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The Unique Clinical Features and Outcome of Infectious Endocarditis and Vertebral Osteomyelitis Co-infection

      Abstract

      Objective

      The clinical significance of vertebral osteomyelitis and infectious endocarditis co-infection is unclear. This study investigates the rate, clinical features, and outcome of vertebral osteomyelitis with and without concomitant infectious endocarditis.

      Methods

      A retrospective study of all cases of osteomyelitis with spinal imaging (n = 176), from January 2007 to April 2013, that were diagnosed as vertebral osteomyelitis. Sixty-two patients with spontaneous vertebral osteomyelitis were identified after excluding postsurgical, decubitus ulcers and spinal metastases. Seventeen (27%) were identified with concomitant infectious endocarditis.

      Results

      All patients presented with back pain and 59% were diagnosed with infectious endocarditis subsequent to vertebral osteomyelitis. Distinguishing features among the co-infection group include the increased use of transesophageal echocardiography (94% vs 58%, P = .004), predisposing cardiac conditions (59% vs 16%, P = .001), and Gram-positive bacteremia, of which Streptococcus sp. and Enterococcus sp. were more common (35% vs 11%, P = .026). Adverse neurologic events were increased significantly in the co-infection group (59% vs 22%, P = .006). On transesophageal echocardiography, 88% of co-infection patients had highly mobile vegetations, 9 of which measured 10 mm or more. The overall mortality was 41% and 29% in the co-infection and lone vertebral osteomyelitis groups, respectively (P = .356). One-year mortality was identical for both groups at 24% (P = .999), and higher than previously reported (11.3% for lone vertebral osteomyelitis).

      Conclusions

      Patients with vertebral osteomyelitis, in whom infectious endocarditis is not excluded, are at increased risk for adverse neurologic events and mortality. The prompt diagnosis of infectious endocarditis, and associated high-risk features that may benefit from surgical intervention, require early evaluation by transesophageal echocardiography.

      Keywords

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      References

        • Longo D.F.
        • Fauci A.
        • Kasper D.
        • Hauser S.
        • Jameson J.
        • Loscalzo J.
        Harrison's Principles of Internal Medicine.
        18th ed. McGraw-Hill Professional, New York2011
        • Sexton D.J.
        • Spelman D.
        Current best practices and guidelines. Assessment and management of complications in infective endocarditis.
        Infect Dis Clin North Am. 2002; 16 (xii): 507-521
        • Murdoch D.R.
        • Corey G.R.
        • Hoen B.
        • et al.
        Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study.
        Arch Intern Med. 2009; 169: 463-473
        • Pigrau C.
        • Almirante B.
        • Flores X.
        • et al.
        Spontaneous pyogenic vertebral osteomyelitis and endocarditis: incidence, risk factors, and outcome.
        Am J Med. 2005; 118: 1287
        • McHenry M.C.
        • Easley K.A.
        • Locker G.A.
        Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals.
        Clin Infect Dis. 2002; 34: 1342-1350
        • Li J.S.
        • Sexton D.J.
        • Mick N.
        • et al.
        Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
        Clin Infect Dis. 2000; 30: 633-638
        • Meyers O.L.
        • Commerford P.J.
        Musculoskeletal manifestations of bacterial endocarditis.
        Ann Rheum Dis. 1977; 36: 517-519
        • Honan M.
        • White G.W.
        • Eisenberg G.M.
        Spontaneous infectious discitis in adults.
        Am J Med. 1996; 100: 85-89
        • Ninet J.
        • Gayet J.L.
        • Etienne J.
        • et al.
        Bacterial endocarditis presenting as acute vertebral osteomyelitis: 14 cases.
        Eur Heart J. 1984; 5: 101-105
        • Sapico F.L.
        • Montgomerie J.Z.
        Vertebral osteomyelitis.
        Infect Dis Clin North Am. 1990; 4: 539-550
        • Kang D.H.
        • Kim Y.J.
        • Kim S.H.
        • et al.
        Early surgery versus conventional treatment for infective endocarditis.
        N Engl J Med. 2012; 366: 2466-2473
        • Hoen B.
        • Duval X.
        Clinical practice. Infective endocarditis.
        N Engl J Med. 2013; 368: 1425-1433
        • Zimmerli W.
        Clinical practice. Vertebral osteomyelitis.
        N Engl J Med. 2010; 362: 1022-1029
        • Mulleman D.
        • Philippe P.
        • Senneville E.
        • et al.
        Streptococcal and enterococcal spondylodiscitis (vertebral osteomyelitis). High incidence of infective endocarditis in 50 cases.
        J Rheumatol. 2006; 33: 91-97
        • Le Moal G.
        • Roblot F.
        • Paccalin M.
        • et al.
        Clinical and laboratory characteristics of infective endocarditis when associated with spondylodiscitis.
        Eur J Clin Microbiol Infect Dis. 2002; 21: 671-675
        • Murillo O.
        • Roset A.
        • Sobrino B.
        • et al.
        Streptococcal vertebral osteomyelitis: multiple faces of the same disease.
        Clin Microbiol Infect. 2014; 20: O33-O38
        • Thuny F.
        • Di Salvo G.
        • Belliard O.
        • et al.
        Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study.
        Circulation. 2005; 112: 69-75
        • Habib G.
        • Hoen B.
        • Tornos P.
        • et al.
        Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer.
        Eur Heart J. 2009; 30: 2369-2413
        • Sexton D.J.
        • Spelman D.
        Current best practices and guidelines. Assessment and management of complications in infective endocarditis.
        Cardiol Clin. 2003; 21 (vii-viii): 273-282