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Hereditary haemorrhagic telangiectasia (HHT) leads to arteriovenous malformations (AVM) that increase the risk of haemorrhage and cause right-left shunting bypassing the reticuloendothelial system increasing the risk for recurrent infections. A 60+ year old male patient with HHT type 1 (status post six pulmonary AVM coiled embolisations) with epistaxis presented with intractable back pain, methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia and spinal MRI revealing spondylodiskitis and L4-L5 epidural phlegmon. He has an extensive history of deep-seated infections including two prior spinal infections, two joint infections and one muscular abscess-all with MSSA. The patient was treated with 6 weeks of intravenous nafcillin with symptom resolution. Infectious disease prescribed cefalexin 500 mg daily for suppression of infection recurrence considering his extensive deep-seated infection history and multiple risk factors. This case raises important questions about preventative antimicrobial management of high-risk patients with HHT, which is a grey area in current international HHT guidelines., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Spinal infection comprises pyogenic and non-pyogenic spondylodiscitis. This condition may manifest with non-specific clinical symptoms, elevated infective parameters and imaging findings that are difficult to distinguish. The cornerstone of a definitive diagnosis and subsequent successful treatment lies in tissue analysis through culture and histopathological studies. In this context, we present a case of Salmonella pyogenic spondylodiscitis affecting the C5/C6 vertebrae, complicated by Salmonella bacteraemia and characterised by mechanical neck pain that curtails daily activities and overall functioning, although without neurological deficits. The uniqueness of this case stems from its occurrence in an immunocompetent individual from a non-endemic area, with no identifiable sources of Salmonella infection or preceding gastrointestinal symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient's discitis resolved with an M. xenopi -directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

This report describes a case of a spondylodiscitis in an immunocompromised patient with an HIV infection caused by Propionibacterium acnes The patient was admitted to hospital with a sudden loss of motor function and sensation in both of the patient's legs. A biopsy taken during the first debridement operation proved to be negative for Mycobacterium tuberculosis DNA and growth, but was positive for the growth of P. acnes Following a course of antibiotic therapy and the aforementioned debridement, the patient was moved to a specialised clinic for physical therapy. The patient's condition quickly deteriorated, and the patient once again required extensive debridement. Repeated spinal surgery, antibiotics for 12 weeks and subsequent rehabilitation resulted in almost complete recovery of sensorimotor limb function., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 57-year-old man was admitted to our department reporting persistent low back and leg pain; this patient had undergone chemotherapy 1 year earlier for acute myeloid leukaemia (AML). During chemotherapy, he exhibited bilateral pneumonia due to Candida tropicalis , which was treated by specific antibiotic therapy, and septicaemia by Enterococcus faecalis MRI showed the presence of spondylodiscitis. A CT-guided needle biopsy was performed and the culture from the excised material tested positive for C. tropicalis We report a rare case of spondylodiscitis by C. tropicalis in a patient treated for AML, which, in turn, was followed by sepsis from E. faecalis and C. tropicalis Without adequate treatment, the disease is progressive, and leads to vertebral destruction with secondary kyphosis and neural or spinal cord compression. Although MRI has high sensitivity in the diagnosis of spondylodiscitis, open or needle biopsy allows to identify the aetiology., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Proteus mirabilis is a gram-negative bacterium frequently considered a pathogen of the urinary tract. Septic discitis and septic pulmonary emboli resulting from P. mirabilis urosepsis is a rare phenomenon. We report a 39-year-old woman who was admitted to our hospital with a complicated urinary tract infection resulting in bacteraemia, septic discitis, paraspinal abscesses and septic emboli. She was treated with a prolonged course of intravenous antibiotics resulting in the clinical resolution of her symptoms. Based on our PubMed search of the English literature, this is only the second reported case of septic discitis caused by P. mirabilis This paper illustrates that physicians should include septic discitis caused by P. mirabilis as a possible aetiology of low back pain in patients with active or recently treated urinary tract infection. Additionally, this article discusses the pathogenesis and other complications resulting from P. mirabilis bacteraemia., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Lumbar spondylodiscitis due to radiation proctitis-related fistula is a rare finding in the literature. After having isolated Actinomyces odontolyticus , a rare finding in the osteomuscular system, we present one of such cases.A 75-year-old patient with a history of rectum adenocarcinoma, submitted to surgery and radiotherapy, presented himself in our emergency department with a 3-month history of lumbar pain radiating to both legs. Physical examination was compatible with cauda equina syndrome and subsequent investigation revealed L4-L5 spondylodiscitis. Despite a 6-month antibiotic therapy regimen, the symptoms recurred. Intravertebral disc biopsy revealed A. odontolyticus and directed antibiotic therapy was started. However, the symptoms recurred after a new 6-month antibiotic therapy regimen, this time with rectal purulent drainage. Additional study revealed two rectal fistulae. It was assumed those were caused by radiation proctitis and constituted the primary cause of spondylodiscitis. Laminectomy was performed with a satisfactory clinical response., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

While the incidence of spondylodiscitis is rising because of longer life expectancy and the increasing use of immunosuppressant drug, indwelling devices and spinal surgeries, the fungal aetiology remains rare, sometimes affecting intravenous drug users. Candida spondylodiscitis is an extremely rare complication post aortic aneurysm repair. It is potentially fatal due to the risk of aneurysm rupture and septic complications. The growing problem of systemic diseases caused by Candida species reflects the enormous increase of patients at risk. The treatment of this complicated entity is challenging and often requiring a multidisciplinary team. We reported the rare case of Candida spondylodiscitis contiguous to infected aortic aneurysm in a 74-year-old male intravenous drug user, to the extent which the vertebral body bony destruction progressed to need one-stage posterior and anterior spinal fusion surgery with curettage. Our surgical intervention combined with prolonged course of antifungal therapy could successfully eradicate the infection and resolve the neurological deficits., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Fusobacterium nucleatum is part of the commensal flora of the oral cavity, frequently associated with periodontal infections. We describe the case of a 49-year-old woman, on immunsuppressive therapy for multiple sclerosis, who presented with a 3-month history of debilitating back pain. She had a recent episode of periodontitis, and was under regular dental review. Her MRI scan demonstrated findings suggestive of L2-L3 spondylodiscitis. Her CT-guided biopsy yielded negative cultures and the patient failed two courses of empirical antibiotic treatment. With clinical and radiological disease progression, she underwent a percutaneous disc washout and biopsy, which subsequently grew F. nucleatum Treatment with clindamycin and metronidazole was commenced orally for 6 weeks. She improved gradually, and at 1 year follow-up was asymptomatic. The diagnosis of spondylodiscitis caused by F. nucleatum is challenging. The perseverance on identification by surgical biopsy, minimally invasive washout and targeted antibiotics are the mainstay of effective treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Vertebral osteomyelitis is an infection of the vertebrae that can lead to spinal degeneration, most commonly caused by Staphylococcus aureus Here, we report an unusual case of pyogenic osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a 61-year-old postmenopausal woman. The patient presented with a 2-week history of worsening lower back pain and fever and a recent episode of cystitis following re-engagement of sexual activity. Imaging revealed a deterioration of vertebrae discs and spinal canal stenosis at the L3-L4 levels with a formation of abscess in the right psoas muscle. Needle aspiration of the abscess identified G. vaginalis and S. parasanguinis and the patient was successfully treated with a 6-week course of ceftriaxone and metronidazole. This case describes an unusual coinfection of two pathogens that normally reside in the urogenital tract and oral cavity, respectively, and highlights the risk posed when these organisms breach the body's normal barriers., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 44-year-old male person with tetraplegia (C-5 AIS-A (American Spinal Cord Injury Association Standard Neurological Classification of Spinal Cord Injury Impairment Scale)) developed urinary tract infection and received appropriate antibiotic. Subsequently, he started sweating and shivering when he was sitting up; these symptoms resolved while lying on his back. Autonomic dysreflexia triggered by truncal movements continued to occur for 3 months. CT of the spine showed L5-S1 discitis. MRI of the spine showed diffuse marrow oedema in L5 and S1 vertebrae and a large abscess at L5/S1 level. Blood culture yielded Serratia marcescens sensitive to meropenem. Meropenem followed by ertapenem was given for 12 weeks. After 11 months, MRI showed resolution of discitis and epidural collection. The patient was able to sit up for 9 hours without developing autonomic dysreflexia. If a person with cervical spinal cord injury develops posture-related autonomic dysreflexia (eg, in sitting position, lying on sides or while hoisted), disco-vertebral pathology should be suspected., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 76-year-old woman presented following two episodes of unexplained falls at home. Blood cultures were positive for Bacteroides fragilis and following investigations she was diagnosed with L4/L5 spondylodiscitis confirmed on spine MRI. She was initially treated with intravenous metronidazole and flucloxacillin prior to switching to ceftriaxone with good results. No primary cause of B. fragilis bacteraemia was found in this case. B. fragilis is a rare cause of spondylodiscitis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 54-year-old woman presented to a Sports Physician with a 4-year history of haemochromatosis, and she had a medical history that included a congenital spondylolisthesis resulting in a fusion of L4-S1 at age 16 years, episodic mechanical low back pain and an absence of other significant musculoskeletal symptoms. On presentation, she reported 18 months of severe low back pain that started after a scuba diving trip. After the onset of this low back pain, she developed gastrointestinal symptoms from Salmonella The gastrointestinal symptoms improved with a course of antibiotics, but the back pain persisted in spite of analgesics, non-steroidal anti-inflammatories and several attempts at different conservative management. CT imaging ordered by the Sports Physician demonstrated an erosive spondylodiscitis of L2/3 that was not present on initial investigations. However, even in the presence of significant bony changes, the patient was successfully treated with targeted conservative therapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The authors present a case involving an 80-year-old man with infectious T10/T11 discitis on the background of a recent Clostridium perfringens bacteraemia. This case report describes a case of probable C. perfringens discitis as further investigations failed to identify any causative agents. He was treated with intravenous piperacillin/tazobactam to good effect, achieving favourable clinical outcome. Diagnosis of discitis/osteomyelitis can often be delayed and mismanaged due to its non-specific presentations. Timing of empirical antimicrobial therapy requires careful consideration based on haemodynamic stability and neurological function to maximise microbiological yield., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Endarteritis is a major complication in patients with patent ductus arteriosus, causing significant morbidity and mortality. We report an adult patient with asymptomatic patent ductus arteriosus and endarteritis involving the main pulmonary artery and secondary infective spondylodiscitis at the L5-S1 intervertebral disc caused by Abiotrophia defectiva A. defectiva , commonly referred to as nutritionally variant streptococci, cannot be identified easily by conventional blood culture techniques from clinical specimens. Its isolation was confirmed by 16S ribosomal RNA sequencing. The patient was successfully managed with a combination of penicillin G and gentamicin, pending surgical repair of the patent ductus arteriosus., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Extraintestinal Salmonella infection involving the thoracic spine is very rare. It commonly presents with non-specific chronic back pain and can occur with no gastrointestinal manifestation. Blood test results and imaging findings are often indistinguishable from more common chronic spine infections such as spine tuberculosis. Culture studies remain the key to establishing a definitive diagnosis and subsequently successful treatment. We report a case in which a patient presented with symptoms and signs suggestive of spine tuberculosis, yet the culture examination revealed otherwise., (2016 BMJ Publishing Group Ltd.)

A 42-year-old woman presented to our hospital with weeks of worsening pain around her lower ribs. Preceding this, she was managed in primary care with anti-inflammatory drugs and physiotherapy for presumed costochondritis. Assessment in accident and emergency suggested a tender right upper quadrant with fever and neutrophilia. A surgical review of the patient was requested to assess for cholecystitis or delayed pancreatitis. On direct questioning, the patient's back pain was the predominating symptom with no neurological deficit. To assess for delayed pancreatitis, CT imaging was obtained, demonstrating unremarkable intra-abdominal organs. There was also the incidental finding of thickened prevertebral soft tissues anterior to T9 and T10 vertebrae, with vertebral endplate irregularity locally. Subsequent MRI demonstrated typical appearances of infective spondylodiscitis at this level. The patient made a good recovery with intravenous antimicrobials. This case highlights how vertebrodiscitis can present insidiously and unexpectedly, manifesting as abdominal pain., (2016 BMJ Publishing Group Ltd.)

Spondylodiscitis, which is most commonly caused by Staphylococcus aureus, is an uncommon infection in adults. The diagnosis of spondylodiscitis is often delayed by its vague and non-specific presentations. As part of the normal flora in human mouth and sinuses, Streptococcus mitis is a very rare cause of spondylodiscitis. We report a case of thoracic spondylodiscitis caused by S. mitis in a patient with chronic sinusitis. The patient atypically presented with a sharp chest pain that radiated to the back and the imaging studies were initially negative. He failed outpatient pain management and the diagnosis of spondylodiscitis was confirmed by bone biopsy 6 weeks later. Treatment with antibiotics completely alleviated the pain. Increased awareness and a high index of suspicion are essential for early diagnosis of spondylodiscitis with an atypical presentation., (2014 BMJ Publishing Group Ltd.)

A 61-year-old man was admitted with a history of right upper quadrant and left iliac fossa pain and raised inflammatory markers. Initial investigations, including contrast-enhanced CT scan of the abdomen and pelvis, were reported as normal. Following readmission 2 months later with thoracolumbar back pain and recurrent fevers, an MRI showed T11/12 discitis and an adjacent mycotic aneurysm of the aorta. CT angiogram confirmed an 8 cm mycotic aneurysm. A second, more distal aneurysm was found located at the left common femoral artery. The aortic aneurysm was treated by antegrade stenting. The left common femoral artery aneurysm was excised. The patient was also treated with antibiotics. He made a good recovery and was well 8 months later apart from mild residual thoracolumbar spinal pain. To date, he has been followed up for 1 year and remains asymptomatic.

We describe the case of a 3-year-old girl with a 15-day clinical history of lower back pain. We diagnosed a spondylodiscitis of vertebral bodies L5-S1 caused by Salmonella species group B that totally recovered with appropriate antibiotic therapy. Spondylodiscitis in children is a rare condition and Salmonella infection is one of the rarest aetiology. A high index of suspicion is needed for prompt diagnosis to ensure better long-term outcome. Microbiological diagnosis is essential for the appropriate choice of antibiotic treatment.

A 70-year-old Greek lady presented with fever, arthralgias of knees, cervical and lumbar pain during the last month. On clinical examination the patient was found to have tenderness of the cervical and the lumbar spine with great motion restriction. The blood tests revealed high erythrocyte sedimentation rate and C-reactive protein, abnormal liver function tests and a positive rheumatoid factor. Serological test for Brucella was positive while cervical MRI revealed epidural abscess and spondylodiscitis. Conservative treatment with streptomycin (it was substituted by rifampicin after the third week) and doxycyclin for 4 months significantly improved her symptoms. The frequency as well as the diagnosis and management of this manifestation are discussed.

Isolated native tricuspid valve endocarditis (TVE) in non-intravenous drug users is a very rare condition. We describe an unusual presentation of Enterococcus faecalis TVE associated with spondylodiscitis, positive cytoplasmic antineutrophil cytoplasmic antibodies and antiproteinase-3 antibodies vasculitic rash in an otherwise healthy patient with no history of intravenous drug use or underlying cardiac abnormalities. A high index of clinical suspicion is required in patients presenting with unusual features and pyrexia of unknown origin. Simple tests including serial blood cultures and echocardiography may help to establish the correct diagnosis and commence appropriate treatment.