Asian Spine J.  2016 Dec;10(6):1065-1071. 10.4184/asj.2016.10.6.1065.

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

• Arockiaraj J
• Karthik R
• Jeyaraj V
• Amritanand R
• Krishnan V
• David KS
• Sundararaj GD

• KMID: 2362184
• DOI: http://doi.org/10.4184/asj.2016.10.6.1065

Abstract

STUDY DESIGN: Retrospective clinical analysis. PURPOSE: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. OVERVIEW OF LITERATURE: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent.
METHODS
We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels.
RESULTS
Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up.
CONCLUSIONS
Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

Keyword

Burkholderia pseudomallei; Melioidosis; Tuberculosis; Spondylitis; Non-caseating granuloma; Antibiotics

MeSH Terms

Abscess
Anti-Bacterial Agents
Back Pain
Blood Sedimentation
Burkholderia pseudomallei
C-Reactive Protein
Ceftazidime
Delivery of Health Care
Developing Countries
Diabetes Mellitus
Diagnosis
Discitis
Doxycycline
Drainage
Follow-Up Studies
Health Education
Hematologic Tests
Humans
Inflammation
Leukocytosis
Magnetic Resonance Imaging
Melioidosis
Mortality
Neutrophils
Psoas Abscess
Radiography
Retrospective Studies
Return to Work
Spine
Spondylitis*
Surgeons
Trimethoprim, Sulfamethoxazole Drug Combination
Tuberculosis
Anti-Bacterial Agents
C-Reactive Protein
Ceftazidime
Doxycycline
Trimethoprim, Sulfamethoxazole Drug Combination