A 49-year-old Saudi man, a known case of insulin-dependent diabetes mellitus (IDDM), hypertension and ischemic heart disease, presented to the emergency department with a three-day history of fever, chills and ankle pain after trauma to his left foot. He reported a nonhealing ulcer on his left heel following a hot surface injury 20 days prior to his presentation. On examination, our patient looked ill and septic, with minimal ambulation. His temperature was 38.9°C and his blood pressure and pulse were 140/90mmHg and 108 beats/minutes respectively. A lower limb examination revealed bilateral decrease of sensation and a foot ulcer on his left heel. Careful examination of his left foot showed a 7×5cm deep ulcer on the lateral side that looked badly infected with change of skin color and profuse pus discharge. Our patient was seen by the orthopedic surgeon and an urgent extensive wound debridement involving the bone was undertaken. Blood, pus and bone tissue specimens were collected and sent to the microbiology laboratory for culture and sensitivity testing. A laboratory examination showed a white cell count (WBC) of 29×109g/L with 90% neutrophils, hemoglobin of 6.9g/L, and an erythrocyte sedimentation rate (ESR) of 97mm/h. His serum creatinine was 123umol/L, and urea mmol/L 8.9. His liver function test results were within normal limits except for serum alkaline phosphatase (ALP), which was raised (785IU/L). A left foot X-ray revealed soft tissue swelling, gas formation and fracture of the calcaneus bone. A left foot magnetic resonance imaging (MRI) scan revealed a calcaneus fracture with high suspicion of calcaneus anterior fragment osteomyelitis (Figure \n). An MRI scan of his right foot revealed mild neuropathic arthropathy (Charcot joint) with no evidence of osteomyelitis. Our patient was started empirically on intravenous ciprofloxacin 400mg twice daily, and intravenous clindamycin 600mg eight hourly. During the first three days after starting treatment, our patient showed no clinical improvement and he continued to run a low-grade fever. A pus culture grew Escherichia coli sensitive to ciprofloxacin, imipenem, meropenem, gentamicin and Enterococcus avium sensitive to ampicillin. A bone and tissue biopsy grew Morganella morganii sensitive to gentamicin, imipenem and resistant to ciprofloxacin, ampicillin, amoxicillin-clavulanic acid, piperacillin/tazobactam and cotrimoxazole. No growth occurred on the anaerobic plates despite prolonged incubation. Based on culture results, the initial antibiotics were suspended and our patient was started on imipenem 500mg intravenously (IV) six hourly, vancomycin 1g IV 12 hourly, and colistin 2 million units IV eight hourly. The blood culture obtained before treatment initiation, which was inoculated in an anaerobic bottle (Bactec Lytic/10, Anaerobic/F, Beckton Dickinson, Franklin Lakes, NJ, USA) and processed by an automated blood culture system (Bactec FX, Beckton Dickinson), grew very scanty Gram-negative cocci within 18 hours shown on Gram stain. The blood then was subcultured on Trypticase soy agar with sheep blood (BBL Microbiology Systems, Cockeysville, MD, USA) and incubated at 35°C in 5% CO2, in an anaerobic GasPak™ jar (BBL Microbiology Systems). After 48 hours of anaerobic incubation, the blood agar grew slow-growing tiny colonies (Figure \n) that showed Gram-negative cocci on Gram stain (Figure \n). The organism was identified by the Vitek 2 automated system (bioMérieux, Marcy-l'Étoile, France), as Veillonella species with a 99% probability rate. It was sensitive to imipenem (1.5μg/ml), clindamycin (0.047μg/ml), ceftriaxone (8μg/ml) and colistin, and resistant to penicillin (>32μg/ml), vancomycin, erythromycin and metronidazole. Further identification to species level and genotyping was unable to be performed, as the subcultured isolates failed to grow and the significant time delay before attempting to reisolate the organisms from the blood culture bottle rendered them nonviable. Over the subsequent five days, our patient’s condition worsened with a high temperature (38.9°C), rigors, a high WBC and ESR count. The wound was reevaluated by the surgical team and a decision of above-knee amputation was taken. Colistin and vancomycin were discontinued and imipenem was continued for four weeks. On follow-up, our patient showed gradual improvement of his condition and was discharged.
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.