case Conference 11-28-07 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases.

ID Case Conference 11-28-07ID Case Conference 11-28-07

Gretchen Shaughnessy, MDClinical FellowDept of Infectious Diseases

CC: neck painCC: neck pain

43 year old woman without significant PMH who presents with neck pain. She initially presented to her primary care physician in August 2007 with mild neck discomfort and feeling “like my head is too heavy for my neck.” She initially thought it was from sleeping on the couch for a week but the pain persisted after she slept in her bed. She was diagnosed with probable musculoskeletal strain and treated with NSAIDS and physical therapy. The pain persisted.

HPI (cont)HPI (cont)

In late-October 2007 she had a sudden onset of neck swelling and trouble swallowing. She was admitted to her local hospital and started on steroids and antibiotics. CT scan of the neck revealed bone destruction of C2 & C3 with ventral soft tissue swelling concerning for a mass. An open biopsy was done 11/5/07 in the OR and pathology revealed only inflamed mucosa with fibrosis. This was not sent for culture.

HPI (Cont)HPI (Cont)

She was discharged without steroids or antibiotics and referred to UNC ENT clinic for further evaluation of her neck mass.UNC ENT physician saw the patient on 10/20/07. After reviewing the CT scan from the outside hospital, the physician put the patient in a C-collar, admitted her to the hospital, called ID and neurosurgery.

PMHPMH

Mild anxiety, controlled with low dose paxilH/o Bartholin gland cysts in July 2007 – it was excised and drained at her local ED then 36 hours later she had fevers and chills with drainage. She had multiple I&Ds and ultimately a surgical excision with drain placement in August 2007 (she was sleeping on the couch because of the wounds)

10 days of clindamycin for +MRSA culture in the wound, no blood cultures, wound resolved.

G4P4004 – h/o C sections

MedicationsMedications

Allergies – sulfa, flagylHome Meds – Roxicet PRN, Paxil 10mg po daily

Social HistorySocial History

Denies alcohol, tobacco, or drug use.Has one dog at home – dog is not ill.No recent travel.The patient’s husband is in the military and spent 10 months in Afghanistan in 2004 and 2 more weeks there just prior to her illness. He was overseas October 12-28 and her neck swelling occurred just after he returned.She reports that 3 soldiers from her husband’s regimen contracted TB while abroad, no known TB in her husband.

Social/Family HistorySocial/Family History

Currently works as a housewife. Previously worked as a preschool teacher where they required yearly PPDs (last negative 16 months ago) Colon cancer in her father3 Children – ages 19, 16, and 6.5. History of a 4th child who died at a young age in an accident.

ROSROS

20 lb weight loss in the past month – blamed it on pure liquid diet since the neck swellingNo fevers, no chillsNo recent tooth infections – history of root canals in 2002 and 2003Complains of difficulty swallowingNo bowel or bladder dysfunction, no weakness or numbness

Physical ExamPhysical Exam

Afebrile – P 74, R 18, BP 134/75, 97% on RAINAD, wearing c-collarEOMI, PERRLA, nonictericNo e/e on OPNo JVDNo LAD appreciated in cervical, supraclavicular, axillary, or inguinal regionsRRR no murmursCTABNo rashes or skin lesions, no nail lesions

A&Ox3, pleasant and cooperative, talkative.Soft NT NABSNo c/c/e, pulses 2+ and equal in BU and LENormal tone, full ROM present. No tenderness to palpation of thoracic or lumbar spine. No apparent tenderness to palpation when I watched neurosurgery palpate the patient’s cervical spine.CN II-XII intact, strength 5/5 in BU and LE, reflexes 2+ in BU and LE, cerebellar exam intact

LabsLabs

35.56.9

12.0301

1414.0

10329

6

0.6102 ESR 35

TProt 7.3Alb 3.8Uric Acid 5.0LD 440TBili 0.5AST 36ALT 67Alk Phos 110GGT 131TSH 0.22

N-4.6L-1.5M-0.4E-0.2B-0.0

9.11.73.8

PT 13.4PTT 35.4INR 1.2

Discussion

“A Diagnostic test was performed…”“A Diagnostic test was performed…”

FNA and BIOPSY of ventral soft tissue mass done by ENT in the OR

Negative gram stainNo AFB seen on smearPathology - Polypoid fragments of benign squamous mucosa with parakeratosis and submucosal chronic inflammation.- No granulomatous inflammation or carcinoma identified.- AFB and GMS stains negative for AFB or fungi.

Micro results from biopsyMicro results from biopsy

GRAM STAIN RESULT BELOW1+ POLYMORPHONUCLEAR LEUKOCYTES1+ GRAM POSITIVE COCCI 2007-11-25RESULT 1Oxacillin Resistant Staphylococcus aureus 3+2007-11-25PENICILLINR 2007-11-25OXACILLINR 2007-11-25GENTAMICINS 2007-11-25VANCOMYCIN MIC2S 2007-11-25ERYTHROMYCINR 2007-11-25CLINDAMYCINS 2007-11-25TRIMETH/SULFAMETS 2007-11-25DOXYCYCLINES

Vertebral OsteomyelitisVertebral Osteomyelitis

First described by Hippocrates and GalenPrior to antibiotics was fatal in 25% of casesIncidence of vertebral osteomyelitis may be increasing 2/2 increased rates of nosocomial bacteremia, increasing population age, and higher rates of IV drug use.Most common site is lumbar, followed by thoracic. Cervical is rare.

Probable OrganismsProbable Organisms

Staph aureus is >50% of casesBoth HA-ORSA and CA-ORSA are making up an increasing percentage.

Enteric gram negative bacilli – asso w/ urinary tract instrumentationPseudomonas aeroginosa and candida are seen with catheter-related blood stream infections or IV drug useGroup B and G strep in pts w/ DMTB

Organisms based on geographyOrganisms based on geography

Brucella melitensis – middle east and mediterraneanBurkholderia pseudomallei – periequatorial regionsSalmonella and entamoeba histolytica – Africa or South America

Signs and SxSigns and Sx

Neck and back pain. Usually begins insidiously and progressively worsens over weeks to months.Series of 64 pts w/ spontaneous hematogenous vertebral osteo w/o h/o IV drug abuse:

Mean age 59Mean duration of sx was 48 days prior to hospital admissionNeurologic impairment present in 28%Blood cultures positive in 72% of cases

Fever inconsistent – 52% in reivew from 1979, only 30% in review from 2005

SignsSigns

Tenderness to gentle spinal percussion is the most reliable clinical signWBC may be elevated or normal, elevations in ESR and CRP present in >80% of pts

Diagnosis is made by bone biopsyIn one review article 31% of pts w/ vertebral osteo had infective endocarditis as well

Risk factors for IE were heart condition, heart failure, positive blood cultures, and gram positive organisms

ManagementManagement

IV antibiotics directed at causative organismSurgery indicated for

Progression of disease despite adequate antibiotic therapyThreatened or actual cord compression due to spinal instability or vertebral collapseEpidural or paravertebral abscesses

Long term outcome of 253 patients with vertebral osteomyelitis – CID 2002

Long term outcome of 253 patients with vertebral osteomyelitis – CID 2002

Eleven percent of the patients diedResidual disability occurred in more than one-third of the survivorsRelapse occurred in 14%. Median duration of follow-up was 6.5 years (range, 2 days to 38 years). Independent risk factors for adverse outcome (death or qualified recovery) were neurologic compromise, time to diagnosis, and hospital acquisition of infection (P< or =.004). Surgical treatment resulted in recovery or improvement in 86 (79%) of 109 patients.

ReferencesReferences

Nolla JM, Ariza J, Gómez-Vaquero C, Fiter J, Bermejo J, Valverde J, Escofet DR, Gudiol F. Spontaneous pyogenic vertebral osteomyelitis in nondrug users. Semin Arthritis Rheum. 2002 Feb;31(4):271-8. Priest DH, Peacock JE Jr. Hematogenous vertebral osteomyelitis due to Staphylococcus aureus in the adult: clinical features and therapeutic outcomes. South Med J. 2005 Sep;98(9):854-62. Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis. 1995 Feb;20(2):320-8. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002 May 15;34(10):1342-50. Epub 2002 Apr 22. UpToDateMandell’s Principles and Practices of Infectious Disease, 6th Ed.