A 50-year-old man presented to the emergency room with several months of intermittent fever and progressive lower back pain. He described a mechanical fall one week prior to this admission. He had a medical history of alcohol abuse, intravenous drug use, hepatitis C infection, and native tricuspid valve infective endocarditis secondary to methicillin-resistant Staphylococcus aureus (MRSA) five months prior to his current hospital admission. At that time, his transthoracic echocardiogram showed a tricuspid valve vegetation measuring 11 × 6 mm with severe tricuspid regurgitation. He was partially treated with intravenous vancomycin followed by daptomycin with serial negative blood cultures. Magnetic resonance imaging (MRI) of his spine at that time showed no evidence of vertebral osteomyelitis or epidural abscess.\nTwo months prior to the current hospital admission, he presented to the emergency room with back pain. At this time, his blood cultures were positive for the growth of V. dispar, which was identified by matrix-assisted laser desorption/ionization-time of flight mass spectrometry. A transthoracic echocardiogram was performed prior to him leaving the hospital against medical advice and showed that the tricuspid valve vegetation was now smaller in size, measuring 7 × 6 mm (Figure ). He received no antimicrobial treatment at this time.\nDuring his current hospital admission, he was visibly agitated on physical examination and described significant lower back pain. His initial vital signs included a temperature of 39.5 degrees Celsius, heart rate of 120 beats per minute, respiratory rate of 20 breaths per minute, oxygen saturation of 97% on ambient room air, and blood pressure of 106/68 mmHg. His neck was supple and his neurological examination demonstrated normal tone throughout his upper and lower extremities. Strength in his right lower extremity was 3/5 for ankle plantar flexion and dorsiflexion, 2/5 for knee extension and flexion, and 3/5 for hip extension and flexion. His strength was 4/5 throughout his left lower extremity. His sensation was normal apart from decreased light touch sensation to his medial right gastrocnemius region. He had spinal and paraspinal tenderness in his mid and lower back. His reflexes were 2+ in his knees and plantars were down-going bilaterally. He had a grade III/VI systolic murmur best heard at the left lower sternal border. Air entry was equal and clear bilaterally with fine crackles to his right lower lung zone. No other peripheral stigmata of infective endocarditis were present on examination. Examination of the oral cavity showed he was missing upper teeth with overall poor dentition. Initial laboratory investigations are summarized in Table .\nHis electrocardiogram was normal. During his hospital admission, two sets of blood cultures obtained 96 hours apart were again positive for the growth of V. dispar. Given his persistent bacteremia, a transthoracic echocardiogram was performed which showed growth in the size of the vegetation previously noted on his tricuspid valve, now measuring 11 × 7 mm. There were also signs of torrential tricuspid regurgitation including a vena contracta width greater than 0.7 cm, a central jet that was filling greater than 50% of the right atrium, and a triangular-shaped continuous-wave Doppler signal which was as dense as the inflow signal along with evidence of systolic hepatic vein flow reversal (Figures , ).\nAn MRI scan of the spine showed early discitis/osteomyelitis of L3-L4 with a right paravertebral and right paracentral anterior epidural phlegmon with no abscess (Figure ). The neurosurgical team assessed the patient and recommended conservative management with ongoing antimicrobial therapy and physiotherapy, and monitoring for any worsening neurological deficits. In addition, given his poor dentition, a computed tomography (CT) scan of the brain, head, and neck was arranged, which showed no obvious evidence of an abscess collection within the neck, oropharynx, or brain. Furthermore, no septic pulmonary emboli were seen on imaging.\nSusceptibility testing was performed on his V. dispar isolate using broth microdilution and showed susceptibility to penicillin (minimum inhibitory concentration [MIC] < 0.5), amoxicillin-clavulanate (MIC < 4/2), and metronidazole (MIC < 8) compared against breakpoints according to the Clinical and Laboratory Standards Institute. He was treated with intravenous ceftriaxone for six weeks with clinical improvement noted within a few days following his admission. The patient reported near-complete resolution of his back pain and his repeat C-reactive protein level toward the end of therapy was 3.8 mg/L (normal 0.0-7.0 mg/L). Subsequently, he developed a central-line-associated bloodstream infection secondary to Candida dubliniensis with no evidence of endophthalmitis, for which he received a two-week course of intravenous caspofungin.\nA repeat MRI was arranged after his therapy which showed resolution of the anterior epidural phlegmon but interval worsening of the L3-L4 discitis/osteomyelitis with a new enhancement of the L3 and L4 facets without effusion (Figure ). A subsequent CT-guided lumbar spine biopsy of the L3/L4 region was performed, and bacterial, fungal, and mycobacterial cultures were negative. A repeat transthoracic echocardiogram was planned to establish a new baseline for his valvular anatomy given his risk of recurrent endocarditis; however, the patient left against medical advice.
A 76-year-old male diagnosed with Veillonella bacteremia presented with a sudden onset of back pain, fever, and chills of four days duration. Although the fever and chills had since subsided, the back pain continued to persist and was exacerbated with positional change. CT scans revealed a psoas abscess with extradural extension, along with indications of lumbar osteomyelitis. MRI scans were unable to be obtained owing to the patient’s pacemaker. Due to medication allergies and growing sensitivity to the infection, the patient was transferred to MICU for a short period to be desensitized to ampicillin-sulbactam. Interventional Radiology then placed a retroperitoneal drain for the psoas abscess as well as a PICC line for IV antibiotic administration at home.\nDuring the following week, the Neurosurgery service performed laminectomy at levels L4-S1. Bilateral medial facetectomies and foraminotomies were also performed at L4-L5 and L5-S1 to fully decompress the exiting nerve root and thecal sac. Significant facet arthropathy was noted. The extradural abscess, which was revealed to be a large synovial cyst with no pus, was resected. Cultures were taken and sent for laboratory analysis, revealing the presence of Veillonella species. Post-operatively, CT scans indicated a resolving abscess. The patient was discharged and instructed to complete his course of ampicillin-sulbactam at home and switch to metronidazole and levofloxacin for a total six-week course of antibiotics.\nThe patient re-presented to the hospital 18 days after the neurosurgical operation complaining of worsening back pain radiating into his posterior buttocks that began 10 days after the operation. CT scans revealed considerable interval decrease in the psoas abscess but extensive osseous destruction in the L5-S1 region, anterior to the laminectomy sites, thereby advancing concerns of osteomyelitis. CT scans revealed trace retrolisthesis of L2 on L3 and L3 on L4, as well as grade 1 anterolisthesis of L4 on L5. There was multilevel disc height loss, most severe at L3-L4 and L5-S1, and persistent narrowing of the thecal sac. Fluid was observed posterior to the surgical site along with phlegmonous changes extending from L4-S1. A small abscess was also seen in the S1 prevertebral soft tissues. Interval erosions of the L5 and S1 endplates were noted, compatible with discitis. All of these findings were consistent with progressive osteomyelitis. Furthermore, bone and tissue cultures revealed continued Veillonella infection, perhaps due to a combination of both insufficient debridement as well as inadequate duration of antibiotic treatment. The patient was instructed to begin IV vancomycin in addition to metronidazole and levofloxacin for an additional 6 weeks.\nThe patient presented to the office 25 days later with unbearable, radiating lower back pain forcing him to use a wheelchair to move about. CT scans indicated progressive destructive changes of the L5-S1 vertebral body endplates. Two presacral abscesses measuring 4 mm and 7 mm were identified anterior to S1; additional microabscesses were found in the prevertebral phlegmon at the L5 level. A larger abscess measuring 15 mm was identified dorsal to the thecal sac at the previous L5 laminectomy site, leading to a narrowing of the dural sac. Progressive destruction of the vertebral bodies was noted with fragmentation of the inferior endplate of L5 and superior endplate of S1. Reflexes were absent bilaterally in the lower limbs and there was decreased sensation to light touch. Tissue cultures taken from the affected vertebrae were all negative at this time, and given the patient’s debilitated status, reconstructive spine surgery was indicated.\nPreoperative X-ray revealed spondylolisthesis of L5 on S1, and a CT myelogram showed severe multilevel spinal stenosis from L2 to S1. Therefore, the patient underwent a L2-S1 lumbar laminectomy with posterior segmental instrumentation and posterolateral arthrodesis from the L2 to the ilium using pedicle screws and iliac bolts bilaterally. Decompression of spinal nerves was achieved by posterior lumbar laminectomy, bilateral medial facetectomies, and bilateral foraminotomies at all spinal levels between L2 and S1. Given the patient’s history of infection, an allograft was used to form a final instrumented fusion mass. (Figs. , , , and ).\nThe patient recovered well after surgery. Final blood and tissue cultures were all negative. CT scans indicated resolution of the remaining abscesses. He was discharged and instructed to complete the previously prescribed course of antibiotics and follow-up with rehabilitation facilities. After 12 months of rehabilitation therapy, the patient regained a majority of mobility and ambulated with cane. However, at the 12 month follow up visit, he complained of groin pain. Additional physical therapy including aqua therapy was ordered and followed. At the 18 month follow up visit, the patient is noted to be doing quite well with occasional back discomfort and continues to ambulate with a cane.