|Year : 2018 | Volume
| Issue : 2 | Page : 144-147
Achromobacter spondylodiscitis: A case report and review of literature
Hamza Shaikh, Thomas J Kishen
Spine Care Centre, Manipal Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||2-Aug-2018|
Dr. Thomas J Kishen
Spine Care Centre, Manipal Hospital, Old Airport Road, Bengaluru - 560 017, Karnataka
Source of Support: None, Conflict of Interest: None
We present a case of a 71-year-old male with T12-L1 spondylodiscitis, who was initially treated as a tubercular spondylodiscitis with antituberculous therapy drugs. One month later, the patient developed difficulty in walking with motor weakness in both lower limbs and a second magnetic resonance imaging scan revealed an increase in the volume of pus with cord compression. Pedicle screw stabilization (T9–L4) with T12-L1 laminectomy and curettage of the disc space was performed. Achromobacter denitrificans was identified in aerobic culture. He was treated with an extended course of antibiotics, and subsequently, the lower limb motor power recovered, and biochemical parameters returned to normal. To the best of our knowledge, there has been no report of Achromobacter causing spondylodiscitis in English medical literature. This report focuses on the steps taken in management with special reference to antibiotic therapy.
Keywords: Achromobacter denitrificans, community-acquired infections, nosocomial infection, spondylodiscitis
|How to cite this article:|
Shaikh H, Kishen TJ. Achromobacter spondylodiscitis: A case report and review of literature. Indian Spine J 2018;1:144-7
| Introduction|| |
Achromobacter denitrificans (formerly called Alcaligenes denitrificans) is an aerobic, motile, Gram-negative, nonglucose fermenting, and oxidase and catalase positive bacilli. The organism, first described by Yabucchi in 1971, is found in soil and water and only rarely causes human infections. However, these opportunistic bacteria can cause infections in immunocompromised hosts including those with HIV infection, malignancy, cystic fibrosis, and undergoing prolonged hospitalization. We present a case of A. denitrificans spondylodiscitis in an otherwise healthy 71-year-old male. To the best of our knowledge, this is the first report in English literature.
| Case Report|| |
A 71-year-old male presented with mid back pain, loss of appetite, and weight loss of 3 months duration. The pain was constant, aggravated by activity, disturbed his sleep, and was not relieved by simple pain medications. He was neither a diabetic nor did he have any medical illness that could potentially impair his immunity. On examination, an increased thoracic kyphosis (round back) was noted with deep tenderness at the thoracolumbar junction. No swellings or sinuses were present over the back. The movements of the thoracolumbar spine were restricted and painful in all directions. The straight leg raise test did not produce back or leg pain and the lower limb neurology was normal.
Radiographs [Figure 1] and magnetic resonance imaging (MRI) scan [Figure 2]a and b] of the thoracolumbar spine revealed the destruction of the adjacent endplates of T12 and L1 vertebrae with fluid (pus) in the intervertebral disc space. The hemoglobin was 11.4 g/dl; differential count showed 66% neutrophils, 30% lymphocytes, 3% eosinophils, and 1% monocytes and the erythrocyte sedimentation rate (ESR) was 88 mm/1 h. A computerized tomography (CT)-guided percutaneous vertebral biopsy performed on two occasions was inconclusive. Four-drug antituberculous therapy (ATT) regimen was commenced, and a thoracolumbar brace was prescribed. At one month followup, although the ESR reduced to 33 mm/1 h, the patient developed difficulty in walking with Grade 4/5 power in the lower limb muscles with normal sensations and absent upper motor neuron signs. A second MRI scan, at this stage, revealed an increase in the volume of fluid (pus) in the epidural space behind the T12-L1 interspace [Figure 3]a and b].
|Figure 1: Lateral radiograph of the thoracolumbar spine showing a collapse of the adjacent endplates of T12-L1 vertebrae with obliteration of the disc space|
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|Figure 2: (a) Magnetic resonance imaging scan sagittal view showing an infective focus at T12-L1 vertebrae with prevertebral collection. (b) Magnetic resonance imaging scan axial view showing an infective focus at T12-L1 vertebrae with paravertebral collection|
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|Figure 3: (a) Magnetic resonance imaging scan sagittal view showing an increase in the volume of pus/fluid and spinal cord compression. (b) Magnetic resonance imaging scan axial view showing an increase in the volume of pus/fluid and spinal cord compression|
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Given the worsening neurological status, posterior pedicle screw stabilization (T9-L4) with T12-L1 laminectomy and curettage of the disc space was performed. The disc space was subsequently filled with local bone graft. Histopathological examination of the tissue removed from the site of infection did not reveal any malignancy or granulomatous infection. A. denitrificans was identified and antibiotic susceptibility ascertained using the VITEK®/2 COMPACT system (bioMerieux, La Balme les Grottes, France). Based on the antibiotic sensitivity report, a combination of intravenous ampicillin + sulbactam (1 g + 500 mg) and oral sulfamethoxazole + trimethoprim (800 mg + 160 mg) was prescribed for 6 weeks followed by oral therapy with both drugs for a further 6 weeks.
At the 6-week mark, the lower limb motor power had returned to normal, and the ESR dropped to 29 mm/1 h. The ESR returned to normal at 3 months when the antibiotics were stopped. At the last follow-up (2 years after the surgery), the patient was ambulant with no pain, neurological deficits or restriction of activities and the X-ray showed the healed T12-L1 lesion [Figure 4]a and [Figure 4]b.
|Figure 4: (a) Radiographs of the spine anteroposterior view showing a healed T12-L1 lesion, 2 years after surgery. (b) Radiographs of the spine lateral view showing a healed T12-L1 lesion, 2 years after surgery|
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| Discussion|| |
The genus Achromobacter xylosoxidans, belonging to the Alcaligenaceae family, is a ubiquitous environmental Gram-negative, oxidase-positive, nonglucose-fermenting rod with two subspecies, A. xylosoxidans subsp. xylosoxidans and A. xylosoxidans subsp. denitrificans.A. denitrificans inhabits aquatic sources in the environment and hospitals,, as well as the human gut and may cause nosocomial or community-acquired infections. Nosocomial outbreaks are associated with an aqueous source (usually saline or hemodialysis fluid), incubators, and mechanical ventilators.,, Community-acquired infection is rare, and restricted to immunocompromised patients, especially those with cystic fibrosis,,,,, The 71-year-old immune competent male discussed in this report, regularly visited his farm outside the city from where he could have acquired the infection from an aquatic source (community acquired).
A. denitrificans can cause infections ranging from endocarditis, meningitis, pneumonia, peritonitis, conjunctivitis, osteomyelitis, intra-abdominal abscess, and prosthesis infections.,,,,A. xylosoxidans infections are usually polymicrobial and commonly present as a co-infection with coagulase-negative staphylococci (28% incidence). Infected intravenous catheters and bladder catheters are a significant source of bacteremia.
Duggan et al. reviewed risk factors, clinical presentation, sequelae, and treatment of 77 patients with A. denitrificans infection. Nearly 70% of these patients had nosocomial bacteremia, of which 36% had an infection associated with an outbreak or an isolated point source, 16% had a community-acquired infection, 13% were neonates or premature infants, and 27% were immunosuppressed. The most common underlying illness was a malignancy and cardiovascular disease. The overall mortality among the 73 reviewed cases was 30% with a high case-fatality rate among neonates (80%) and those with pneumonia (66%) and endocarditis (75%). Nearly 65% of the deaths (15/23) occurred as a result of nosocomial infection, and 60% of these (9/15) were associated with outbreaks.
Based on in vitro testing, 91% of the strains were inhibited by piperacillin, 79% were inhibited by ticarcillin-clavulanic acid, 100% were susceptible to imipenem, and 81% of the isolates were susceptible to ceftazidime. However, A. denitrificans subsp. xylosoxidans was not susceptible to expanded-spectrum cephalosporins (except ceftazidime), aminoglycosides (including amikacin) or 4-quinolone derivatives. Trimethoprim-sulfamethoxazole (TMP-SMZ), one of the most reliable antimicrobial agents against this species was not uniformly active with one-third of the isolates being resistant to this drug.
Clinical reports have shown good response to a 6-week course of meropenem in infective endocarditis and a 14-day course of cefoperazone sulbactam for an infected pancreatic pseudocyst. Incidentally, the organism causing the pancreatic pseudocyst infection was sensitive to amikacin, gentamicin, cefotaxime, ceftazidime, ciprofloxacin, piperacillin, doxycycline, cefoperazone sulbactam, piperacillin-tazobactam, and meropenem, and resistant to ampicillin, cefazolin, and cefuroxime. An extensive review of 77 patients revealed that most isolates were resistant to aminoglycosides, narrow-spectrum penicillins, and first-and second-generation cephalosporins and were susceptible to extended-spectrum penicillins, third-generation cephalosporins, TMP-SMZ, and imipenem. Eleven of 20 isolates were found to be resistant to ciprofloxacin.
The 71-year-old immunocompetent gentleman discussed in this report presented with back pain and imaging and laboratory test reports suggestive of spondylodiscitis. CT-guided percutaneous vertebral biopsy on two occasions was inconclusive. Given the absence of significant vertebral destruction and nonexistence of neurological deficits, medical management was considered. A four-drug ATT was commenced given the high prevalence of tuberculosis in the country. Although the ESR levels reduced after 1 month of ATT, the patient developed weakness in both lower limbs and inability to walk unassisted. An MRI scan at this stage revealed an increase in the volume of pus/fluid and spinal cord compression [Figure 3]a and [Figure 3]b. Subsequently, a T9–L4 posterior spinal stabilization (three levels above and below) with a T12-L1 laminectomy, curettage of the involved disc space, and packing with autologous local bone graft was performed. Following surgery, the pain subsided and independent ambulation was possible before discharge from the hospital on the 10th day. A. denitrificans identified on aerobic culture was sensitive to a combination of ampicillin + sulbactam and sulfamethoxazole + trimethoprim. The patient received a 6-week course of intravenous ampicillin + sulbactam (1 g + 500 mg) and oral sulfamethoxazole + trimethoprim (800 mg + 160 mg) followed by oral therapy of both drugs for a further 6 weeks. The inflammatory markers returned to normal at the 3-month mark and at the last follow-up, 2 years after the surgery, the patient was pain-free and functioning normally.
| Conclusion|| |
The aim of this report is to highlight a rare organism (A. denitrificans) causing spondylodiscitis and discuss the management with specific reference to the antibiotic therapy. The A. denitrificans identified was sensitive to a combination of ampicillin + sulbactam and sulfamethoxazole + trimethoprim.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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