Abhimanyu Beri

AJ Sanfilippo

AS Bayer

Bishav Mohan

CH Cabell

D Horstkotte

G Habib

MA Churchill

O Dizdar

Rohit Tandon

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
A rare case of embolic spondylo-discitis after treatment of aortic 
valve endocarditis
Abhimanyu Beri*1, Bishav Mohan2 and Rohit Tandon2
Address: 1B301 Clinical Center, 138 Service Road, East Lansing, MI, USA and 2Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, 
India
Email: Abhimanyu Beri* - abhiberi@gmail.com; Bishav Mohan - bmohan@yahoo.co.uk; Rohit Tandon - rohittandon@hotmail.com
* Corresponding author    
Abstract
Background: Infective Endocarditis is associated with a high incidence of embolic events,
commonly involving the central nervous system, spleen, kidney, lungs, heart and eyes.
Case presentation: We report a case of infective endocarditis with late embolization to the L5/
S1 region of the spine leading to spondylo-discitis. The disc space infection presented ten days after
completion of antibiotic therapy based on blood culture and antibiotic sensitivity.
Conclusion: This is the first reported case of acute infective spondylo-discitis demonstrated on
MR imaging following completion of appropriate antibiotic therapy.
Background
Infective Endocarditis (IE) is associated with a high inci-
dence of embolic events, ranging from 10–49% [1]. Com-
mon sites include the central nervous system, spleen,
kidney, lungs, heart and the eyes [2]. We report a case of
infective endocarditis with embolization to the L5/S1
region of the spine, despite appropriate intravenous anti-
biotic therapy.
Case presentation
A 38-year-old male presented to out patient department
with 10-day history of intermittent fever. The patient had
an uneventful inguinal hernia surgery two weeks prior to
the onset of fever. Physical examination revealed the pres-
ence of a Grade III/VI decrescendo, high-pitched diastolic
murmur along the left sternal border. Transthoracic (TTE)
and transesophageal echocardiography (TEE) showed the
presence of a congenitally bicuspid aortic valve with two
4 mm size vegetations (Figure 1, 2). The left ventricle was
mildly dilated with moderate to severe aortic regurgita-
tion. Blood cultures were positive for growth of non-
hemolytic Streptococci (NHS). The patient was hospital-
ized and started on intravenous antibiotics (Vancomycin
and Ciprofloxacin) based on the antibiotic sensitivity
report. These were continued for four weeks. The patient
became afebrile and was discharged. Ten days after dis-
charge, the patient had sudden onset of severe lower back
pain while bending to lift a weight. The patient came to
the emergency where tenderness at the level of L5/S1 was
detected. No neurological deficits were present. MRI
(Magnetic Resonance Imaging) of the spine showed
Modic Type II end plate changes with hyperintense signals
in the L5 and S1 vertebrae and in the intervening disc on
STIR sequences. Associated marrow edema seen as
hypointense signal on T1 weighted images. There were no
paravertebral collections. These changes were suggestive
of acute infective spondylo-discitis (Figure 3). A TEE at
that time showed the formation of an aortic valve abscess.
Blood cultures performed were again positive for NHS.
Appropriate antibiotic therapy was instituted based on
Published: 22 October 2008
Cases Journal 2008, 1:261 doi:10.1186/1757-1626-1-261
Received: 1 September 2008
Accepted: 22 October 2008
This article is available from: http://www.casesjournal.com/content/1/1/261
© 2008 Beri et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2008, 1:261 http://www.casesjournal.com/content/1/1/261sensitivity report for 10 days following which aortic valve
replacement surgery was performed. The native valve was
excised and a bioprosthetic valve (21 mm Perimount
Edwards) was placed. The abscess cavity was scooped out
and debrided. Postoperatively, the patient became afe-
brile and symptomatically better. On follow-up, the
patient reported a subjective improvement in his back
pain. A repeat MRI 10 weeks after the previous episode of
back pain showed resolution of the hyperintense signal
previously present at the L5/S1 level in the STIR images.
Discussion
The incidence of IE remains high at 1.7–6.2 per 100 000
person years in the US and Europe [3]. It is associated with
high in-hospital mortality ranging from 16–25% [1].
There is a lot of morbidity and mortality due to destructive
valvular lesions causing valve regurgitation and heart fail-
ure, and a high incidence of embolic events. Predisposing
factors include damaged native valves, prosthetic heart
valves and intravenous drug use. Most patients can be suc-
cessfully treated with intravenous antibiotics for 4–6
weeks based on blood cultures and organism sensitivity
[4]. Surgery is performed when there is intractable conges-
tive heart failure, recurrent embolization and local abscess
formation [2].
Emboli often involve major arterial beds, including cen-
tral nervous system (65%), spleen (49%), kidneys (22%),
Long axis transthoracic echocardiography of patient showing echogenic mass on ventri ular si e of aortic valve attached tothe right coronary leaflet (vegetation)Figur  1
Long axis transthoracic echocardiography of patient 
showing echogenic mass on ventricular side of aortic 
valve attached to the right coronary leaflet (vegeta-
tion).
Short axis view on transesophageal echocardiography with valve thickening a d a  attached echogenic mass (vegetation)Figure 2
Short axis view on transesophageal echocardiogra-
phy with valve thickening and an attached echogenic 
mass (vegetation).
MRI (STIR sequence) showing hyperintense signal from L5 and S1 vertebra  and the intervert bral di c uggestive of cute infective dis itisFigure 3
MRI (STIR sequence) showing hyperintense signal 
from L5 and S1 vertebrae and the intervertebral disc 
suggestive of acute infective discitis.Page 2 of 3
(page number not for citation purposes)
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lungs (16%), extremities (13%) and coronary arteries
(2%) [1]. More than 90% of central nervous system
emboli lodge in the distribution of the middle cerebral
artery. These emboli are associated with a high mortality
rate. Most emboli occur within the first 2 to 4 weeks of
diagnosis. The rate of embolic events drops significantly
during the first 2 weeks of successful antibiotic therapy,
from 13 to < 1.2 embolic events per 1000 patient-days [2].
The type of organism, size and number of vegetations, the
number of valves involved, and vegetation characteristics
(e.g. lack of calcification) predict embolic complications
[2,5].
Dizdar et al reported the case of Group B Streptococcal
endocarditis leading to arthritis in the left L5/S1 facet joint
in a patient who presented as lower back pain and bacter-
emia. On investigation, the site of infection was found to
be mitral valve endocarditis [6].
Churchill et al had studied 192 of IE. Five cases out of
these who presented with lower back pain were found to
have lumbar disc space infection. In all these patients, the
symptoms of IE appeared after the back pain [7]. How-
ever, this series was performed in the pre-MRI era where
this diagnosis was clinical. The diagnosis and treatment of
infective endocarditis has undergone a lot of change since
then. It is also not confirmed whether the valves or the
spine was the primary source of bacteremia.
Ours is a rare case of spondylo-discitis following appro-
priate treatment of IE. He had IE due to NHS in a congen-
itally bicuspid aortic valve with small size vegetation at
the outset. He had none of the above-mentioned high-risk
characteristics that are thought to be predictors of an
embolic event and was treated with intravenous antibiot-
ics based on culture sensitivity for four weeks. Despite
this, the vegetations persisted and he suffered an embolic
episode.
This case shows that IE can present with late embolic epi-
sodes, even after the completion of appropriate antibiotic
therapy. Lower back pain in patients of IE should not be
ignored as this can be due to disc space infection. Our
report shows that spondylo-discitis can be a source of bac-
teremia for endocarditis [7] as well as the result of embol-
ization from infected valves to the spine as in the present
case.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AB and BM were the main contributors in writing the
manuscript. RT helped in obtaining and selecting Images.
All authors read and approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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A rare case of embolic spondylo-discitis after treatment of aortic valve endocarditis

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AE: Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications.

Alyamac E, Onal IK, Uzun O: Group B Streptococcal Facet Joint Arthritis: Case Report. Spine

Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med

Diagnosis and management of infective endocarditis and its complications. Circulation

Embolic risk in subacute bacterial endocarditis. Role of transesophageal echocardiography. Curr Cardiol Rep

Hunder GG: Musculoskeletal manifestations of bacterial endocarditis. Ann Intern Med

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A rare case of embolic spondylo-discitis after treatment of aortic valve endocarditis

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