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Bifocal spondylodiscitis caused by Streptococcus oralis: A rare complication of infective endocarditis
Espondilodiscitis bifocal por Streptococcus oralis: complicación infrecuente de la endocarditis infecciosa
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Left: mitral valve vegetation (arrow). Center: mitral valve regurgitation shown in the color Doppler echocardiogram (arrow). Right: mitral valve microperforation (arrow). B) Ocular fundus. Roth’s spots (arrows). C) Thoracolumbar MRI. Left: signal intensity alteration in the lower portion of vertebral body D8 (arrow). Right: decrease in the height and signal intensity of the L5-S1 intervertebral disk (arrows). D) PET-CT scan. Increased metabolic activity in vertebral bodies D8 and L5-S1 (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Spondylodiscitis is an infection of the vertebral body and adjacent disks, whose main form of dissemination is the hematogenous route. Although it is a rare entity, its incidence is increasing due to the growing rate of bacteremias linked to intravascular devices and other instruments. The most common cause of spondylodiscitis is infection by <span class="elsevierStyleItalic">Staphylococcus aureus</span>, with infections by other pathogens, such as species of the <span class="elsevierStyleItalic">Streptococcus</span> genus, being much less frequent despite their growing interest.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although <span class="elsevierStyleItalic">Streptococcus oralis</span> is part of the flora of the oral cavity and nasal sinuses, under certain circumstances, such as in cases of infective endocarditis, it can cause spondylodiscitis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this paper we present the case of a patient with a double focus (dorsal and lumbosacral) of spondylodiscitis caused by <span class="elsevierStyleItalic">S. oralis</span> in the context of native valve infective endocarditis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 50-year-old, ex-smoker, diabetic, and hypertensive man. He reported an approximately two-week history of lowgrade fever and lumbar pain that increased when applying pressure on the spine, as well as flexing and extending his trunk. Physical examination revealed a panfocal systolic murmur that did not radiate toward the axillary region and was not modified by the Valsalva maneuver. No skin lesions, Osler’s nodes, nor Janeway lesions were detected. Blood work revealed figures of normocytic anemia (9.4 g/dl), C-reactive protein levels of 10.1 mg/dl, and an erythrocyte sedimentation rate of 50 mm as the main findings. Both an electrocardiogram and a chest X-ray revealed normal images. Given the suspected diagnosis of infective endocarditis, a transthoracic and transesophageal echocardiogram was requested, observing a 0.85 cm<span class="elsevierStyleSup">2</span> image compatible with a vegetation on the anterior cusp of the mitral valve, as well as moderate mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Empirical antibiotic therapy was consequently started, and blood cultures were taken, identifying isolates of <span class="elsevierStyleItalic">S. oralis.</span> An ophthalmological study was also performed, detecting Roth's spots in the patient’s right eye (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). A spinal magnetic resonance imaging (MRI) scan was also requested, viewing signal intensity alterations in the right portion of the lower endplate of vertebral body D8, as well as a decrease in the height and signal intensity of the L5-S1 intervertebral disks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). A positron emission tomography (PET)/computed tomography (CT) scan performed revealed images compatible with spondylodiscitis of probable septic etiology at the level of vertebral bodies L5-S1 and D8 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Given the conclusive results of the blood cultures and the imaging studies performed, the conduct of a lumbar puncture was ruled out. Targeted antibiotic therapy in the form of a six-week course of ceftriaxone and rifampicin, as well as a two-week course of gentamicin, was administered, achieving a good analytical and clinical response. A follow-up echocardiogram revealed a decrease in the size of the vegetation until its complete disappearance, with the only subsequent sequelae being a small perforation in the anterior cusp of the mitral valve and moderate regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Rheumatic manifestations are common in patients with infective endocarditis and, although their incidence varies according to the case series, may be present in up to 42% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> While back and joint pain are the most common findings, spondylodiscitis is a complication that is only observed in 2% to 6% of cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In contrast to conditions caused by <span class="elsevierStyleItalic">S. aureus</span>, cases involving streptococci of the <span class="elsevierStyleItalic">viridans</span> group are usually characterized by a subacute presentation and give rise to a larvate clinical picture that occasionally delays the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Treatment of streptococcal spondylodiscitis is usually conservative and based on the administration of antibiotic therapy, with surgical or percutaneous approaches being reserved for cases of spinal cord abscessification or compression.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although it is a frequent microorganism among the etiological causes of infective endocarditis, the actual incidence of spondylodiscitis associated with <span class="elsevierStyleItalic">S. oralis</span> is still unknown. To date, the case described in this paper is an exceptional finding in the literature, with only two similar cases having been published thus far.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> For its part, bifocal thoracolumbar spondylodiscitis is also extremely rare, accounting for less than 5% of all cases.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">We have received no funding for the conduct of this research.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors of this document declare no conflict of interest in relation to the publication of this letter.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Águila Gordo D, González Peñas M, Piqueras Flores J. Espondilodiscitis bifocal por <span class="elsevierStyleItalic">Streptococcus oralis</span>: complicación infrecuente de la endocarditis infecciosa. Med Clin (Barc). 2021;157:501–503.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2152 "Ancho" => 2917 "Tamanyo" => 551812 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Transesophageal echocardiogram. Left: mitral valve vegetation (arrow). Center: mitral valve regurgitation shown in the color Doppler echocardiogram (arrow). Right: mitral valve microperforation (arrow). B) Ocular fundus. Roth’s spots (arrows). C) Thoracolumbar MRI. Left: signal intensity alteration in the lower portion of vertebral body D8 (arrow). Right: decrease in the height and signal intensity of the L5-S1 intervertebral disk (arrows). D) PET-CT scan. Increased metabolic activity in vertebral bodies D8 and L5-S1 (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Streptococcal vertebral osteomyelitis: multiple faces of the same disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Murillo" 1 => "A. Roset" 2 => "B. Sobrino" 3 => "J. Lora-Tamayo" 4 => "R. Verdaguer" 5 => "E. Jiménez-Mejias" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Microbiol." 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