ID Case Conference 11-28-07

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

2. CC: 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.

3. 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.

4. 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.

5. PMH • Mild anxiety, controlled with low dose paxil • H/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

6. Medications • Allergies – sulfa, flagyl • Home Meds – Roxicet PRN, Paxil 10mg po daily

7. Social 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.

8. Social/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 father • 3 Children – ages 19, 16, and 6.5. History of a 4th child who died at a young age in an accident.

9. ROS • 20 lb weight loss in the past month – blamed it on pure liquid diet since the neck swelling • No fevers, no chills • No recent tooth infections – history of root canals in 2002 and 2003 • Complains of difficulty swallowing • No bowel or bladder dysfunction, no weakness or numbness

10. Afebrile – P 74, R 18, BP 134/75, 97% on RA INAD, wearing c-collar EOMI, PERRLA, nonicteric No e/e on OP No JVD No LAD appreciated in cervical, supraclavicular, axillary, or inguinal regions RRR no murmurs CTAB No rashes or skin lesions, no nail lesions A&Ox3, pleasant and cooperative, talkative. Soft NT NABS No c/c/e, pulses 2+ and equal in BU and LE Normal 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 Physical Exam

11. 12.0 6 141 103 6.9 301 29 0.6 4.0 35.5 102 Labs 9.1 ESR 35 TProt 7.3 Alb 3.8 Uric Acid 5.0 LD 440 TBili 0.5 AST 36 ALT 67 Alk Phos 110 GGT 131 TSH 0.22 PT 13.4 PTT 35.4 INR 1.2 1.7 3.8 N-4.6 L-1.5 M-0.4 E-0.2 B-0.0

20. Discussion

21. “A Diagnostic test was performed…” • FNA and BIOPSY of ventral soft tissue mass done by ENT in the OR • Negative gram stain • No AFB seen on smear • Pathology - 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.

22. Micro 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

23. Vertebral Osteomyelitis • First described by Hippocrates and Galen • Prior to antibiotics was fatal in 25% of cases • Incidence 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.

24. Probable Organisms • Staph aureus is >50% of cases • Both HA-ORSA and CA-ORSA are making up an increasing percentage. • Enteric gram negative bacilli – asso w/ urinary tract instrumentation • Pseudomonas aeroginosa and candida are seen with catheter-related blood stream infections or IV drug use • Group B and G strep in pts w/ DM • TB

25. Organisms based on geography • Brucella melitensis – middle east and mediterranean • Burkholderia pseudomallei – periequatorial regions • Salmonella and entamoeba histolytica – Africa or South America

26. Signs 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 59 • Mean duration of sx was 48 days prior to hospital admission • Neurologic impairment present in 28% • Blood cultures positive in 72% of cases • Fever inconsistent – 52% in reivew from 1979, only 30% in review from 2005

27. Signs • Tenderness to gentle spinal percussion is the most reliable clinical sign • WBC may be elevated or normal, elevations in ESR and CRP present in >80% of pts • Diagnosis is made by bone biopsy • In 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

28. Management • IV antibiotics directed at causative organism • Surgery indicated for • Progression of disease despite adequate antibiotic therapy • Threatened or actual cord compression due to spinal instability or vertebral collapse • Epidural or paravertebral abscesses

29. Long term outcome of 253 patients with vertebral osteomyelitis – CID 2002 • Eleven percent of the patients died • Residual disability occurred in more than one-third of the survivors • Relapse 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.

30. References • 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. • UpToDate • Mandell’s Principles and Practices of Infectious Disease, 6th Ed.