Empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture: a case report
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Empyema and pyogenic spondylitis are common diseases that are often caused by oral pathogens in direct or hematogenous infection. However, there exists no report describing empyema and pyogenic spondylitis caused by oral pathogens after a compression fracture of the vertebral body. Herein, we report a case of empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture of the vertebral body.
A 74-year-old man had back pain while working. At 1 week after experiencing back pain, he underwent periodontal debridement. At 3 weeks after periodontal debridement, he visited our hospital owing to the absence of improvement in back pain. He was admitted on the same day with a diagnosis of compression fracture of the 12th thoracic vertebral body. Magnetic resonance imaging (MRI) revealed a compression fracture of the 12th thoracic vertebral body and a hematoma anterior to the vertebral body. Computed tomography (CT) showed no findings suggestive of infection. After admission, antibiotic therapy was initiated, as the patient developed fever and his blood cultures grew S. gordonii. CT performed after antibiotic therapy revealed a right-sided pleural effusion, and drainage was performed. As the inflammation did not improve after thoracic drainage for empyema, surgical debridement through video-assisted thoracic surgery was performed. Intraoperative pleural effusion cultures also grew S. gordonii. Postoperative MRI showed low T1-weighted signals and high T2-weighted signals in the 12th thoracic vertebral body, and the signals spread to the upper and lower intervertebral disk space; hence, a diagnosis of empyema and pyogenic spondylitis due to direct infection spread was established. Intravenous antibiotic therapy was continued for 6 weeks and then was switched to oral antibiotic treatment. His C-reactive protein level and erythrocyte sedimentation rate gradually decreased and remained within normal limits. Neither empyema nor pyogenic spondylitis had recurred at 12 months after surgery.
Compression fracture with dental procedures possibly results in the thoracic cavity and spinal infection caused by oral pathogens. We emphasize the importance of early imaging examinations, diagnosis, and appropriate treatment for patients with compression fractures who develop a fever.
KeywordsEmpyema Compression fracture Video-assisted thoracic surgery Pyogenic spondylitis
Erythrocyte sedimentation rate
Minimum inhibitory concentration
Magnetic resonance imaging
Video-assisted thoracic surgery
White blood cell
Empyema and pyogenic spondylitis are common diseases, and their early diagnosis and appropriate treatment can shorten hospital stay and reduce mortality. Both empyema and pyogenic spondylitis are often caused by oral pathogens in direct or hematogenous infection. However, there exists no report describing empyema and pyogenic spondylitis caused by oral pathogens after a compression fracture of the vertebral body. Herein, we report a case of empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture of the vertebral body.
We reported a case of empyema and pyogenic spondylitis caused by direct S. gordonii infection after a compression fracture of the vertebral body. To our knowledge, this is the first report describing empyema and pyogenic spondylitis due to oral pathogen infection after a compression fracture.
Empyema is a common disease resulting from pneumonia, postoperative complications, and trauma, particularly in elderly individuals, diabetic patients, and immunocompromised patients. Early diagnosis and complete drainage through VATS can shorten the hospital stay and reduce mortality. Empyema is relatively frequently caused by oral pathogens; however, empyema caused by S. gordonii is extremely rare, with only one case being reported in the literature . S. gordonii is a Gram-positive, non-motile, coccus belonging to the viridians streptococcal group . Generally present in the mouth and upper airway, this facultative anaerobe is capable of spreading to extraoral sites and causing infective endocarditis, septic arthritis, and toxic shock-like syndrome [3, 4]. Furthermore, some reports have described empyema caused by periodontal disease . A route for dental infection to spread to the mediastinum and thoracic cavity via the neck and a route for bacteria to reach the thoracic cavity via blood are possible.
Pyogenic spondylitis is also usually due to hematogenous infection via the arterial and venous routes and direct infection spread. Essential elements for the successful treatment of pyogenic spondylitis include fixation of the affected section of the spinal column and antibiotic therapy. Pyogenic spondylitis after a compression fracture of the vertebral body is rare, with only 14 cases reported in the literature . Further, there is no report on empyema after a compression fracture of the vertebral body. In order for pyogenic spondylitis to develop after a compression fracture, the coexistence of both fracture and bacteremia is required. Some areas of blood stagnation have been observed with vertebral fracture under these conditions. Once blood stagnation occurs, bacterial inoculation could arise through the end-arterial arcades, resulting in pyogenic spondylitis . Circulation to the endplates of the collapsed vertebral bodies is impaired by the bone fragments, and the same site becomes easily infected with further formation of hematoma .
In conclusion, the lack of typical imaging findings led to a delay in diagnosis. Compression fracture with dental procedures possibly results in the thoracic cavity and spinal infection caused by oral pathogens. We emphasize the importance of early imaging examinations, diagnosis, and appropriate treatment for cases in which patients with compression fracture develop a fever.
We would like to thank Editage (www.editage.jp) for English language editing.
None of the authors have any funding to disclose.
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The authors declare that all the data in this article are available within the article.
DN drafted the manuscript. RK and DN performed the operation. DN, RK, AM, and KI managed the perioperative course. RK revised the manuscript. All authors read and approved the final manuscript.
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