Mrs. B, a 65-year-old farmer, presented with sudden lower back pain and bilateral lower limb weakness. Imaging showed spondylodiscitis at D10-11. Blood cultures grew Pantoea agglomerans, an uncommon pathogen. She was treated with intravenous then oral ciprofloxacin for 6 weeks. Biopsy showed infective changes but was negative for tuberculosis. Her symptoms and inflammatory markers improved with antibiotics. Pantoea agglomerans is an opportunistic pathogen typically causing wound or urinary infections, and this represents a rare case of spondylodiscitis from this organism.

1. Spondylodiscitis
Case presentation
Dr.J.A.A.S.Jayaweera
MD trainee
TH Kandy

2. Case presentation
• Mrs. B. 65 years
• Transferred -GH Ampara
• Known pt. with Essential HT and Dyslipidemia
• On/off dysuria for 3/12 and renal colic -while in hospital;
Sudden onset of b/l lower limb weakness and backache
• No fever
• No history of fall or trauma (no prick injuries)
• No history or contact of tuberculosis
• Farmer
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3. Examination
• Not ill looking
• Afebrile
• CNS- GCS-15/15 Cranial nervous-NAD UL-5/5
LL-Tone- spastic power- 1/5
• RS- NAD
• CVS-140/80 mmHg DR
• Abdomen-NAD
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4. Time line
2016.01.23
• Admitted to THA for lower backache No LOA or LOW
• Renal calculi was detected on USS-dysuria 3/12 and renal colic No fever
2016.01.26
• Sudden on set b/l lower limb weakness with backache-no fall
• Transferred to THK for neurosurgical opinion
2016.01.31
• WBC-16900/cmm N-90.45%
• ESR-120 mm/First hr. CRP-42 mg/dL
• UFR-Pus cells 100-200 U/C-NG
• CT lumbar-sacral spine- D10-11 compression #
• MRI-pending results
• Chest referral- sputum AFB and Monteux-negative
• CXRAY-NAD
•
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5. Time line…
2016.02.02
• B/C- Pantoea agglomerans after 41 hrs. of incubation in Batec automated machine
• Ramel identification system –with 99.9 % probability
• Pantoea agglomerans susceptible to ciprofloxacin and IV Ciprofloxacin 400 mg 12 hourly for 21 days
• (S-ciprofloxacin, carbapenams, aminoglycosides and R-Ceftazidime, Aztreonam)
2016.02.04
• Chest referral- sputum AFB and Monteux-negative
2016.02.12
• MRI- Spinal Tuberculosis –Pott’s disease (discitis with minimal tissue component and vertebral body
destruction, features more suggestive of tubercle rather than pyogenic spondylitis )
• ESR-80 mm/first hr.
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6. MRI
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CT

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8. Differential diagnosis
• Pyogenic Spondylodiscitis
• Tuberculous Spondylodiscitis
• Degenerative bone disease
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9. 2016.02.16
• Lower limb power- 3/5 No backache
• Date for CT-guided biopsy taken
2016.02.19
• ESR- 70 mm/first hr.
• Continue IV Ciprofloxacin 400 mg bid (D-16)
2016.02.26
• CT guided biopsy and samples-Histology, TB culture and bacterial culture & AST
• ESR- 27 mm/first hr.
• Convert IV (D-23) Oral Ciprofloxacin 500 mg bid for another 19 more days. (D -42)
• WBC-8950/mm3 N-60.3% L- 25.4%
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10. 2016.03.03
• ESR-22 mm/first hr.
• Biopsy- Infective changes and negative for TB
2016.03.04
• Discharged
• LL power 4/5
• Continue lower limb physiotherapy (D-29 Ciprofloxacin )
• Review with repeat ESR
2016.03.17
• ESR-12 mm/first hr.
• LL power 5/5
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11. • Infection of the intervertebral disc and the adjacent vertebral bodies
It usually starts at the interface of the disc and the vertebra
• Spondylodiscitis represent 2%–4% of all cases of skeletal infection
• 2 types
Pyogenic Tuberculous
History
• Spinal infection is an ancient entity- Iron age
• In 1779, Pott described about tuberculosis in the spine
• Later in France, pyogenic osteomyelitis of the spine
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Spondylodiscitis

12. Spondylodiscitis- Epidemiology
• Spondylodiscitis is the main manifestation of haematogenous osteomyelitis in
patients aged over 50 years
• Estimates of its incidence in developed countries range from 4 to 24 per
million per year
• Bimodal age distribution with peaks at age <20 years and 50–70 years
• Male preponderance, with a male to female ratio of 1.5–2:1
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13. Pathophysiology
Direct inoculation
Penetrating trauma
Spinal procedures (percutaneous or open)
Contiguous spread from an adjacent infection
Local spread following intra-abdominal or retro-peritoneal infections
Hematogenous
From distant septic foci. Skin and soft tissue infections, infected vascular
access sites, UTI.
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14. Pathophysiology:
• Infection at -end plate of one vertebral body
• Rupture -adjoining disk and infect the next vertebral body
• The disk material avascular and is destroyed by the bacterial enzymes
• Extension to spinal canal-epidural abscess or even bacterial meningitis
• Destruction of the vertebral body and intervertebral disk –collapse and bone
retro pulsed into the spinal canal-neural compression or vascular occlusion
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15. Spondylodiscitis
Duration of Symptoms
Acute <3 weeks Sub acute 3 weeks - 3 months Chronic >3 months
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16. Etiology
• In the past, tuberculosis infection was the major cause
• Nowadays, the majority of spinal infections are bacterial monomicrobial –
Staphylococcus aureus with an incidence between 30 and 80 %
Gram-negative bacteria such as Escherichia coli - 25 %
• Mycobacterium tuberculosis is particularly common in HIV positive patients, reaching in
this susceptive
• Anaerobic agents are also a cause of infections, especially in penetrating spine trauma
• Other rare organisms-Pantoea agglomerans
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17. Pantoea agglomerans
• Formerly called Enterobacter agglomerans
• Opportunistic pathogen in the immunocompromised
• Wound, blood, and urinary-tract infections
• It is commonly isolated from plant surfaces, seeds, fruit (e.g. mandarin
oranges), and animal or human feces
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18. Pantoea agglomerans
• Difficult to differentiate From Enterobacter, Klebsiella, and Serratia species.
• Pantoea does not utilize the amino acids lysine, arginine, and ornithine
• This was identified by Ramel rapid kit with 99 % probability
• CLSI-AST
S- Amc, CTX,CXM,AMP,SXT,VA,CN,Mero,AK and Cip
R-CAZ and ATM
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19. Review of the literature
• Uncommon cause, with only 31 cases found in the literature
• Destructive bone lesions after direct penetrating injuries have been described
• Histology revealed chronic granulation
• Ten cases of osteomyelitis were found: one case after an open fracture,
eight -penetrating injuries without fractures
• A single case of discitis -22-year-old farmer on long-term tetracycline therapy for acne
• Our case no direct inoculation occurred and haematogenous spread from an unnoticed skin
penetration is the presumed cause OR urinary tract infection…, not on long-term antibiotics or
immunocompromised(association of renal stones cannot made)
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20. Symptoms
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Non-specific back or neck pain –initial
15 % doesn’t having pain
Fever-46 % pyogenic and 17 % in tuberculous

21. Gulioris T et.al 2010. Spondylodiscitis. Up dates of diagnosis j Antimicro.chemo
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22. Diagnosis
• Diagnosis is generally difficult -high level of suspicion significant delay
• Diagnosis should be supported by clinical, laboratory, and imaging findings
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ESR-Sensitive marker for diagnosis
and monitor the response to the
treatment
Duarte M.2013.Spinal infection:
state of the art and management
algorithm. Eur Spinal J

23. Imaging studies
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Bone scintigraphy
MRI
XRAY

24. Duarte M.2013.Spinal infection: state of the art and management algorithm.
Eur Spinal J12/28/2020 24

25. Treatment
• Antibiotics for minimum 6 weeks and afterwards duration depends on
clinical response (6-12 weeks)
(Positive blood cultures, neurological anomalies and Stap. Sp -varies)
• If isolate presents can decide the antimicrobial according to susceptibility
• Other vice required to cover common etiologies S.aureus and E.coli
• Oral antibiotic therapy -six weeks to three months is recommended for non-
specific spondylodiscitis
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26. Treatment
Gulioris T et.al 2010. Spondylodiscitis. Up dates of diagnosis j Antimicro.chemo 26

27. Surgical management
• Indications
compression of neural elements
spinal instability due to extensive bony destruction
severe kyphosis
failure of conservative management
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28. Prognosis
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29. References
• Jensen AG,Espersen F, Skinhoj P, et al.. Increasing frequency of vertebral
osteomyelitis following Staphylococcus aureus bacteraemia in Denmark
1980–1990. J Infect 1997;34:113-8.
• Sapico FL,Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of
nine cases and review of the literature. Rev Infect Dis 1979;1:754-76.
• Cottle. L , Riordan T., “Infectious spondylodiscitis,” Journal of Infection,
vol. 56, no. 6, pp. 401–412, 2008.
• K.-H. Park, O. H. Cho, M. Jung et al., “Clinical characteristics and outcomes
of hematogenous vertebral osteomyelitis caused by gram-negative
bacteria,” Journal of Infection, vol. 69,42–50, 2014.
• Gouliouris T, Aliyu SH, Brown NM .2010. Spondylodiscitis: update on
diagnosis and management J. Antimicrob. Chemother. 65 (suppl 3): 24.
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30. THANK YOU
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