Spondylodiscitis and epidural empyema as a complication of diabetic foot

Česká verzia

Authors: D. Čechurová; S. Lacigová; M. Žourek; J. Gruberová; I. Haladová; J. Tomešová; Z. Rušavý
Authors place of work: Diabetologické centrum I. interní kliniky Lékařské fakulty UK a FN Plzeň, přednosta prof. MU Dr. Martin Matějovič, Ph. D.
Published in the journal: Vnitř Lék 2013; 59(5): 412-415
Category: Case Report

Práce byla přednesena formou orálně prezentovaného posteru dne 23. 11. 2012 v Praze na mezioborovém sympoziu s mezinárodní účastí: Syndrom diabetické nohy. Abstrakt byl publikován (Suplementum – pouze abstrakta z daného sympozia): Čechurová D, Lacigová S,Žourek M, Gruberová J, Rušavý Z. Spondylodiscitida, epidurální empyém jako komplikace syndromu diabetické nohy. Syndrom diabetické nohy – mezioborové symposium s mezinárodní účastí Praha, 23. 11. 2012, Kazuistiky v diabetologii 2012; 10: (Suppl. 2): S26.

Summary

Spinal column infection (vertebral osteomyelitis, discitis, epidural empyema/ abscess) is a rare condition, albeit its incidence has been increasing in recent years. Staphylococcus aureus is the most frequent pathogen. The routes of infection are predominantly hematogenous. Any delay in making correct diagnosis increases risk of adverse outcome of the patient. The authors present 3 case reports of patients with diabetic foot syndrome, who were diagnosed with spondylodicitis in the period of 2009– 2012, two patients had associated epidural empyema. Apart of a chronic neuropathic foot wound, the patients reported severe or deteriorated dorsal pain (2 in the lumbal region, one in thoracic spine), had no new neurologic lesion in the beginning, some had fever, but all had high laboratory parameters of inflammation that did not correlate with local finding on the foot. Methicillin‑sensitive Staphylococcus aureus cultured from the foot defect in all cases, in two patients from blood cultures and from epidural empyema. They were patients with recurrent local infectious complications of diabetic foot ulcers. Two patients had a concomitant diabetic nephropathy, classified into stages 3– 4/ 5 according to K/ DOQI. Glycemic control (Type 1, Type 2 and secondary DM) ranged from excellent to unsatisfactory (HbA_1c 43– 100 mmol/ mol). Apart of patient history and clinical examination, the magnetic resonance imaging of the spine was essential for the diagnosis of spondylodiscitis, or epidural empyema. The treatment was founded on long‑term (initially parenteral) antibiotic treatment, bed rest, then mobilization with orthosis. Neurosurgical procedure was necessary in the patients with epidural empyema. All patients were mobile following a varied time period of convalescence and rehabilitation. Conclusion: Dorsal pain and degenerative changes of the spinal column belong to common findings in our population. When searching for the origin of an infection in patients with elevated inflammatory parameters (inadequate finding for a diabetic ulcer), the history of dorsal pain suddenly becomes the fundamental clue for diagnosis of spondylodiscitis with or without epidural empyema.

Key words:
diabetic foot – spondylodiscitis – epidural empyema – Staphylococcus aureus – infection

Zdroje

1. Tompkins M, Panuncialman I, Lucas P et al. Spinal epidural abscess. J Emer Med 2010; 39: 384– 390.

2. Fantoni M, Trecarichi EM, Rossi B et al. Epidemiological and clinical features of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16: (Suppl. 2): 2– 7.

3. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long‑term outcome for 253 patients from 7 Cleveland– area hospitals. Clin Infect Dis 2002; 34: 1342– 1350.

4. Sobottke R, Rollinghoff M, Zarghooni K et al. Spondylodiscitis in the elderly patient: clinical mid‑term results and duality of life. Arch Orthop Trauma Surg 2010; 130: 1083– 1091.

5. Pola E, Logroscino CA, Gentiempo M et al. Medical and surgical treatment of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16: (Suppl. 2): 35– 49.

6. Goulioris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010; 65: 11– 24.

7. Wirtz DC, Genius I, Wildberger JE et al. Diagnostic and therapeutic management of lumbar and thoracic spondylodiscitis: an evaluation of 59 cases. Arch Otop Trauma Surg 2000; 120: 245– 251.

8. Nicholas JJ, Smith WF, Anderson GB. Bacterial discitis caused by limb gangrene requiring below– knee amputation. Arch Phys Med Rehabil 1996; 77: 301– 304.

9. Fejfarová V, Jirkovská A, Skibová J et al. Vliv rezistentních patogenů a ostatních rizikových faktorů na četnost amputací dolních končetin u pacientů se syndromem diabetické nohy. Vnitř Lék 2002; 48: 302– 336.

10. Jirkovská A. Možnosti plnění mezinárodních doporučení terapie syndromu diabetické nohy v České republice. Vnitř Lék. 2011; 57: 908– 912.