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Picked Up by a Wasp? Watch Out the Spine! A Case of Multifocal Pyogenic Spondylodiscitis | OMICS International
ISSN: 2165-7920
Journal of Clinical Case Reports
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Picked Up by a Wasp? Watch Out the Spine! A Case of Multifocal Pyogenic Spondylodiscitis

Geniere Nigrag S*, Casazza A, Carnevale L and Ricevuti G
Emergency Medicine Resident, Intensive Care Unit, University of Pavia, Vigevano Public Hospital, Italy
Corresponding Author : Geniere Nigrag S
Emergency Medicine Resident, University of Pavia
Intensive Care Unit, Vigevano Public Hospital, Italy
Tel: +39 0382 989898
E-mail: [email protected]
Received: September 16, 2015 Accepted: October 06, 2015 Published: October 13, 2015
Citation: Geniere Nigrag S, Casazza A, Carnevale L, Ricevuti G (2015) Picked Up by a Wasp? Watch Out the Spine! A Case of Multifocal Pyogenic Spondylodiscitis. J Clin Case Rep 5:627. doi:10.4172/2165-7920.1000627
Copyright: © 2015 Geniere Nigrag S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Introduction: spondylodiscitis represents 3-5% of all cases of osteomyelitis. S. aureus is isolated in 50% of cases. Mortality ranges is 0-11%. Disability may occur. Diagnosis is often a challenge. Lumbar spine is preferentially affected with multifocal involvement in 4% cases. Septic shock mortality rate is high (22-76%). Purpose: to describe a case of septic shock due to pyogenic multifocal spondylodiscitis successfully-treated in Intensive Care Unit (ICU). Methods: 63-year-old woman presented in Emergency Department complaining 7 days back pain, weakness and diarrhea. Clinical setting suggested intra-abdominal infection. Rapid hemodynamic derangement required ICU transfer to treat septic shock and multiple organ failure. Cerebrospinal fluid (CSF) analysis showed normal count cells and hyperproteinorachia. Methicillin-sensitive S. aureus (MSSA) was isolated from blood cultures and in a very low charge from CSF. In addiction C. difficile toxin was found. Vertebral spine Magnetic Resonance Imaging showed spondylodiscitis in multiples vertebral bodies and intervertebral disks, paravertebral and Psoas muscles abscesses. Further anamnestic information allowed identification of recent wrist wasp sting (infected by the same MSSA). In ICU, patient underwent C. albicans fungemia and P. aeruginosa sepsis. She was treated with antibiotics and we performed advanced-cardiovascular-support, protective-mechanicalventilation and continuous-venovenous- hemofiltration. Results: after 79 days, patient was transferred to rehabilitation ward and then back home. Conclusions: despite previous delay in sepsis recognition and its underlying cause, early application of intensive support and close adherence to Survival Sepsis Campaign treatment guidelines were critical issues for the survival of this unusual spondylodiscitis case.

Keywords
Spondylodiscitis; Osteomyelitis; Mortality; Multifocal
Introduction
Spondylodiscitis is an uncommon infection that represents 3-5% of all cases of osteomyelitis [1,2]. The incidence seems to be increasing in the last years as a result of higher life expectancy of older patients with chronic debilitating diseases. Spondylodiscitis is in most cases a hematogenous infection. Staphylococcus aureus is the most frequent microorganism isolated, accounting about 50% of the all cases [3]. Mortality ranges is from 0 to 11% [2]. In a significant number of cases, recrudescence, residual neurological defects or persistent pain may occur. Diagnosis is difficult and often delayed or missed due to rarity of disease and high frequency of low back pain in general population [2]. Hematogenous pyogenic spondylodiscitis affects preferentially the lumbar spine. Multifocal involvement occurs in 4% of cases [4,5].
Purpose: the objectives of this report are to describe a case of a multifocal pyogenic spondylodiscitis successfully treated in Intensive Care Unit (ICU) and to review physician attempt to this rare infection.
Clinical Case
We describe a case of 63-year-old woman living in a farm situated in Lomellina’s countryside, complaining 7 days back pain, weakness and diarrhea. Clinical setting suggested intra-abdominal infection. Rapid hemodynamic derangement required ICU transfer to treat septic shock and multiple organ failure. Cerebrospinal fluid (CSF) analysis showed normal count cells and hyperproteinorachia (Table 1). Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from blood cultures and, later, in a very low charge from CSF. In addiction Clostridium difficile toxin was found. There was no history of immunodeficiency or previous antibiotics therapy. Vertebral spine Magnetic Resonance Imaging (MRI) showed spondylodiscitis in multiples vertebral bodies and intervertebral discs, paravertebral and Psoas muscles abscesses (Figures 1-6). Further anamnestic information allowed identification of recent wrist wasp sting (infected by MSSA). When questioned, the daughter referred that her mother was picked up by a wasp few days earlier the appearance of the back pain. In ICU, patient underwent Candida albicans fungemia and Pseudomonas aeruginosa sepsis. She was treated with antibiotics (Table 2) and we performed advanced cardiovascular support, protective mechanical ventilation and continuous veno-venous hemofiltration. After 79 days hospitalization in ICU, the patient was transferred to neurological rehabilitation in spontaneous breathing, normal renal function without signs of neurological damage. Then she went back home.
Discussion
We present a rare case of multifocal pyogenic spondylodiscitis treated in our hospital in ICU. There are two key-points about this clinical case we want to discuss: firstly, the CSF analysis showed normal count cells and hyperproteinorachia. Only during the following days we documented extremely slow growth associated to a very low charge of Methicillin-sensitive Staphylococcus aureus. The interpretation of laboratory findings might be confused and misunderstood; This liquor findings are common in different situations such as contaminated fluid and autoimmune illness. The second mayor point is the importance to discover the main entry door of infection source. The wound due to wasp puncture was contaminated by the same MMSA. In conclusion, despite the delay in recognition of underlying causes of sepsis, early application of intensive support and close adherence to Survival Sepsis Campaign treatment guidelines were critical issues for the survival of this unusual spondylodiscitis case.
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