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A Rare Lumbar Pyogenic Spondylodiscitis Caused by Staphylococcus Caprae with Initial Misdiagnosis

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A Rare Lumbar Pyogenic Spondylodiscitis Caused by Staphylococcus Caprae with Initial Misdiagnosis Fan et al. BMC Surgery (2020) 20:200 https://doi.org/10.1186/s12893-020-00860-2 CASE REPORT Open Access A rare lumbar pyogenic spondylodiscitis caused by staphylococcus caprae with initial misdiagnosis: case report and literature review Zihan Fan, Yong Yang†, Dong Li and Qi Fei*† Abstract Background: Staphylococcus caprae (Sc) is an uncommon causative organism for human. Lumbar pyogenic spondylodiscitis (LPS) of Sc is extremely rare and only a few cases have been reported. As far as we know, there is no specific literature on the diagnosis and treatment for LPS of Sc with L5 nerve root irritation. Case presentation: A 65-year-old male patient complained of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. Physical examination revealed tenderness point on his low back, 3/5 dorsiflexor strength in his left 1st toe and decreased sensation of pin prick over the left lateral shank and medial dorsal foot. The individual was initially misdiagnosed with lumbar disc herniation (LDH) without further examination in outpatient, which was then found to be LPS of Sc with L5 nerve root irritation after admission to our hospital. Magnetic resonance images (MRI) of lumbar spine exhibited inflammation signal at L4-L5 level of the vertebral body and disc with hypointense on T1-weighted images (T1-WI) and hyperintense on T2-weighted images (T2-WI). The causative organism was confirmed by the culture of irrigation fluid obtained from L5 vertebrae by needle puncture. After systemic conservative treatment including using sensitive antimicrobial agents and immobilization, the rare infection was finally cured. The patient also showed a satisfactory recovery during the 36-month follow-up period. Conclusions: Confirming the diagnosis and identifying the causative organism as soon as possible is the key point for the treatment of LPS. LPS of Sc causing nerve root irritation is rare but curable with early diagnosis and proper therapy. The culture of irrigation fluid obtained from vertebrae by needle puncture may be an effective and sensitive attempt for potential infection of spine to identify the causative organism at early stage of the disease. Keywords: Pyogenic lumbar spondylodiscitis, Staphylococcus caprae, Vertebral needle biopsy, Case report * Correspondence: [email protected] †Yong Yang and Qi Fei contributed equally to this work. Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, No.95, Yong’an Road, Xicheng District, Beijing 100050, China © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Fan et al. BMC Surgery (2020) 20:200 Page 2 of 9 Background history of hypertension which was controlled well with Staphylococcus caprae (Sc) was firstly reported by Devri- medication for 10 years without history of any kinds of ese et al. in 1983 based on a strain which was the main infection. There was no contact history of cows, goats or species isolated from goat’s milk [1]. The organism has raw milk as well. The patient had a 30 years history of been well described in veterinary medicine [2–4]. As a smoking, about ten cigarettes per day. There was no his- kind of coagulase-negative species of Staphylococcus, Sc tory of tuberculosis (TB), alcohol abuse or illicit drug is considered to be a commensal organism of the skin use as well as family history of other diseases for him. and mammary glands of goats. However, this kind of On physical examination, the patient had no fever or Staphylococcus may also typically colonize human skin, loss of weight, and his vital signs were stable. However, nose and nails. It has been reported in several cases as a he had tenderness points on his low back, and had 3/5 human pathogen causing peritonitis, meningitis, urinary dorsiflexor strength in his left 1st toe. Decreased sensa- tract infections, endocarditis, endophthalmitis, prosthetic tion of pin prick over left lateral shank and medial dorsal joint infections, recurrent sepsis, bacteremia and osteo- foot was documented. The straight leg raising test was myelitis [5–9]. Many risk factors for the infection of Sc positive in this patient’s bilateral lower extremities. The have begun to emerge including immunosuppression, Visual Analogue Score (VAS) was 7. diabetes, chronic renal failure, obesity, open or traumatic Laboratory examinations indicated a normal white fractures and contact with sheep or goats [6]. In recent blood cell count of 7.6 K per mm3, erythrocyte sedimen- − years, Sc has also been reported as a human hospital- tation rate of 69 mm h 1, and C-reactive protein of 47 − acquired pathogen, mostly implicated in bone and joint mg L 1. Lumbar X-ray showed degeneration of lumbar infection after orthopedic operations [5, 10, 11]. But spine, hyperplasia of vertebrae, no significant narrowing there are rare cases for infection of Sc occurring in na- of inter-vertebral space at L4-L5 level (Fig. 1a and b). tive bone and joints without orthopedic prostheses. When the patient firstly arrived at the outpatient depart- Lumbar pyogenic spondylodiscitis (LPS) is an uncom- ment, he was diagnosed as LDH due to low back pain mon lumbar infection involving intervertebral disks and radiating to left lower extremity. After admission to in- adjacent vertebral bodies. The most well-known causa- patient department, further examination revealed more tive microorganism of LPS is Staphylococcus aureus (Sa). details, which were not detected before, leading to a new Hence, LPS caused by Sc is more rarely reported. At the and more accurate result. The rose bengal plate tests, early stage of the disease, LPS of Sc with L5 nerve root anti-mycobacterium tuberculosis antibody and PPD were irritation is quite familiar with lumbar disc herniation tested, showing negative results. Computed tomography (LDH), but the therapy of these two kinds of diseases is (CT) scan revealed vertebral worm-eaten-like damages, totally different. Therefore, differential diagnosis be- the formation of sequestrum, hyperplasia of vertebrae at tween LPS of Sc and LDH must be seriously concerned, L4-L5 level (Fig. 1c and d). Magnetic Resonance Imaging as misdiagnosis and delayed treatment may lead to an ir- (MRI) of the lumbar spine revealed inflammation like reversible damage in neurologic function even physical signal at L4–L5 level of the vertebral body and disc disability for the patient. Here, we present the clinical, which exhibited hypointense on T1-weighted images bacteriological, pathological, radiological findings, and and hyperintense on T2-weighted images (Fig. 1e and f). treatment outcomes in a new case of LPS of Sc with L5 To exclude neoplastic disease, PET-CT was also per- nerve root irritation. formed which showed the significant uptake of the radioactive FDG, high suspicion of infection (Fig. 1g). Case presentation Iliac bone biopsy was also implemented by hematologist A 65-year-old male patient was referred to our hospital for the possibility of hematological disease, pathological because of chronic low back pain for 10 years, acute report of which showed there was no finding of malig- worsening with radiating pain to left lower extremity nant tumor cells. over a month. The patient had a chronic low back pain To confirm the diagnosis, fluoroscopy guidance- for 10 years. He was diagnosed with LDH and lumbar guided needle (Dragon crown, Shandong, China) punc- fasciitis and received conservative treatment in local hos- ture of the L5 vertebral body was performed (Fig. 2a and pital. The back pain was acute worsening with radiating b). We decided to choose the left transpedicular ap- pain and numbness to the left shank and 1st toe over a proach as the puncture path, because the left side of the month. The patient had experienced Traditional Chinese vertebral body was mostly affected (Fig. 1c and d). On Medicine (TCM) acupuncture treatment on lower back the anterior–posterior (AP) view of fluoroscopy, the tip for five times in the past 1 month before admitting to of needle was inserted on the superior-lateral quadrant our hospital. The patient told the longest needles were of the pedicle. The trajectory of the needle passed about 7–8 cm and he could feel the needle hit on the through the soft tissues and left pedicle into the verte- bone during the process of acupuncture. He had a bral body. The biopsy forceps (JZ classic, Shanghai, Fan et al. BMC Surgery (2020) 20:200 Page 3 of 9 Fig. 1 Radiological findings before treatment. Notes: (a and b) X-ray before treatment showed degeneration of lumbar spine, hyperplasia of vertebrae, no significant narrowing of L4–5 inter-vertebral space. (c and d) CT showed vertebral worm-eaten-like damages (arrow), the formation of sequestrum, hyperplasia of vertebrae. (e and f) MRI showed hypointense on T1-WI and heterogeneous hyperintense on T2-WI (arrow) in L4–5 level of vertebrae and disc.
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