Spinal infections due to Eikenella corrodens: Case report and literature review

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Short

clinical

case

Spinal

infections

due

to

Eikenella

corrodens:

Case

report

and

literature

review

Infections

spinales

à

Eikenella

corrodens

:

à

propos

d’un

cas

et

résumé

de

la

littérature

C. Yetimoglu

a,∗

_,

_P.

_Rafeiner

b

_,

_D.

_Engel

a

_,

_J.-Y.

_Fournier

a

a_Service_de_{neurochirurgie,}_hôpital_Cantonal_de_St._Gall,_Rorschacher_Strasse_95,₉₀₀₇_St._Gall,_Switzerland b_Clinique_de_medicine_interne,_hôpital_de_Zoﬁngen,₄₈₀₀_Zoﬁngen,_Switzerland

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received21November2012

Receivedinrevisedform26February2014 Accepted29March2014

Availableonline27May2014 Keywords:

Spinalinfection Eikenellacorrodens Cervicalspondylitis Surgicalsiteinfection

a

b

s

t

r

a

c

t

SpinalinfectionswithEikenellacorrodensarerare.Wereportauniquecaseofinfectioncausedby

E.corrodensdiagnosedmorethantwoyearsaftercervicalsurgery.Allotherpublishedcasesofspinal

infections caused by E.corrodens were searched. Characteristics of this bacterium, itschallenging

diagnosisandtherapyarediscussed.

Motsclés: Infectionspinale Eikenellacorrodens Spondylodiscitecervicale Infectiondusitechirurgical

r

é

s

u

m

é

L’infectionspinaleàEikenellacorrodensestrare.Cetarticlerapporteuncasd’infectionàE.corrodens

survenuplusdedeuxansaprèschirurgiecervicale.Parailleurs,nousanalysonslesautrescas

pub-liésd’infectionsspinalesàE.corrodens.Lescaractéristiquesprincipalesdecegermesontdécriteset,

comptetenudesdifﬁcultésd’isolementdecettebactérieenculturestandard,nousdiscutonslesoutils

diagnostiques.

1. Introduction

Eikenellacorrodensisaubiquitousbacteriumoftheoralﬂora.

Furthermore, it colonizes the gastrointestinal and the

genito-urinarytract.APubMedliteraturesearchrevealedonlytencasesof

spinalinfectionscausedbythisbacterium(Table1).Onlyonecase

oflumbarinfectionaftersurgeryandonecaseofspontaneous

cer-vicalspondylodiscitiswithoutpriorsurgeryhavebeenreported.A

cervicalinfectionwithE.corrodensafteraneurosurgical

interven-tionhasnotbeendescribedtodate.

∗ Correspondingauthor.

E-mailaddress:cem.yetimoglu@kssg.ch(C.Yetimoglu).

2. Observation

A47-year-oldfemaledeskclerkwasseeninouroutpatientclinic

withthechiefcomplaintofcervicobrachialgia.Themajorcervical

painexistedforhalfayearandwasoftenaccompaniedby

cephal-gias andoccasionallymigraineandparaesthesiaoftheleftarm.

Conservativetreatmentremainedunsuccessful.Besides,she

pre-sentedahistoryofacaraccidentwithcervicaldistortion3years

before,agynaecologicalroutineintervention30yearsagoanda

motorcycleaccidentwithmildtraumaticbraininjury34yearsago.

Clinicalexaminationrevealedacervicalsyndromewithout

neu-rologicaldeﬁcits.AnMRIofthecervicalspineshowedadvanced

degenerative discdiseaseat C4/5 and C5/6 levels, aswell as a

cervicalkyphosis,osteochondrosis,ventralspondylosisdeformans

andadischerniationatC4/5withnarrowingofthespinalcanal

http://dx.doi.org/10.1016/j.neuchi.2014.03.002

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198 C.Yetimogluetal./Neurochirurgie60(2014)197–200

Table1

LiteraturereviewofarticlesreportingspinalinfectionofEikinellacorrodens.

RevuedelalittératuresurdesarticlesrapportantuneinfectionspinaleàEikinellacorrodens.

Nameofstudy Typeofstudy Location Spontaneous Postoperative Antibiotics Surgicalrevision

Angetal.,2002[1] Casereportetreview L4-L5 No Yes Yes Yes

Bridgemanetal.,1990[2] Casereport Lumbar Yes No Yes No

Emmettetal.,2000[3] Casereport T10-T11 Yes No Unknown Unknown

Lehmanetal.,2000[4] Casereport C5-C6C6-C7 Yes No Yes Yes

Noordeenetal.,1992[5] Casereport Lumbar Yes No Yes No

Peereboometal.,1987[6] Casereport Cervical No Yes(transoral) Yes Yes

Raabetal.,1993[7] Casereport L3 Yes No Yes No

Sayanaetal.,2003[8] Casereport L4-L5 Yes No Yes No

Tsaietal.,2009[9] Casereport L4-L5 Yes No Yes Yes

Zeitfangetal.2002[10] Casereport L3-L4 Yes No Yes Yes

withasagittaldiameterof8mm.Similarchangeswereobserved

atC5/6withconsecutivespinalstenosiswithasagittaldiameterof

10mm.

In ordertodecompressthesymptomatic spinalcanal

steno-sis,ananteriordiscectomyC4/5and C5/6withinterbodyfusion

withatricorticalautogenousiliaccrestgraftandanteriorplating

was recommended. This procedure was conducted under

rou-tineantibioprophylaxis(cefamandole2gintravenous)withoutany

intraoperativeor postoperativecomplications.The cervical

syn-dromeregressedsatisfactorily.

One month aftertheoperation, at theroutinepostoperative

assessment,thepatientpresentedwithlowbackpainwithout

neu-rologicaldeﬁcitsandwithoutrelevantpathologiesonlumbarMRI.

Inaddition,CT-myelographywasperformedandneural

compres-sionwasdeﬁnitivelyruledout.Lumbarfacetjointsyndromewas

diagnosedandtreatedwithcorticosteroidinﬁltrations.

Twoyearsandﬁvemonthsafterthecervicalintervention,the

patientwasadmittedatouremergencydepartmentforrespiratory

distress,inspiratorystridor,dysphagiaandexacerbatedright-sided

cervicobrachialpain.Thepatientcomplainedofsuffering,overthe

pasttwodays,fromaslightprogressivedysphagiasincethe

cervi-caloperation.Duringa 6-monthperiodthepatientexperienced

anocturnal cervical pain (ataround 4a.m). Laboratoryanalysis

revealedincreasedinﬂammatoryparameters(C-reactiveprotein

(CRP)150mg/L,leucocytes12.6G/L).Twobloodcultures

submit-tedforsamplingwerenegative.Fiberopticevaluationofthelarynx

didnotshowanytypicalstigmataoflaryngitis.ACTscanindicated

aquestionablethickeningofthesofttissueoverthespondylodesis.

Anempiricintravenoustherapywithclavulanicacidand

amox-icillin(2.2gthreetimesaday)wasstartedwiththedifferential

diagnosis of beginning bacterial laryngitis versus viral

laryngi-tisorquestionablecervicalforeignbodyassociatedinfection.An

MRI wasable to excludean abscess and revealed a moderate

enhancementofthevertebraeC3-C6withrestrictedoverall

inter-pretationofthisareaduetothemetallicplate.Clinically,thepatient

improvedquickly;theCRPdecreasedto41mg/Lwithin4 days,

andco-amoxicillinwasswitchedtooralformula(625mgt.i.d.)and

discontinued10daysafteradmission(CRP19mg/L).

The patient was re-admitted and re-assessed 3 weeks after

discontinuationoftheempiricantibiotictherapybecauseof

pro-gressivepainduringswallowing.TheMRIatthattimeshoweda

reductionofthethickenedsofttissueoverthespondylodesisand

a newintervertebralenhancementbetweenC3and C6

suggest-ingspondylodiscitis(Fig.1AandB).Bloodculturessubmittedfor

samplingwerenegative.Arevisionoperationwithintraoperative

samplingwassuggested.Intraoperatively,thesofttissue

thicken-ingturnedouttobepus.Thoroughdebridementwithremovalof

theventralplate,aC3/4discectomywithtitaniumcage-augmented

fusionandfreshventralplateosteosynthesiswasconducted.

Sam-plesformicrobiologicalanalysiswerecollected(1swabofthepus

forcultureandforeubacterialpolymerasechainreaction(PCR)and

1intervertebralbiopsyC3/4).Empiricintravenousantibiotic

ther-apywithamoxicillinandclavulanicacid(2.2gt.i.d.)wasstarted

againuntildeﬁnitivemicrobiologicalresultswereavailableafter

Fig.1. A–D.MRIexaminationtwoyearsafterspondylodesisC4-C6.T2weightedsequencesinthesagittalplane(1A)showsignalintensitiesintheinterdiscalspaceC3/C4 with(1B)contrastenhancementinT1weightedsequenceswithgadolinium.T2weightedsequencesinthesagittalplane(1C)showsignalintensitiesprevertebralatthe hightofC4with(1D)contrastenhancementinT1weightedsequenceswithgadolinium,suggestinghighlyspondylodiscitiswithaprevertebralabscess.

ExamenparIRMdeuxansaprèsspondylodèseC4-C6.EnséquenceT2sagittale(1A)hypersignalenregarddel’espaceinterdiscalC3/C4avec(1B)prisedecontrasteenséquence T1avecgadolinium.EnséquenceT2sagittale(1C)hypersignalpré-vertébralenregarddeC4avec(1D)prisedecontrasteenséquenceT1avecgadolinium,suggérantfortementune spondylodisciteavecabcèspré-vertébral.

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Fig.2. T1weightedMRIsequenceswithgadoliniumintheaxialplanshow prever-tebralcontrastenhancementatthelevelofinterdiscalspaceC3/4.

IRMséquenceT1axialavecgadoliniumdémontrantuneprisedecontrasteprès-vertébral auniveaudel’espaceinterdiscalC3/C4.

11days.E.corrodenswasidentiﬁedinbothmicrobiologicalcultures

andbyPCR.Theantibiotictherapywasswitchedtointravenous

ceftriaxonein an outpatient setting. A transthoracal

echocardi-ography(TTE)wasconductedbutdidnotrevealanyvegetation

or valvedysfunction. Accordingto theDuke’s modiﬁed criteria

(potentialarterialembolusas1positiveminorcriterion)an

endo-carditiswasunlikely[11].Duetothepatients’intolerancetodaily

injection,ceftriaxonewasreplacedafter6daysbyciproﬂoxacin

orally(750mgb.i.d.),afteratotalof18dayswithbetalactamine

antibiotics. Ciproﬂoxacin had to be discontinued 28 days later

becauseofabilateralAchillestendonitis,acommonsideeffectof

ﬂuoroquinolones.Atthattimethenocturnalcervicalpainand

dys-phagiahaddeclinedcompletelyandinﬂammatoryparametershad

normalized.MRI imagesshowed marginalprevertebralcontrast

enhancement,clearregressionofprevertebralsofttissueswelling,

withoutsignsofanabscess(Fig.2).Fourweeksafter

discontinu-ationofantibiotictherapy,MRIﬁndingsremainedstable(Fig.3.).

Signsandsymptomsofaninfectionremainedabsentatthelast

follow-up6monthsafterdiscontinuationofantibiotictherapy.

3. Discussion

SpinalinfectionduetoE.corrodensisrare.Inthemajorityofthe

casesthisinfectionoccursinthelumbarspinewithoutprevious

surgery.E.corrodensisafastidious,slow-growing,facultative

gram-negativerod.Thepathogenprimarilyspreadhaematogenously.The

entrysiteisclassicallyapostulatedminormucosallesionlocatedin

theorobuccalregion.Intransoralsurgerythegermcanalsospread

bycontinuity.Theaetiologyoftheinfectioninourcaseremains

speculative.Insummary,latesurgicalsiteinfectionsare

statisti-callymostlycausedbyhaematogenousspreading.Haematogenous

spreadingcanbeduetotransientorpersistentbacteremia.The

lat-tersituationisseeninendovascularinfectionsi.e.inendocarditis.

Accordingtothesymptoms,theinoculationofthepathogencould

haveoccurredintraoperatively(dysphagiasincetheoperationand

nocturnalpain).Accordingtothedetectedgerm,haematogenous

aetiologyispossibleasE.corrodensisnotaskingermandtheoral

mucosawasoutsidetheoperativesite.

Ruling out endovascular affection in cases of Eikenella

bacteraemia remains essential, as Eikenella is a HACEK

organ-ism (Haemophilus parainﬂuenzae, Aggregatibacter aphrophilus,

Aggregatibacteractinomycetemcomitans,Cardiobacteriumhominis,

E.corrodens and Kingella kingae), a set of slow-growing

gram-negativebacteriathatformanormalpartofthehumanﬂoraand

canbeassociatedwithendocarditis.HACEKorganismsareknown

tocausefalseculture-negativeendocarditis,especiallyifinoculated

lessthanoneweekorifinoculatedinnon-enrichedculturemedia.

Modernculturemediaandautomatedbloodculturesystemskeep

therateoffalsenegativeresultsratherlow[12,13].

Becauseofprogressivelocalsymptoms(nocturnalpain

suggest-ingastatusofinﬂammation)foratleastahalfayear,lackoffever

andotherclinicalstigmataofendocarditis,andbecauseofseveral

negativebloodculturesanacuteendovascularinfectionwasnot

likely(lowpretestprobability),accordingtothemodiﬁedDuke’s

criteriaproposedbyLietal.[11].Inthesettingoflowprobabilitya

TTEistherecommendeddiagnostictoolofchoice[11].

TheidentiﬁcationofE.corrodenscanbedifﬁcultduetoitsoften

minimalintricategrowthinculture.Thismaybeoneofthe

rea-sonswhyEikenella israrelyidentiﬁed orassociated withspinal

infections.TheeubacterialPCRmethodrepresentsasupplementary

diagnostictoolincasesoffastidiousgrowthbacteria,particularly

ifthediagnosticsamplingisperformedunderempiricantibiotic

therapy[14,15].

Thetherapyofchoiceisrigorousdebridementandantibiotic

treatment.Duetothelackofdata,thereisnorecommendationfor

implantassociatedinfectionsbytheHACEKgroup.Inendovascular

Fig.3. A–C.InMRIexamination4weeksafterdiscontinuationofantibiotictherapynomoresignsofdiscitisorprevertebralabscessinT2sequences(3A)orT1sequences withgadolinium(3Band3C)aredetectablein.

Quatresemainesaprèsl’arrêtdesantibiotiquesl’examenparMRTnemontreplusdesignesdedisciteoud’unabcèsprès-vertébralenséquenceT2(3A),niprisedecontrasteen séquenceT1avecgadolinium(3Bet3C).

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200 C.Yetimogluetal./Neurochirurgie60(2014)197–200

infections,accordingtotheUSguidelines[16],thetherapyofchoice

isceftriaxoneoralternativelyaﬂuoroquinolone.European

guide-linesfortreatmentofendocarditis[17]recommendceftriaxoneor

thecombinationofampicillin(ifsensitive)andgentamycin,or,after

consultinganinfectiousdiseasespecialist,alternativelya

ﬂuoro-quinolone.Inendocarditiswithanativevalve,atreatmentduration

of4weeksisnecessary.Regardinggram-negativebacteria,most

experienceinimplantassociatedinfectionshasbeenmadewith

enterobacteriaceae and therefore (in prosthetic joint infections

[18])anintravenousbetalactamineaccordingtotheinvitro

sus-ceptibilitiesoralternativelyciproﬂoxacin(750mgbidbyoralroute)

isrecommended.Incasesofreimplantationofforeignmaterialat

thetimeofdebridement,aprolongedtimeofantibiotictreatment

mightbewarranted.Ouroriginalintentionwasatreatmentof8to

12weeksafterreimplantationofforeignmaterialandpostulated

chronicspondylitis.Toourknowledgetherearenosystematicdata

toconﬁrmthisapproach.Ourpatientwasfreeoflocalandsystemic

symptomsafterextensivedebridementandanoveralltreatment

duringsixandahalfweekswithsystemicantibiotictherapy.This

stressestheimportanceofthoroughdebridement.

Disclosureofinterest

Theauthorsdeclarethattheyhavenoconﬂictsofinterest

con-cerningthisarticle.

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