Thoracic spondylodiscitis secondary to Klebsiella oxytoca urosepsis-a case report

Abstract

Spondylodiscitis is an insidious and infectious pathology of the spinal column attributable to pathogenic micro-organisms and occurs in a variety of contexts. These micro-organisms can be inoculated surgically or can metastasise from distant sites of infection. Klebsiella species are important community-acquired and nosocomial pathogens but are uncommonly implicated in spinal infection. Klebsiella oxytoca is more obscure than its generic relative Klebsiella pneumoniae and has only five times previously been reported in spondylodiscitis. It possesses the ability to acquire inducible and recombinant antibiotic resistance, especially in the hospital setting. We describe the case of an elderly man with complex urology and this rare sequela due to incomplete treatment of a K. oxytoca urinary infection. He developed sepsis that recurred after incomplete antibiosis and seeded to his thoracic spine causing overt spondylodiscitis. The infection fulminated and his spinal lesion deteriorated into acute spinal cord compression with neurological compromise, requiring surgical decompression, fixation and long-term antibiotics. This is a sixth documented instance of a rare spinal bacterial infection. We describe the relevant microbiology and pathology, neurosurgical considerations, and general practice points for clinicians. Our report is a novel illustration of the potentially catastrophic consequences of inadequately treated urosepsis and is a stark reminder of the importance of antimicrobial stewardship.

Keywords: Klebsiella oxytoca; Spondylodiscitis; case report; extradural abscess; osteomyelitis.

Figure 1

Sagittal CT of our patient’s thoracic spine at his initial presentation (A) and repeat CT (B) and MRI (C,D) following his representation 1 month later. (A) Bone-windowed CT demonstrating diffuse spondylosis, but no evidence of fracture, misalignment or infection; (B) bone-windowed CT, showing a destructive, erosive process of the T5 and T6 vertebral bodies. The T5 vertebral body has lost 90% of its height. There is a purported fracture line visible through the T5 spinous process; (C) T2-weighted MRI sequence; (D) T1-weighted gadolinium-enhanced sagittal MRI sequence. (C) and (D) demonstrate T5/6 spondylodiscitis and cord deformation. The white arrow in (C) indicates a focus of myelomalacia. Note that the focus of T2-hyperintensity at T10 in (C) is representative of a vertebral haemangioma. The vertebral levels of the thoracic spine are labelled in all images. CT, computed tomography; MRI, magnetic resonance imaging.

Figure 2

MRI of our patient’s thoracic spine following his in-hospital neurological deterioration (3 weeks following representation). (A) T2-weighted sagittal MRI sequence; (B) T1-weighted gadolinium-enhanced sagittal MRI sequence; (C) T2-weighted axial MRI sequence in the plane of the yellow line depicted in (B); (D) T1-weighted gadolinium-enhanced axial MRI sequence in the same plane as (C). (A) and (B) demonstrate interval deterioration of the spinal column and canal morphology, with worsened cord deformation. (C) and (D) demonstrate a cross-section of a right-sided posterior extradural abscess displacing the cord to the left. This is indicated by the white arrows. The vertebral levels of the thoracic spine are labelled. MRI, magnetic resonance imaging.

Figure 3

Post-operative plain films demonstrating the thoracic screw-rod fixation construct. (A) A lateral radiograph; (B) an anteroposterior radiograph. The vertebral levels are labelled where possible.

Figure 4

Contrast-enhanced CT of the prostate. (A) Axial view; (B) sagittal view; (C) coronal view. These images demonstrate gross prostatic enlargement and unilateral coarse calcifications (indicated by white arrows), potentially indicative of chronic prostatitis. Labels B and P denote the bladder and prostate, respectively. CT, computed tomography.