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Lumbar Pain In A Neutropenic Patient

 Jiménez Martín A*, Ricardo Mena-Bernal Escobar. José Lara Bullón

* Orthopaedic Surgery and Traumatology Service. Hospital Nuestra Señora de Valme. Seville.

Address for Correspondence:  

Antonio Jiménez Martin.
Urb. Al-Alba, c/Brisa, nº 10, D. CP 41020, Sevilla. Spain.
Mobile: 609012308


We present the clinical review of a patient of 20 years, diagnosed with Acute Lymphoblastic Leukaemia B, FAB L2, treated by means of Pethema-LAL-RI protocol, who developed a spondylodiscitis. We review the analytical, histological and image studies made.
Objective: to demonstrate the existence of spondylodiscitis caused by Escherichia coli in neutropaenic patients associated to acute lymphoblastic leukaemia.
Methods: We made clinical reviews over three years, analysing the CAT, Rx, NMR, gammagraphy and microbiological and histopathological studies.
Results: Spondylodiscitis caused by E.coli in a neutropaenic patient with acute lymphoblastic leukaemia. Antibiotic and antineoplastic treatments and orthopaedic treatment by means of a Boston brace were administered with favourable results.
Conclusions: In patients with neutropaenia caused by anti-leukaemic chemotherapy, vertebral involvement is exceptional, especially by Escherichia coli (6.6% of non-tuberculous bacterial spondylodiscitis), since the few cases described are of fungal origin, emphasising Candida, Scedosporium, Blastoschizomyces or Aspergillus. We consider the great importance of the current states of immunosuppression and their vertebral repercussion. An early diagnosis, correct antibiotic, antineoplastic and orthopaedic treatments allows the control of this disease, reserving surgical treatment for the worst cases.

J.Orthopaedics 2008;5(3)e1

Keywords:spondylodiscitis, Escherichia coli, acute lymphoblastic leukaemia, Boston brace.

Due to the increase of immunosuppressive states unusual pathological processes arise. In patients with neutropaenia caused by anti-leukaemic chemotherapy, vertebral involvement is exceptional, especially by Escherichia coli, since the few cases described are of fungal origin.

Case Report :

A 20 year old man was admitted in May 2002 for asthenia, haematomas and micro-adenopathies of 40 days evolution. Haemogram: 11,100 leukocytes/ mm3, 70% of blast cells of lymphoid nature. Bone marrow aspiration: massive infiltration of lymphoid blasts, L2 morphology, hyperploidy of 50 chromosomes in mosaic (complex karyotype), t (9.22) negative, bcr/abl negative: Acute Lymphoblastic Leukaemia Pre-B (F.A.B. of L2). Corticoid therapy by means of Hickman type tunnelled central catheter for inducer treatment according to Pethema-LAL-RI protocol.

After 6 months of remission he was readmitted for a fever of 40ºC and lumbalgia. A haemogram was made with 3,300 leukocytes/mm3, hypocellular marrow aspirate, thoracic radiology, abdominal echography, NMR of lumbar spine, gammagraphy, thick film, Rose Bengal normal. Blood cultures: Escherichia coli sensitive to imipenem, ineffective against persistent fever, necessitating levofloxacin.

CAT: appearance of abscessed lesions in both psoas. CAT guided fine needle aspirate (FNA): haemopurulent material with Escherichia coli. Change of the treatment to cefotaxime and amikacine, with favourable evolution until ambulatory discharge with ceftriaxone.

Two months later in the CAT the abscesses persist in the psoas of 1.2 cm in the right side and of 2.6 cm in the left side, with peripheral captation halo, marked rarefaction in the vertebral bodies from L1 to S1 and involvement of discs. (See Figure 1).

Figure 1. CAT: abscesses in the psoas of 1.2 cm in the right side and 2.6 cm in the left side, with peripheral captation halo, marked rarefaction in the vertebral bodies from L1 to S1 and involvement of the discs.

Results :

Spondylodiscitis caused by Escherichia Coli.

Two months later a new CAT was made: diminution of the space between L1-L2 and L3-L4, hypodense areas, probable exostosis, spondylolisthesis L3-L4 grade I and pattern of osteopenia. Rose Bengal and Salmonella agglutination negative. Thoracolumbar scoliotic posture, rectification of the thoracic kyphosis. Lumbar kyphosis, good mobility, conserved osteotendinous reflexes, bilaterally negative Lasègue and lumbar pain. Boston brace is prescribed continuing with oral mercaptopurine, methotrexate, ondansetron, ceftriaxone and levofloxacin.

A month later, negative Gammagraphy with Technetium 99 and FNA, antibiotics being suspended.

A year later suffers viral oesophagitis treated with foscarnet and Pneumocystis carinii pneumonia treated with cotrimoxazole.  

The patient is treated by Rehabilitation, a riser wedge is prescribed and in March 2004, on obtaining normal densitometry, ESR and CRP, the removal of the brace is decided. Since then he has improved remarkably and at the moment he is asymptomatic.


 The increase in patients with neutropaenia (neutrophils <500/mm3) due to chemotherapy is more and more frequent (1), highlighting agents involved in spondylodiscitis such as Candida, Scedosporium apiospermum (2), Aspergillus (3-6)or Blastoschizomyces capitatus (7;8). In fact, Park, considers that oncology patients, neutropaenic through chemotherapy, with spondylodiscitis, as is our clinical case, would be commonly affected by Candida and Aspergillus (9). In fact Aspergillus even arises in spondylodiscitis of bronchitics treated with corticoids (10). With respect to the bacterial aetiology we found a series of 1780 cases of non-tuberculous Spondylodiscitis (NTS) between 1936 and 1992 (2).
S.aureus causes more than 50% of the NTS.
Streptococcus produces approximately 10% of the NTS.

E.coli follows causing 10-30% (11;12)of the NTS, or in 6.6% of the cases (13). The portal of entry can be digestive, urinary(14;15), biliary, cutaneous or pulmonary (hospitals). Spread by blood. Spondylodiscitis has been described after prostate biopsy (16), spinal surgery (17), diabetes or old vertebral fractures (18). The Enterobacteria are emphasised in the aged and Pseudomonas in iatrogenics and drug addicts. In a study made in 1999 on 30 patients with spontaneous spondylodiscitis focal endocarditis was found in 43.3%, tuberculosis in 23.3%, urinary infection in 13.3%, focal bacteraemia in 6.7% and without focus in 6.7%, The main aetiologic organisms are considered to be Streptococcus in 33.3% of the cases, Mycobacterium tuberculosis in 20%, Staphylococcus spp. in 16.6%, Escherichia coli in 6.6% and Pseudomonas aeruginosa in 6.6% with lumbar involvement in 60% of the cases, dorsal in 26.6% and cervical in 13.3%, which are examples of the main pathogeneses, aetiologies and locations (13).

Among the clinical manifestations are emphasised fever, vertebral rigidity, radiculalgias, myositis of the psoas (19) or exceptionally tetraplegia after manipulation of urinary tract manipulations (20). In fact, in a study with 25 patients with spondylitis, in spite of the neurological complications, the results were favourable and the prognosis was positive (21;22). Notable sequelae are recurrences, kyphosis and neurological complications (23).

Regarding the diagnosis, it will be the clinical picture, together with x-ray (24), CAT(25) or NMR, gammagraphy with Technetium 99 or Gallium-67 citrate (26), FNA or biopsies. Inflammation of the normal bone marrow, impingement of the disc space, abnormality of paraspinal soft tissues and cortical erosions(13) have been described in NMR. In fact, Ponte and McDonald (15), described septic discitis in a woman of 77 years, confirmed by NMR, and the FNA served to determine the agent and its antibiotic treatment. The intradisc inoculation of bacterial suspensions in dogs would cause vertebral fusions at 8 weeks, with the most severe clinical picture being seen with Staphylococcus and the least with Pseudomonas (27). It would entail vascular proliferation, myxoid degeneration and necrosis of the disc tissue causing a chronic osteomyelitis in the proximities (28).

The empirical treatment would be the combinations of cloxacillin or cefotaxime plus metronidazole or clindamycin; or beta-lactamics plus aminoglycoside (gentamicin), or the combination of beta-lactamic with fluorinated quinolones (ciprofloxacin) or the use of aztreonam in monotherapy. Also the necessity of the drainage of the abscesses in the psoas associated to antibiotic treatment has been evaluated (18 ;29;30).

In 2003 the intradisc application of the combination of gentamicin, cefazolin and clindamycin in the presence of iohexol was considered for preventing discitis after diagnostic procedures (31). Finally, corticoid therapy has been associated to a greater risk of osteonecrosis (32) and chemotherapy to growth, intellect, endocrine, cardiac and ocular alterations, which complicates the clinical picture of these patients still further (33).

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This is a peer reviewed paper 

Please cite as : Jiménez Martín A : Lumbar Pain In A Neutropenic Patient

J.Orthopaedics 2008;5(3)e1





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