Printed in the USA * Copyright 0 1990 Pergamon Press plc
The Journal of Emergency Medicine, Vol. 8, pp. 291-295, 1990
STREPTOCOCCUS VIRIDANS OSTEOMYELITIS WITH ENDOCARDITIS PRESENTING AS ACUTE ONSET LOWER BACK PAIN Alan L. Buchman, MD Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California and Nutrition, Department Reprint address: Alan L. Buchman, MD, Division of Pediatric Gastroenterology Medical Center, Los Angeles, CA 90024-1752
UCLA
temperature of 37.8 “C. Spinal examination was not done. The neurological exam noted only that deep tendon reflexes were normal. Again, no cardiac examination was performed. Lumbrosacral radiographs revealed disc space narrowing from L,, being most severe at L,-S,, He also had mild spinal canal narrowing secondary to posterior vertebral body osteophytes at L”. Total white blood cell count was 14.4 x 109/L. Urinalysis revealed O-l white blood cells and, 5-12 red blood cells per high power field. Hemoglobin was 5.7 mmol/L and hematocrit 28.0%. The patient was discharged home with the diagnosis of “viral syndrome” to be treated with acetaminophen (Tylenol) and codeine and bed rest. Because of continued back pain for the next 24 hours, the patient called his private physician who admitted him to the medicine service. The pain was described as dull and continuous without radiation to the legs. The patient had a history of occasional right-sided sciatica that was not as severe as the presenting complaint. He denied numbness, paresthesias, urinary or stool incontinence, trauma, excessive straining, heavy lifting, dysuria, cough, fever, or chills. The patient had his teeth cleaned two weeks prior to admission. The patient was alert and oriented. Any torso movement aggravated the back pain. The temperature was 38 .O“C orally, pulse 92, and blood pressure 136/82. The posterior pharynx was noninjected. Moderately severe gingivitis was present. No Roth spots were seen on fundoscopic examination. The neck was, supple and without lymphadenopathy. The lungs were clear to auscultation. Cardiac examination revealed a grade 3/6 holosystolic murmur with radiation throughout the precordium. The abdomen was benign and the stool was
0 Abstract - An elderly male with a history of diabetes mellitus and a recent dental procedure presented to the emergency department with acute lumhrosacral pain and low grade fever. Computerized tomography (CT scan) and magnetic resonance imaging (MRI) yielded a presumptive diagnosis of pyogenic vertebral osteomyelitis. A diagnosis of viridans Streptococcus vertebral osteomyelitis was confirmed by gallium scanning and blood culture. The literature has emphasized the occurrence of pyogenic vertebral osteomyelitis as a chronic process. A review suggests that viridans Streptococci, although an uncommon cause of this disorder, is usually associated with back pain of more acute onset. It is therefore recommended that pyogenic vertebral osteomyelitis be considered in any patient presenting to the emergency department with the acute onset of lower hack pain, fever, leukocjtosis and an elevated erythrocyte sedimentation rate. 0 Keywords - osteomyelitis, endocarditis, Streptococcus vinihs. discitis
CASE REPORT
The patient was a 74-year-old Caucasian male with a history of non-insulin dependent diabetes mellitus who presented to the emergency department with a complaint of acute onset of excruciating lower back pain. The patient had a temperature of 37 5 “C orally, a normal neurological examination and no spinal tenderness. A cardiac examination was not performed. He was discharged home with a diagnosis of low back pain and strain. The pain persisted for the ensuing 36 hours, which prompted his return to the emergency department. At that time the patient was noted to have a rectal
RECEIVED: 19 June 1989; FINALSUBMISSIONRECEIVED:8 ACCEPED: 10 October 1989
of Pediatrics,
September 1989; 291
0736-4679/90 $3.00 + .OO
Alan L. Buchman
Figure 1: CT scan revealing disc distension and fragmentatlon of the L4 superior plate and the L5 (Inferlor end plate) wlth paravertebral soft tlssue thickening.
heme negative. The neurological exam revealed no limb ataxia. Knee jerks were 2f and symmetric, and ankle jerks were trace to l+ and symmetric. The patient had decreased vibratory sensation in his feet, but otherwise sensory and motor testing was normal. Laboratory data included a hemoglobin of 9.98 grn/ dL, WBC count of 16.7 X 1O-9” with 85% neutrophils and 2% bands, ESR of 92 mrnihr, and a urinalysis that revealed 5 to 10 RBCs without bacteria or pyuria. All other laboratory findings were normal. A CT scan (Figure 1) obtained within 2 hours of hospital admission revealed disc distension and fragmentation of the L4 superior plate and the L, (inferior end plate) with paravertebral soft tissue thickening. An MRI of the lumbar sacral spine was performed on the evening of admission and revealed no evidence of abscess, although the disc space at Ls-L4 was narrowed (Figure 2). There was evidence of a mild spinal fluid block at this level, as evidenced by slow flow distal to this area. Mild rightsided foramin encroachment from an osteophyte as well as both anterior and posterior disc hemiation was present at this level. The disc space of L,-L, was narrowed and degenerated, and a small midline disc hemiation was present with right-sided foraminal encroachment. The L,-Si disc was also narrowed and degenerated. The chest radiograph revealed cardiomegaly, but was otherwise unremarkable. Streptococcus viriduns was grown from 3 of 4 blood culture bottles at 24 hours and was sensitive to penicillin. An echocardiogram was consistent with an aortic vegetation. Dental radiographs
Flgure 2: MRI of the lumbar sacral spine revealing no evidence of abscess, although the disc space at b-L, was narrowed.
were normal. A gallium scan revealed focal uptake at La-L,. The patient was treated with 12 million units of intravenous penicillin G daily for six weeks. Successful treatment was confirmed by the normalization of a gallium scan performed at the completion of treatment and clinical resolution of pain and fever.
DISCUSSION Lower back pain is a common presenting complaint of patients seen in the emergency department. Physicians who see such patients should include endocarditis and pyogenic vertebral osteomyelitis in their differential diagnosis. In a review of 192 patients with endocarditis
Streptococcus
Viridans Osteomyelitis
293
with Endocarditis
seen at the Mayo Clinic, Churchill and colleagues found that 23% had low back pain either as the presenting symptom or among their initial symptoms (1). He also found that unlike our case, spinal tenderness and positive straight leg raises were frequently present. Sapico and Montgomerie (2) in a review of 318 patients with pyogenic vertebral osteomyelitis in the literature, found that neck or back pain was the presenting complaint in 92% of patients, although such symptoms had persisted for more than 3 months in over 50%. He also found that 52% had an oral temperature over 37.8 “C, although Ambrose (3), in a review of 24 cases of pyogenic vertebral osteomyelitis, found that the peak temperature averaged 38.2 “C and that only 17% had a fever of more than 39”. Sapico also found that of patients who were later found to have pyogenic vertebral osteomyelitis, 92% had an elevated ESR, 42% had leukocytosis, 17% had neurological findings of varying degrees, mostly related to spinal cord or nerve root involvement, and 15% tested positive for straight leg raises. In addition, he found the lumbar region to be the site of pyogenic vertebral osteomyelitis in 57% of cases. Although pyogenic vertebral osteomyelitis typically has an insidious course, 20% present with back pain of less than 3 weeks duration (2). It is unclear from published reviews at what point symptoms began during this 3-week period. Streptococcus viridans is an uncommon cause of this disease. However, a review of previously reported cases revealed that the acute onset of lower back pain, with a persistence for 3 days or less prior to presentation for medical treatment, was the initial complaint in 5 of the 6 cases (5-9). Streptococcus viridans is normally found in the gingival sulci. They may transiently enter the blood stream during dental manipulations. Diabetes mellitus has been described as a probable risk factor predisposing to pyogenic vertebral osteomyelitis (lo-12), although it is not particularly associated with Streptococcus viridans. Sapico found diabetes present in 19% of the cases reviewed. It is assumed that vascular and ischemic changes together with altered neutrophil function, particularly, chemotaxis, contribute to such infection in diabetics (13-15). Degenerative lumbosacral spine disease may also permit the establishment of infection in abnormal bone. None of the following have been shown (3) to be risk factors for vertebral osteomyelitis: blunt
trauma, the use of steroids, immunosuppressive medications, or alcohol. Previous reports have suggested that urinary tract infections are the most likely sources of pyogenic vertebral osteomyelitis although usually predisposing to gramnegative or enterococcal species (3). Soft tissue infections have also been reported in 13% and respiratory tract infections in 11% of cases (3). Other less likely risk factors include antecedent spinal surgery, indwelling intravenous catheters, diarrhea, intravenous drug abuse, and endocarditis as described in this report. The diagnosis of pyogenic vertebral osteomyelitis may be difficult to differentiate from pyogenic abscess in a patient such as the one presented herein. Of patients with the latter, 35% also have osteomyelitis (3). The CT scan and MRI are individually useful in both situations. The former is available from the emergency department in most medical centers. The MRI may be less commonly available on an immediate basis. Gallium scanning, as was done in the case described, may serve as a confirmatory test in the absence of a tissue diagnosis made from biopsy. Our patient refused biopsy. However, both needle and open surgical biopsies are often falsely negative, due to sampling error (3). In addition, blood cultures and the Tc 99m MDP bone scan may often be negative, especially in early vertebral osteomyelitis (3, 15, 16). Store and Bonfiglio (12) found that because early symptoms and signs of vertebral osteomyelitis were minimal, errors and delays in diagnosis were common. A delay in diagnosis may lead to such complications as longitudinal extension to involve other vertebrae, or anterior extension to form a spinal abscess (the sequalae of which include paraplegia and frank meningitis). Therefore, the diagnosis of endocarditis and vertebral osteomyelitis should be considered in any patient who presents to the emergency department with the acute onset of lower back pain and fever, especially if the patient is elderly, has a history of diabetes mellitus, and is found to have a leukocytosis or elevated ESR. The physical examination performed on such patients should always include cardiac auscultation and a complete neurological examination. Radiographic techniques such as the CT and MRI scans are useful in making a rapid, presumptive diagnosis of vertebral osteomyelitis. Such prompt recognition should allow for rapid therapy with few resultant complications.
REFERENCES 1. Churchill MA, Geraci JE, Hunder GG. Musculoskeletal
manifestations of bacterial endocarditis. Ann Int Med. 1977;87:7549. 2. Ambrose GB, Alpert M, Neer CS. Vertebral osteomyelitis, a
diagnostic problem. JAMA. 1966;197:619-22. 3. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis.
Alan L. Buchman
1979;1:754-76. 4. Applefeld MM, Horrick RB. Infective endocarditis in patients over age 60. Am Heart J. 1974:88:90-4. 5. Green L, Bemer YN, Schteger 2, Bentwhich 2. Streptococcus viridans vertebral osteomyelitis with bacteremia. Isr J Med Sci. 1985;21:1734. 6. Guri JP. Pyogenic osteomyelitis of the spine. J Bone Joint Surg. 1946;28:29. 7. Mathai WH, Werkel CS, McDermott AM, Wenzel RP. Streptococcus bovis endocarditis with vertebral osteomyelitis. So Med J. 1986;79:1192. 8. Allen SL, Salmon JE, Roberts RB. Streptococcus bovis endocarditis presenting as acute vertebral osteomyelitis. Arthritis Rheum. 1981;24:1211-2. 9. Ullman RF, Strampfer J, Cunha BA. Streptococcus mutans vertebral osteomyelitis. Heart Lung. 1988;17:319-21. 10. Garcia A Jr, Gransthen SA. Hematogenous pyogenic vertebral
osteomyelitis. J Bone Joint Surg. 1960;45:429. 11. Stauffer RN. Pyogenic vertebral osteomyelitis. Orthop Clin North Am, 1975:1015-27. 12. Store DB, Bonfiglio M. Pyogenic vertebral osteomyelitis, a diagnostic pitfall for the internist. Arch Intern Med. 1963;112: 491-500. _ 13. Bagdade JD, Root RR, Bulger RG. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes. 1974:23:9-15. 14. Mowet AG, Baud J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. N Engl J Med. 1971;284:621-7. 15. Tan JS, Anderson JL, Watanakunakom C, Phair JP. Neutrophil dysfunction in diabetes mellitus. J Lab Clin Med. 1975;85:26-33. 16. Schlaeffer F, Mikolich DJ, Mates SM. Technetium Tc 99m diphosphonate bone scan: false normal findings in elderly patients with hematogenous vertebral osteomyelitis. Arch Intern Med. 1987;147:2024-6.
The Journal of Emergency
Medicine,
Vol. 8, pp. 295-297,
Printed in the USA
1990
* Copyright 0 1990 Pergamon Press plc
FATAL MYOCARDITIS SECONDARY TO SALMONELLA SEPTICEMIA IN A YOUNG ADULT Carolyn R. Burt, *Department
DO,*
Jeffrey C. Proudfoot,
DO,*
Mont Roberts,
R.H. Horowitz,
MD,
FAcPt
of Emergency
Reprint address:
Medicine, Michigan State University Emergency Medicine Residency Program and tDepartment of Laboratories, Section of Pathology, Sparrow Hospital, Lansing, Michigan Jeffrey C. Proudfoot, DO, Emergency Medicine Department, Sparrow Hospital, 1215 E. Michigan Avenue, Lansing, MI 48909
returned 24 hours later complaining of diarrhea with low abdominal pain and flatus. Vital signs were temperature 36.5 “C, pulse 120, respirations 20, and blood pressure 102/64 mmHg. Physical examination was unremarkable, and no laboratory studies were performed. The diagnosis of gastroenteritis was made, and the patient was instructed to stop taking the previously prescribed medications. The patient presented ambulatory to our ED 72 hours later still complaining of persistent nonbloody diarrhea without vomiting. He was able to take clear liquids but had had no solid food for the prior 5 days. He was taking Immodium@ prescribed per phone by his family doctor. Vital signs were temperature 38°C pulse 116, respirations 24, and blood pressure 1lo/70 mmHg. Physical examination was unremarkable except for the tachycardia and diffuse abdominal tenderness. Bowel sounds were present and there was no guarding, rebound or costovertebral angle tenderness. Rectal exam was positive for trace blood. An IV of DS/Lactated Ringers was started and the patient given 1000 cc over 30 minutes and then an additional 250 cc in the next hour. Additional laboratory studies were as follows: WBC 5,400/mm3 (segs 49, bands 13, lymphocytes 24, monocytes 13, and eosinophils l), hemoglobin 15.7 gm/dL, hematocrit 44%, sodium 134 mEq/L, potassium 3.2 mEq/L, chloride 96 mEq/L, bicarbonate 28.3 mEq/L, and glucose 128 mg%. The patient was given 40 mEq KC1 orally and discharged after 3 hours and 45 minutes in the department with a diagnosis of gastroenteritis and instructed to follow up with his family doctor in 48 hours. The patient was unable to produce a stool sample while in the depart ment. Five hours after discharge the patient became
0 Abstract - A 29-year-old white male with a recent history of gastroenteritis sustained a cardiac arrest at home. He was found to be in ventricular fibrillation and could not be resuscitated. Pathologic findings included focal aggregates of histiocytes, lymphocytes and occasional neutrophils in the myocardium as well as inilammatory changes in the colon, liver, and spleen. Blood cultures were positive for Salmonelhz heidelberg. The patient was seen 3 times by emergency departments prior to his demise. Death from Salmonella is rare except when associated with septicemia. The severity of iBness and prognosis are often related to the site of infection and underlying disease processes. 0 Keywords - myocarditis; salmonella septicemia; Salmonelk heidelberg; gastroenteritis; cardiac arrest
INTRODUCTION
Salmonellosis is primarily a disease of children. The largest number of outbreaks occur because of mishandling of food. Poultry, meat, eggs, and dairy products have been the most important vehicles of transmission, although person-to-person and pet-to-person exposures are also significant. Most cases of salmonella gastroenteritis are self-limited. We report a fatal case of salmonella septicemia associated with gastroenteritis and myocarditis . CASE REPORT
A 29-year-old white male presented to a small community emergency department (ED) complaining of low back pain after lifting 80 pounds at home. He was diagnosed as a low back strain and started on Flexerilm and ibuprofen and placed off work for 48 hours. He
RECEIVED: 28
MD, FACEP,*
June 1989;
ACCEPTED: 22
September 1989
0736-4679190 $3.00 + .OO 295
The Journal of Emergency Medicine, Vol. 8, pp. 291-295, 1990
STREPTOCOCCUS VIRIDANS OSTEOMYELITIS WITH ENDOCARDITIS PRESENTING AS ACUTE ONSET LOWER BACK PAIN Alan L. Buchman, MD Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California and Nutrition, Department Reprint address: Alan L. Buchman, MD, Division of Pediatric Gastroenterology Medical Center, Los Angeles, CA 90024-1752
UCLA
temperature of 37.8 “C. Spinal examination was not done. The neurological exam noted only that deep tendon reflexes were normal. Again, no cardiac examination was performed. Lumbrosacral radiographs revealed disc space narrowing from L,, being most severe at L,-S,, He also had mild spinal canal narrowing secondary to posterior vertebral body osteophytes at L”. Total white blood cell count was 14.4 x 109/L. Urinalysis revealed O-l white blood cells and, 5-12 red blood cells per high power field. Hemoglobin was 5.7 mmol/L and hematocrit 28.0%. The patient was discharged home with the diagnosis of “viral syndrome” to be treated with acetaminophen (Tylenol) and codeine and bed rest. Because of continued back pain for the next 24 hours, the patient called his private physician who admitted him to the medicine service. The pain was described as dull and continuous without radiation to the legs. The patient had a history of occasional right-sided sciatica that was not as severe as the presenting complaint. He denied numbness, paresthesias, urinary or stool incontinence, trauma, excessive straining, heavy lifting, dysuria, cough, fever, or chills. The patient had his teeth cleaned two weeks prior to admission. The patient was alert and oriented. Any torso movement aggravated the back pain. The temperature was 38 .O“C orally, pulse 92, and blood pressure 136/82. The posterior pharynx was noninjected. Moderately severe gingivitis was present. No Roth spots were seen on fundoscopic examination. The neck was, supple and without lymphadenopathy. The lungs were clear to auscultation. Cardiac examination revealed a grade 3/6 holosystolic murmur with radiation throughout the precordium. The abdomen was benign and the stool was
0 Abstract - An elderly male with a history of diabetes mellitus and a recent dental procedure presented to the emergency department with acute lumhrosacral pain and low grade fever. Computerized tomography (CT scan) and magnetic resonance imaging (MRI) yielded a presumptive diagnosis of pyogenic vertebral osteomyelitis. A diagnosis of viridans Streptococcus vertebral osteomyelitis was confirmed by gallium scanning and blood culture. The literature has emphasized the occurrence of pyogenic vertebral osteomyelitis as a chronic process. A review suggests that viridans Streptococci, although an uncommon cause of this disorder, is usually associated with back pain of more acute onset. It is therefore recommended that pyogenic vertebral osteomyelitis be considered in any patient presenting to the emergency department with the acute onset of lower hack pain, fever, leukocjtosis and an elevated erythrocyte sedimentation rate. 0 Keywords - osteomyelitis, endocarditis, Streptococcus vinihs. discitis
CASE REPORT
The patient was a 74-year-old Caucasian male with a history of non-insulin dependent diabetes mellitus who presented to the emergency department with a complaint of acute onset of excruciating lower back pain. The patient had a temperature of 37 5 “C orally, a normal neurological examination and no spinal tenderness. A cardiac examination was not performed. He was discharged home with a diagnosis of low back pain and strain. The pain persisted for the ensuing 36 hours, which prompted his return to the emergency department. At that time the patient was noted to have a rectal
RECEIVED: 19 June 1989; FINALSUBMISSIONRECEIVED:8 ACCEPED: 10 October 1989
of Pediatrics,
September 1989; 291
0736-4679/90 $3.00 + .OO
Alan L. Buchman
Figure 1: CT scan revealing disc distension and fragmentatlon of the L4 superior plate and the L5 (Inferlor end plate) wlth paravertebral soft tlssue thickening.
heme negative. The neurological exam revealed no limb ataxia. Knee jerks were 2f and symmetric, and ankle jerks were trace to l+ and symmetric. The patient had decreased vibratory sensation in his feet, but otherwise sensory and motor testing was normal. Laboratory data included a hemoglobin of 9.98 grn/ dL, WBC count of 16.7 X 1O-9” with 85% neutrophils and 2% bands, ESR of 92 mrnihr, and a urinalysis that revealed 5 to 10 RBCs without bacteria or pyuria. All other laboratory findings were normal. A CT scan (Figure 1) obtained within 2 hours of hospital admission revealed disc distension and fragmentation of the L4 superior plate and the L, (inferior end plate) with paravertebral soft tissue thickening. An MRI of the lumbar sacral spine was performed on the evening of admission and revealed no evidence of abscess, although the disc space at Ls-L4 was narrowed (Figure 2). There was evidence of a mild spinal fluid block at this level, as evidenced by slow flow distal to this area. Mild rightsided foramin encroachment from an osteophyte as well as both anterior and posterior disc hemiation was present at this level. The disc space of L,-L, was narrowed and degenerated, and a small midline disc hemiation was present with right-sided foraminal encroachment. The L,-Si disc was also narrowed and degenerated. The chest radiograph revealed cardiomegaly, but was otherwise unremarkable. Streptococcus viriduns was grown from 3 of 4 blood culture bottles at 24 hours and was sensitive to penicillin. An echocardiogram was consistent with an aortic vegetation. Dental radiographs
Flgure 2: MRI of the lumbar sacral spine revealing no evidence of abscess, although the disc space at b-L, was narrowed.
were normal. A gallium scan revealed focal uptake at La-L,. The patient was treated with 12 million units of intravenous penicillin G daily for six weeks. Successful treatment was confirmed by the normalization of a gallium scan performed at the completion of treatment and clinical resolution of pain and fever.
DISCUSSION Lower back pain is a common presenting complaint of patients seen in the emergency department. Physicians who see such patients should include endocarditis and pyogenic vertebral osteomyelitis in their differential diagnosis. In a review of 192 patients with endocarditis
Streptococcus
Viridans Osteomyelitis
293
with Endocarditis
seen at the Mayo Clinic, Churchill and colleagues found that 23% had low back pain either as the presenting symptom or among their initial symptoms (1). He also found that unlike our case, spinal tenderness and positive straight leg raises were frequently present. Sapico and Montgomerie (2) in a review of 318 patients with pyogenic vertebral osteomyelitis in the literature, found that neck or back pain was the presenting complaint in 92% of patients, although such symptoms had persisted for more than 3 months in over 50%. He also found that 52% had an oral temperature over 37.8 “C, although Ambrose (3), in a review of 24 cases of pyogenic vertebral osteomyelitis, found that the peak temperature averaged 38.2 “C and that only 17% had a fever of more than 39”. Sapico also found that of patients who were later found to have pyogenic vertebral osteomyelitis, 92% had an elevated ESR, 42% had leukocytosis, 17% had neurological findings of varying degrees, mostly related to spinal cord or nerve root involvement, and 15% tested positive for straight leg raises. In addition, he found the lumbar region to be the site of pyogenic vertebral osteomyelitis in 57% of cases. Although pyogenic vertebral osteomyelitis typically has an insidious course, 20% present with back pain of less than 3 weeks duration (2). It is unclear from published reviews at what point symptoms began during this 3-week period. Streptococcus viridans is an uncommon cause of this disease. However, a review of previously reported cases revealed that the acute onset of lower back pain, with a persistence for 3 days or less prior to presentation for medical treatment, was the initial complaint in 5 of the 6 cases (5-9). Streptococcus viridans is normally found in the gingival sulci. They may transiently enter the blood stream during dental manipulations. Diabetes mellitus has been described as a probable risk factor predisposing to pyogenic vertebral osteomyelitis (lo-12), although it is not particularly associated with Streptococcus viridans. Sapico found diabetes present in 19% of the cases reviewed. It is assumed that vascular and ischemic changes together with altered neutrophil function, particularly, chemotaxis, contribute to such infection in diabetics (13-15). Degenerative lumbosacral spine disease may also permit the establishment of infection in abnormal bone. None of the following have been shown (3) to be risk factors for vertebral osteomyelitis: blunt
trauma, the use of steroids, immunosuppressive medications, or alcohol. Previous reports have suggested that urinary tract infections are the most likely sources of pyogenic vertebral osteomyelitis although usually predisposing to gramnegative or enterococcal species (3). Soft tissue infections have also been reported in 13% and respiratory tract infections in 11% of cases (3). Other less likely risk factors include antecedent spinal surgery, indwelling intravenous catheters, diarrhea, intravenous drug abuse, and endocarditis as described in this report. The diagnosis of pyogenic vertebral osteomyelitis may be difficult to differentiate from pyogenic abscess in a patient such as the one presented herein. Of patients with the latter, 35% also have osteomyelitis (3). The CT scan and MRI are individually useful in both situations. The former is available from the emergency department in most medical centers. The MRI may be less commonly available on an immediate basis. Gallium scanning, as was done in the case described, may serve as a confirmatory test in the absence of a tissue diagnosis made from biopsy. Our patient refused biopsy. However, both needle and open surgical biopsies are often falsely negative, due to sampling error (3). In addition, blood cultures and the Tc 99m MDP bone scan may often be negative, especially in early vertebral osteomyelitis (3, 15, 16). Store and Bonfiglio (12) found that because early symptoms and signs of vertebral osteomyelitis were minimal, errors and delays in diagnosis were common. A delay in diagnosis may lead to such complications as longitudinal extension to involve other vertebrae, or anterior extension to form a spinal abscess (the sequalae of which include paraplegia and frank meningitis). Therefore, the diagnosis of endocarditis and vertebral osteomyelitis should be considered in any patient who presents to the emergency department with the acute onset of lower back pain and fever, especially if the patient is elderly, has a history of diabetes mellitus, and is found to have a leukocytosis or elevated ESR. The physical examination performed on such patients should always include cardiac auscultation and a complete neurological examination. Radiographic techniques such as the CT and MRI scans are useful in making a rapid, presumptive diagnosis of vertebral osteomyelitis. Such prompt recognition should allow for rapid therapy with few resultant complications.
REFERENCES 1. Churchill MA, Geraci JE, Hunder GG. Musculoskeletal
manifestations of bacterial endocarditis. Ann Int Med. 1977;87:7549. 2. Ambrose GB, Alpert M, Neer CS. Vertebral osteomyelitis, a
diagnostic problem. JAMA. 1966;197:619-22. 3. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis.
Alan L. Buchman
1979;1:754-76. 4. Applefeld MM, Horrick RB. Infective endocarditis in patients over age 60. Am Heart J. 1974:88:90-4. 5. Green L, Bemer YN, Schteger 2, Bentwhich 2. Streptococcus viridans vertebral osteomyelitis with bacteremia. Isr J Med Sci. 1985;21:1734. 6. Guri JP. Pyogenic osteomyelitis of the spine. J Bone Joint Surg. 1946;28:29. 7. Mathai WH, Werkel CS, McDermott AM, Wenzel RP. Streptococcus bovis endocarditis with vertebral osteomyelitis. So Med J. 1986;79:1192. 8. Allen SL, Salmon JE, Roberts RB. Streptococcus bovis endocarditis presenting as acute vertebral osteomyelitis. Arthritis Rheum. 1981;24:1211-2. 9. Ullman RF, Strampfer J, Cunha BA. Streptococcus mutans vertebral osteomyelitis. Heart Lung. 1988;17:319-21. 10. Garcia A Jr, Gransthen SA. Hematogenous pyogenic vertebral
osteomyelitis. J Bone Joint Surg. 1960;45:429. 11. Stauffer RN. Pyogenic vertebral osteomyelitis. Orthop Clin North Am, 1975:1015-27. 12. Store DB, Bonfiglio M. Pyogenic vertebral osteomyelitis, a diagnostic pitfall for the internist. Arch Intern Med. 1963;112: 491-500. _ 13. Bagdade JD, Root RR, Bulger RG. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes. 1974:23:9-15. 14. Mowet AG, Baud J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. N Engl J Med. 1971;284:621-7. 15. Tan JS, Anderson JL, Watanakunakom C, Phair JP. Neutrophil dysfunction in diabetes mellitus. J Lab Clin Med. 1975;85:26-33. 16. Schlaeffer F, Mikolich DJ, Mates SM. Technetium Tc 99m diphosphonate bone scan: false normal findings in elderly patients with hematogenous vertebral osteomyelitis. Arch Intern Med. 1987;147:2024-6.
The Journal of Emergency
Medicine,
Vol. 8, pp. 295-297,
Printed in the USA
1990
* Copyright 0 1990 Pergamon Press plc
FATAL MYOCARDITIS SECONDARY TO SALMONELLA SEPTICEMIA IN A YOUNG ADULT Carolyn R. Burt, *Department
DO,*
Jeffrey C. Proudfoot,
DO,*
Mont Roberts,
R.H. Horowitz,
MD,
FAcPt
of Emergency
Reprint address:
Medicine, Michigan State University Emergency Medicine Residency Program and tDepartment of Laboratories, Section of Pathology, Sparrow Hospital, Lansing, Michigan Jeffrey C. Proudfoot, DO, Emergency Medicine Department, Sparrow Hospital, 1215 E. Michigan Avenue, Lansing, MI 48909
returned 24 hours later complaining of diarrhea with low abdominal pain and flatus. Vital signs were temperature 36.5 “C, pulse 120, respirations 20, and blood pressure 102/64 mmHg. Physical examination was unremarkable, and no laboratory studies were performed. The diagnosis of gastroenteritis was made, and the patient was instructed to stop taking the previously prescribed medications. The patient presented ambulatory to our ED 72 hours later still complaining of persistent nonbloody diarrhea without vomiting. He was able to take clear liquids but had had no solid food for the prior 5 days. He was taking Immodium@ prescribed per phone by his family doctor. Vital signs were temperature 38°C pulse 116, respirations 24, and blood pressure 1lo/70 mmHg. Physical examination was unremarkable except for the tachycardia and diffuse abdominal tenderness. Bowel sounds were present and there was no guarding, rebound or costovertebral angle tenderness. Rectal exam was positive for trace blood. An IV of DS/Lactated Ringers was started and the patient given 1000 cc over 30 minutes and then an additional 250 cc in the next hour. Additional laboratory studies were as follows: WBC 5,400/mm3 (segs 49, bands 13, lymphocytes 24, monocytes 13, and eosinophils l), hemoglobin 15.7 gm/dL, hematocrit 44%, sodium 134 mEq/L, potassium 3.2 mEq/L, chloride 96 mEq/L, bicarbonate 28.3 mEq/L, and glucose 128 mg%. The patient was given 40 mEq KC1 orally and discharged after 3 hours and 45 minutes in the department with a diagnosis of gastroenteritis and instructed to follow up with his family doctor in 48 hours. The patient was unable to produce a stool sample while in the depart ment. Five hours after discharge the patient became
0 Abstract - A 29-year-old white male with a recent history of gastroenteritis sustained a cardiac arrest at home. He was found to be in ventricular fibrillation and could not be resuscitated. Pathologic findings included focal aggregates of histiocytes, lymphocytes and occasional neutrophils in the myocardium as well as inilammatory changes in the colon, liver, and spleen. Blood cultures were positive for Salmonelhz heidelberg. The patient was seen 3 times by emergency departments prior to his demise. Death from Salmonella is rare except when associated with septicemia. The severity of iBness and prognosis are often related to the site of infection and underlying disease processes. 0 Keywords - myocarditis; salmonella septicemia; Salmonelk heidelberg; gastroenteritis; cardiac arrest
INTRODUCTION
Salmonellosis is primarily a disease of children. The largest number of outbreaks occur because of mishandling of food. Poultry, meat, eggs, and dairy products have been the most important vehicles of transmission, although person-to-person and pet-to-person exposures are also significant. Most cases of salmonella gastroenteritis are self-limited. We report a fatal case of salmonella septicemia associated with gastroenteritis and myocarditis . CASE REPORT
A 29-year-old white male presented to a small community emergency department (ED) complaining of low back pain after lifting 80 pounds at home. He was diagnosed as a low back strain and started on Flexerilm and ibuprofen and placed off work for 48 hours. He
RECEIVED: 28
MD, FACEP,*
June 1989;
ACCEPTED: 22
September 1989
0736-4679190 $3.00 + .OO 295
