Letter to the Editor
Multifocal Hematogenous Vertebral Osteomyelitis Due to Parvimonas micra and a Subsequent Pleural Effusion in a Diabetic Patient
Osteomielitis vertebral hematógena multisegmentaria por Parvimonas micra y derrame pleural secundario en un paciente diabético
María García Gonzáleza,
, José Ramón Muñiz Montesb, Dácil García Rosadoc, Sagrario Bustabad Reyesa
Corresponding author
a Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
b Departamento Médico, Resonancia Magnética IMETISA, Santa Cruz de Tenerife, Spain
c Unidad de Enfermedades infecciosas, Departamento de Medicina Interna, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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"aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteomielitis vertebral hematógena multisegmentaria por <span class="elsevierStyleItalic">Parvimonas micra</span> y derrame pleural secundario en un paciente diabético" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 696 "Ancho" => 1301 "Tamanyo" => 112665 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI of thoracic spine, sagittal spin echo T1 sequences, with (A) and without contrast (B), and STIR (fat suppression) (C) sequence, where extensive epidural and paravertebral soft tissue involvement is observed reducing the diameter of the spinal canal, with a small D7–D8 prevertebral abscess.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hematogenous vertebral osteomyelitis (HVO) is a rare entity (in Spain, 9 new cases per million inhabitants/year),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> yet its incidence is increasing in relation to population aging, immunosuppressive use, increasing nosocomial bacteremia and other predisposing factors, especially diabetes mellitus.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Although there are many possible causal agents<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> pyogenic Gram-positive bacteria, specifically <span class="elsevierStyleItalic">Staphylococcus aureus</span>, is the most common etiology (up to 51% in some series).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,6</span></a> Although mortality is rare,it is associated with high comorbidity, often related to the occurrence of complications secondary to delayed diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> We present a case of extensive HVO due to <span class="elsevierStyleItalic">Parvimonas micron</span> (<span class="elsevierStyleItalic">P. micron</span>) with large epidural involvement, prevertebral abscess, myelopathy and bilateral pleural effusion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 62-year-old male, former smoker, hypertensive, longstanding diabetic, hemiparetic and aphasic after a left frontoparietal hemorrhagic stroke which occurred a year earlier. The family consulted us due to progressive deterioration with back pain, unstable sitting and left lower limb weakness lasting for the previous 6 months.Physical exam: no fever, blood pressure 120/70 <span class="elsevierStyleHsp" style=""></span> mmHg, heart rate 80 bpm.Heartbeat rhythm had no murmurs, vesicular murmur was decreased in both lung bases.The patient had generalized amyotrophy. The patient had paresis, Achilles clonus and Babinski on the left leg. There was residual right hemiparesis and aphasia. Other exploratory findings were unremarkable. Laboratory data: hemoglobin 11.7<span class="elsevierStyleHsp" style=""></span>g/dl, leukocytes 11<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">−3</span> neutrophils 8900<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">−3</span> platelets 447<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">−3</span>; ESR <span class="elsevierStyleHsp" style=""></span> 61<span class="elsevierStyleHsp" style=""></span>mm/h and CRP<span class="elsevierStyleHsp" style=""></span>86.10<span class="elsevierStyleHsp" style=""></span>mg/l. Hepatic and renal biochemistry, electrolytes, total protein and glucose were within normal limits. Cranial CT showed no new lesions. The electromyogram showed sensorimotor axonal and symmetrical polyneuropathy and the MRI of the lumbar spine showed a correction of lordosis and unobtrusive spondylosis without radiculopathy.Spine x rays revealed disorganization of the D7–D8 intervertebral space, with effacement of the discs and decreased height of both vertebral bodies. MRI of the thoracic spine showed significant signal alteration of vertebral bodies from D3 to D12 and paraspinal soft tissue and adjacent epidural tissue being the most affected at the D7–D8 level, with a prevertebral abscess at this level and increased signal by epidural spinal cord compression (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). CT with multiplanar reconstructions confirmed the findings of spinal osteomyelitis with epidural and paraprevertebral extension and spondylodiscitis of D7–D8, and also revealed bilateral, predominantly left, pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Diagnostic thoracentesis objectified features of chronic inflammatory process in the cytology. Blood cultures were negative. Percutaneous biopsy of the intervertebral D7–D8 space was conducted with negative microbiological tests for mycobacteria and positive for <span class="elsevierStyleItalic">P. micron</span>, and a histology indicative of nonspecific chronic inflammation. Given the patient comorbidity and the rejection of the family to receive intravenous antibiotic therapy, we chose a conservative approach based on clindamycin 600<span class="elsevierStyleHsp" style=""></span>mg orally every 8<span class="elsevierStyleHsp" style=""></span>h. After 4 months and improved overall strength of the left leg, the backache disappeared and acute phase reactants decreased (ESR 12<span class="elsevierStyleHsp" style=""></span>mm, 12.9<span class="elsevierStyleHsp" style=""></span>CRP<span class="elsevierStyleHsp" style=""></span>mg/l). On control MRI no significant changes were seen.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P. micra</span> (formerly <span class="elsevierStyleItalic">Peptostreptococcus micros)</span> is a type of strict anaerobic gram-positive cocci, unsporulated and an oropharyngeal commensal.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although it has been associated with polymicrobial infections (intracranial abscesses, sinus infections and periodontitis)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> involvement in vertebral osteomyelitis is rare, with only 2 cases reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the last decade, an increase in anaerobic bacteremias germs has been described, which seems to be related to the increasingly frequent health care to patients with complex comorbid processes underlying changes in susceptibility patterns of these pathogens and better techniques for detecting microbial presence.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our case, we should consider a spontaneous hematogenous spread from the oropharynx or promoted by bronchial aspiration in the context of coma accompanying acute stroke months earlier; other possible sources were quite unlikely, given the quality of the commensal germ, the clinical course and the lack of examination signs and/or microbiological data to support endocarditis or other satellite infectious process. The diagnostic delay due to the lack of suspicion when faced with insidious and atypical symptoms in a patient already weakened and with difficulty communicating and intercurrent processes that delayed imaging tests, justify the extent of involvement and the chronic nature of the process. The concomitant presence of inflammatory pleural effusion is a very rare finding,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> which was interpreted in the context of chronic pleural irritation secondary to paravertebral involvement. The left pyramidal monoparesis was consistent with the finding of compressive myelopathy. Although treatment improved clinical and laboratory parameters, the chronic nature of the injury, the absence of debridement and drainage of the abscessed tissue, and lack of parenteral antibiotic therapy justify the absence of radiological improvement.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García González M, Muñiz Montes JR, García Rosado D, Bustabad Reyes S. Osteomielitis vertebral hematógena multisegmentaria por <span class="elsevierStyleItalic">Parvimonas micra</span> y derrame pleural secundario en un paciente diabético. Reumatol Clin. 2014;10:191–192.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 696 "Ancho" => 1301 "Tamanyo" => 112665 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI of thoracic spine, sagittal spin echo T1 sequences, with (A) and without contrast (B), and STIR (fat suppression) (C) sequence, where extensive epidural and paravertebral soft tissue involvement is observed reducing the diameter of the spinal canal, with a small D7–D8 prevertebral abscess.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 773 "Ancho" => 1301 "Tamanyo" => 147349 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">axial and sagittal CT reconstruction showing the dorsal vertebral disorganization with lysis and sclerosis primarily on the D3–D12 vertebrae, with intervertebral space disappearance of D7–D8 by spondylodiscitis and left pleural effusion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteomielitis vertebral hematógena. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 42 | 29 | 71 |
| 2024 September | 45 | 17 | 62 |
| 2024 August | 73 | 36 | 109 |
| 2024 July | 55 | 32 | 87 |
| 2024 June | 62 | 38 | 100 |
| 2024 May | 62 | 19 | 81 |
| 2024 April | 53 | 28 | 81 |
| 2024 March | 51 | 26 | 77 |
| 2024 February | 44 | 21 | 65 |
| 2024 January | 45 | 16 | 61 |
| 2023 December | 45 | 27 | 72 |
| 2023 November | 46 | 21 | 67 |
| 2023 October | 45 | 24 | 69 |
| 2023 September | 71 | 34 | 105 |
| 2023 August | 42 | 18 | 60 |
| 2023 July | 41 | 21 | 62 |
| 2023 June | 46 | 21 | 67 |
| 2023 May | 49 | 29 | 78 |
| 2023 April | 28 | 13 | 41 |
| 2023 March | 47 | 27 | 74 |
| 2023 February | 46 | 26 | 72 |
| 2023 January | 39 | 23 | 62 |
| 2022 December | 44 | 27 | 71 |
| 2022 November | 52 | 26 | 78 |
| 2022 October | 42 | 36 | 78 |
| 2022 September | 33 | 38 | 71 |
| 2022 August | 35 | 39 | 74 |
| 2022 July | 27 | 34 | 61 |
| 2022 June | 33 | 39 | 72 |
| 2022 May | 37 | 46 | 83 |
| 2022 April | 43 | 35 | 78 |
| 2022 March | 51 | 64 | 115 |
| 2022 February | 38 | 36 | 74 |
| 2022 January | 41 | 41 | 82 |
| 2021 December | 42 | 50 | 92 |
| 2021 November | 43 | 57 | 100 |
| 2021 October | 53 | 50 | 103 |
| 2021 September | 38 | 39 | 77 |
| 2021 August | 27 | 39 | 66 |
| 2021 July | 35 | 43 | 78 |
| 2021 June | 30 | 45 | 75 |
| 2021 May | 48 | 32 | 80 |
| 2021 April | 99 | 88 | 187 |
| 2021 March | 46 | 24 | 70 |
| 2021 February | 39 | 28 | 67 |
| 2021 January | 36 | 21 | 57 |
| 2020 December | 44 | 26 | 70 |
| 2020 November | 42 | 15 | 57 |
| 2020 October | 52 | 17 | 69 |
| 2020 September | 49 | 24 | 73 |
| 2020 August | 57 | 27 | 84 |
| 2020 July | 61 | 42 | 103 |
| 2020 June | 53 | 19 | 72 |
| 2020 May | 49 | 17 | 66 |
| 2020 April | 25 | 21 | 46 |
| 2020 March | 7 | 6 | 13 |
| 2020 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 May | 6 | 1 | 7 |
| 2018 April | 66 | 14 | 80 |
| 2018 March | 58 | 9 | 67 |
| 2018 February | 79 | 8 | 87 |
| 2018 January | 44 | 7 | 51 |
| 2017 December | 57 | 5 | 62 |
| 2017 November | 47 | 7 | 54 |
| 2017 October | 35 | 6 | 41 |
| 2017 September | 42 | 5 | 47 |
| 2017 August | 60 | 9 | 69 |
| 2017 July | 52 | 10 | 62 |
| 2017 June | 80 | 16 | 96 |
| 2017 May | 90 | 10 | 100 |
| 2017 April | 72 | 9 | 81 |
| 2017 March | 48 | 21 | 69 |
| 2017 February | 37 | 5 | 42 |
| 2017 January | 46 | 9 | 55 |
| 2016 December | 75 | 14 | 89 |
| 2016 November | 70 | 7 | 77 |
| 2016 October | 93 | 15 | 108 |
| 2016 September | 137 | 7 | 144 |
| 2016 August | 68 | 9 | 77 |
| 2016 July | 48 | 6 | 54 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 42 | 6 | 48 |
| 2015 June | 50 | 10 | 60 |
| 2015 May | 57 | 7 | 64 |
| 2015 April | 98 | 8 | 106 |
| 2015 March | 81 | 7 | 88 |
| 2015 February | 98 | 2 | 100 |
| 2015 January | 89 | 9 | 98 |
| 2014 December | 67 | 8 | 75 |
| 2014 November | 57 | 12 | 69 |
| 2014 October | 48 | 6 | 54 |
| 2014 September | 54 | 8 | 62 |
| 2014 August | 44 | 19 | 63 |
| 2014 July | 64 | 12 | 76 |
| 2014 June | 70 | 24 | 94 |
| 2014 May | 36 | 18 | 54 |
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