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Case report
Paravertebral abscess and neurological deficits in cervical
brucellar spondylitisV. German,1 N. Papadopoulos,1 C. Diakalis,1 C.
Goritsas1 and A. Ferti1
1Sotiria General Hospital of Athens, Department of Internal
Medicine, Athens, Greece (Correspondence to N. Papadopoulos:
[email protected]).
Received: 30/01/08; accepted: 03/04/08
Introduction
Brucellosis isazoonotic infectionwithaworldwidedistribution,
endemic intheMediterranean region, and is
as-sociatedwithhighmorbidityinhumans[1,2].OsteoarticularcomplicationsarethemostcommonfocalcomplicationsofBrucella
spp. infection [3].Thesecomplications commonly affect
theaxialskeleton,withvertebralspondylitisaccountingfor35%50%ofallosteoar-ticularcomplications[46].Estimatesof
the incidenceof spondylitis rangefrom9% to31%[4,5].While
lumbarspineinvolvementisthemostcommon,cervicalinvolvementisarare,butmoresevere,
complication, accounting
for8.3%ofcasesofvertebralosteomyelitisinarecentstudy[4].
We present a case of brucellarspondylitiswithparavertebralmass
inthe cervical segment that resulted inneurologicaldeficits.
Case report
A 36-year-old female patient, a vet-erinarianwhowasworkingand
livinginAlbania,withahistoryofnephrolithi-asisandanunremarkablefamilyhistory,presentedatourhospitalwithhighfeverthathadstarted20dayspreviously.Co-existing
symptomswerenight sweats,headache,neckpain
extendingdowntheback,andmyalgias,especiallyintherightarm.
The patient had initially beentreatedby a
generalpractitionerwithciprofloxacin for1week,
followedbyampicillinandstreptomycin for4dayswith apparently no
remission of thesymptoms.TheWrighttestwasreport-edasnegativeat
thattime.Thepatientpresentedat
theSotiriaGeneralHos-pitalforChestDiseasesinAthenswithpersistenthigh
fever (up to39.8 C),neck andbackpain,myalgias and
re-strictedmovementoftherightarm.
Physical examination revealednothingbut cervical spine
tendernessatC4C6,whileneurologicalexamina-tion revealedadecrease in
strength
intherightbicepsandtriceps,withattenu-ationoftheirreflexes.
Laboratoryresultsshowedaneryth-rocytesedimentationrateof99mm/h,a
leukocytecountof9480/mm3with49%neutrophilsand32%lymphocytes,ahaemoglobinlevelof11.8g/dLandaplateletcountof348000/mm3.Liverfunction
testswereabnormal:alkalinephosphatase 1484 U/L,
gamma-glutamyl-transpeptidase 443 U/L,serumglutamicoxaloacetic
transami-nase134U/L,serumglutamicpyruvictransaminase 324 U/L and
lactatedehydrogenase348U/L.Bloodurea,creatinine,totalbilirubinandelectrolytelevelswerenormal.Four
consecutivebloodcultureswerenegative.Therewasa diffuse
hypergammaglobulinaemiaandan increase
inC-reactiveproteinvalueto3.41mg/L(normalvalue100 U/mL) using
anenzyme-linked immunsorbent assay(Serion Immundiagnostica
GmbH,Germany).
Cervical spineX-ray showednar-rowedC5C6andC6C7
intraverte-bralspacesandapossibleparavertebralanteriormassintheC6C7area.Tho-racic
spine X-ray had no
abnormalfindings.Acervicalspinecomputerizedtomography(CT)scanconsequentlyperformedrevealedspondylodiscitis
intheC5C6 intravertebral
space,withdestructivechangesintheC5vertebralbodyandpresenceoftissueintherightlateral
paravertebral space. Cervicalmagnetic resonance imaging
(MRI)confirmed
theC5C6spondylitisandtheexistenceofaminimalinflammatoryparavertebralmasswith
rootcompres-sion(Figure1).ThepatientunderwentaCTguidedfine-needleaspirationoftheabscess.Histological
examinationrevealed a nonspecific
inflammatoryinfiltrationwithnoevidenceofmalig-nancy.Allculturetestswerenegative.
Thepatientwasstartedonoraldoxy-cycline100mg2day,oral
rifampicin600mgdailyand intramuscular
strep-tomycin1g4day.Thedoxycyclineand rifampicin regimencontinued
foraperiodof3monthsandstreptomycinwasdiscontinuedafter2weeks.Thirtydays
after admission, thepatientwas
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449
dischargedfreeofsymptomswithamel-iorationof theneurological
signs.Thelaboratory
testsonherdischargewerenormal,includingerythrocytesedimen-tationrateandliverfunctiontests.
Threemonths after discharge
thepatientremainedfreeofsymptoms,neu-rologicalexaminationwasnormalandcomplete
laboratory
testswerewithinnormallimitswithadecreaseintheanti-BrucellaIgMantibodytitreto50IU/mL.
AsecondcervicalMRIshowedremis-sionofspondylitiswithnoevidenceof
theparavertebralmass(Figure2).
Discussion
Brucellosisremainsanimportantpublic
healthproblem in theMediterranean
region,whereefforts toeradicateBru-cella melitensis
inanimalshave failed. In
Greece,284casesofbrucellosiswereofficiallyreportedduring2006[7].
Theclinicalmanifestationsofbru-cellosisarevaried.Themusculoskeletalsystem
is frequently affected and
thespineisthemostcommonsiteofbonebrucellosis.Thespineismostfrequentlyaffectedinthelumbosacralregion,andpatientsareusuallymalesovertheageof50years[1,4,5].Cervical
involvement,however, is accompaniedbymore se-veremanifestations,
suchasparaverte-bralandepiduralmasses,neurologicalandfunctionaldisabilities[1,5].
Diagnosisandtreatmentshouldbequickand intense, sincedelay in
treat-ment leadstoahighmorbidityrate.
Inamulticentreprospectivestudyof593patientswithbrucellosis. the
incidenceof spondylitiswas9.7%[5].The
inci-denceofmedullaorrootcompression,however,dependedontheaffectedseg-mentofthespinalcolumn.Inthegroupof
patientswith cervical spondylitis,71%hadcompressionof themedullaor
roots, versus 11% and21% in thedorsal and lumbargroup
respectively.Inaddition,patientswithcervical anddorsal spondylitis
had a significantlyhigher
rateofparavertebralorepiduralmassesthanthoseinthelumbargroup.Moreover,
therewere a
significantlyhighernumberofpatientswithunsat-isfactoryprogress in
thecervicalgroupcomparedwith thedorsaland
lumbargroups.RecentstudiesinGreecefoundosteoarticular involvement
in nearlyhalfthecasesofacutebrucellosis[2,8].
Occasionallypatientswithparaver-tebral abscess fail to respond
to
con-servativetreatmentandhavetoundergosurgery[1,9];however,successhasbeenreportedwithconservative
treatment,andthismaybesufficientinselectedpa-tients [10].Generally,
little informationisavailableaboutbrucellar
spondylitisandtreatmentregimensvarywidely.TheIoanninarecommendations,developedbyexperts
inNovember2006,advisedthattheoutcomeofspondylitismaybeimprovedwhenastreptomycinregimen
Figure 1 Pre-treatment case of brucellar spondylitis. (A)
Sagittal T1W image: spondylitis is depicted as low signal intensity
lesion of the C5 and C6 vertebral bodies. (B) Transverse FFET2W
image: the paravertebral inflammatory mass is indicated as
high-signal intensity lesion protruding mainly to the left
intervertebral foramen, compressing the homolateral nerve root
Figure 2 Post-treatment case of brucellar spondylitis. (A)
Sagittal T1W image: resolution of the spondylitis is demonstrated;
C5 and C6 vertebral bodies have normal signal intensity. (B)
Transverse FFET2W image: no paravertebral inflammatory mass is
found post-treatment and no root compression is depicted
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EMHJ Vol.16 No.4 2010
EasternMediterraneanHealthJournalLaRevuedeSantdelaMditerraneorientale
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Solera J et al. Brucellar spondylitis: review of 35 cases and
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Colmenero JD et al. Complications associated with 3. Bru-cella
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Colmenero JD et al. Clinical findings, therapeutic approach, 4.
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Basaranoglu M et al. A case of cervical brucella spondylitis
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Epidemiologic data for infectious diseases. 7. Athens, Hellenic
Cen-tre for Infectious Diseases Control, Department of
Epidemio-
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isusedandthatthedurationoftherapy
mustbenotlessthan3months[11].Inarecentstudyof918patientswith
brucellosis, the incidence of vertebral
osteomyelitiswas10.4%,andcervicalin-volvementwasestablishedin8.3%ofthem
[4]. In that studypatientswere
treatedwithdoxycyclinefor3monthsplusstrep-tomycin
for2or3weeks(DOX-STR
regimen)ordoxycyclineplusrifampicin
(DOX-RIFregimen)bothfor3months.
No significantdifferenceswere found
betweenthe2treatmentgroupsintreat-mentfailure,mortalityandrelapse.Inour
case,wepreferredtouseinitiallystrepto-mycinfor2weeksplusdoxycyclineandrifampicin
fora
totalof3months.Theadministrationoftripleregimensisusedforneurobrucellosis[2].Webelievethatthistreatmentstrategycombinesthesu-periorityoftheDOX-STRregimenwiththe
better implementationof
theoralDOX-RIFregimen.However,morewell-designed,controlled
trialsareneededtoestablishthesuperiorityofacertainregi-men.Currentlytherapeuticdecisionsareguidedmainlybyexpertopinion.Inourcase
therewasa rapidresponse
toanti-microbialchemotherapy,aswasreported
inpreviouscasesofbrucellarspondylitis
withparavertebralabscess[6,12].Cervical spondylitis should
be
considered a severe complication of
brucellosis; therefore its treatmentand
follow-upmustbeenergeticinorderto
detectandcorrectasearlyaspossible
compressionsof theneuralaxisand its
roots.Treatmentshouldbeprolonged
topreventbothcomplicationsand re-lapses.Furtherevaluation
incontrolled
studies isneeded toassess theefficacy
andsafetyoftreatmentoptionsinbrucel-larspondylitis.
