Multilevel lumbar spine infection due to poor dentition in an immunocompetent adult: a case report

Abstract

Background: Although spinal infections have been reported following dental procedures, development of a spinal infection attributed to poor dentition without a history of a dental procedure in an immunocompetent adult has not been previously reported. Here we provide a case report of a multilevel lumbar spine infection that developed in an immunocompetent adult with poor dentition.

Case presentation: A 63-year-old white male man with past medical history of hypertension presented to a hospital emergency department with a 4-month history of progressively worsening low back pain. A musculoskeletal examination demonstrated diffuse tenderness in his lumbar spine area and the results of a neurological examination were within normal limits. Computed tomography and magnetic resonance imaging of his lumbar spine demonstrated a prevertebral and presacral fluid collection ventral to the L4 to L5 and L5 to S1 interspaces. Blood cultures grew pan-sensitive Streptococcus intermedius in four of four bottles within 45 hours. Using computed tomography guidance, three core biopsies of the L4 to L5 interspace were taken and subsequent cultures were positive for Streptococcus intermedius. He reported that his last episode of dental care occurred more than 20 years ago and a dental panoramic radiograph demonstrated significant necrotic dentition. Ten teeth were extracted and the necrotic dentition was assumed to be the most likely source of infection. On hospital dismissal, he received a 12-week course of intravenously administered ceftriaxone followed by an 8-week course of orally administered cefadroxil pending repeat imaging.

Conclusions: This case report demonstrates the importance of determining the source of infection in a patient with a spontaneous spinal infection. Even in the absence of a recent dental procedure, dentition should be considered a possible source of infection in an immunocompetent patient who presents with a spontaneous spinal infection.

Keywords: Dentition; Epidural abscess; Immunocompetent; Lumbar spine.

Fig. 1

Initial lumbar spine magnetic resonance imaging performed without gadolinium demonstrated extensive abnormal T2 hyperintensity of the L5 interspace (a and b, sagittal fat-saturated T2-weighted image and axial T2-weighted image at the L5 interspace) indicating discitis. A large multilobulated fluid collection was contiguous with the infected interspace indicating an abscess (arrow, a and b). Follow-up lumbar spine magnetic resonance imaging performed with gadolinium demonstrated extensive abnormal enhancement (c and d, post-gadolinium sagittal T1-weighted with fat saturation and axial T1-weighted images, respectively) and T2 hyperintensity (e and f, sagittal T2-weighted with fat saturation and axial T2-weighted at the L4 interspace) involving the L3 to L4, L4 to L5, and L5 to S1 interspaces. There is abnormal paraspinal and epidural enhancing phlegmon with a focal ventral epidural abscess (arrow, c and e) emanating from the L4 to L5 interspace. An additional abscess involving the left posterolateral soft tissues (arrow, d and f) was targeted during biopsy and yielded 10 cc of fluid

Fig. 2

Dental panoramic radiograph demonstrated multiple missing teeth and dental amalgam due to prior dental caries. Most notably there were numerous erosions of the crowns (arrows) of many teeth with a mottled appearance of the residual root and periapical lucencies (arrowhead). These carious nonrestorable teeth were later extracted