CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
e6
AFRICA
For his back pain he consulted a neurosurgeon and a magnetic
resonance imaging (MRI) study of the lumber spine showed
oedematous change of the end plate around the L5–S1 discs,
compatible with a diagnosis of acute infective spondylodiscitis
(Fig. 2). The MRI also showed sclerotic changes at the L4–L5
vertebral end plates, compatible with a late phase of spondy-
lodiscitis. The antibiotic theraphy continued with pencillin and
rifampicin.
Blood cultures were negative one week after treatment and his
body temperature was normal. The back pain was resolved after
six weeks of theraphy. Every week, TTE was performed to moni-
tor the vegetation. After eight weeks of theraphy, no vegetation or
other complications were detected. He was discharged with oral
antibiotics eight weeks after the initiaiton of antibiotic treatment.
At the six-month follow up, TEE and MRI were performed.
The MRI study showed sclerotic changes at L4–L5 and L5–S1
vertebral end plates, compatible with a late phase of spondylo-
discitis. TEE demonstrated moderate paravavular aortic regurgi-
tation with an eccentric jet, suggestive of paravalvular leak.
Surgery was not considered as the patient was asymptomatic
and elderly. The patient was discharged with the recommenda-
tion of regular clinical and echocardiographic follow up.
Discussion
Infective endocarditis is a rare and severe complication after
valve replacement and it has been reported to occur in 1 to 6%
of cases with valve prostheses. It accounts for 10 to 30% of
all cases of IE and can occur with a 0.3 to 1.2% incidence per
patient-year.
1
TEE is mandatory in the assesment of prosthetic valve endo-
carditis (PVE) because of its better sensitivity and specificity.
However the value of TTE and TEE is lower in the diagnosis of
PVE than with native valvular endocarditis.
1
The association between spondylodiscitis and endocarditis
was first reported 45 years ago by Sèze
et al.
4
Spondylodiscitis
is rarely observed in association with IE and has been described
in case reports, with the frequency of this association varying
from 0.6 to 2.2%.
3
The pathogenesis of this association relies on haematogenous
dissemination of the infective agent or vertebral deposition
of arterial emboli which may contain bacteria and immune
complexes.
3
The most common clinical picture is muskuloskele-
tal symptoms preceding the diagnosis of endocarditis. Localised
pain is always present and the lumbar region is most commonly
involved but it has also been reported on the cervical spine.
2
Morelli
et al
.
3
reviewed the case records of 30 patients with
IE in their department from 1991 to 1998. Among them, three
were affected (10%) with spondylodiscitis. Le Moal
et al
.
2
also
examined the 95 definite cases of IE and spondylodiscitis was
present in 14 (15%) cases. The mean age was 69.1
±
13.6 years
and the male-to-female ratio was 8:6. Back pain was reported
in all cases and a predisposing heart disease was found in nine
cases. Endocarditis predominantly affected the aortic valve, as
in our case.
A diagnosis of spondylodiscitis can be confirmed by bone
scintigraphy, computed tomography scan or MRI. MRI is the
most sensitive technique in the acute phase.
4
Non-homogenous
hypodensity of the intervertebral disc with osteolytic vertebral
areas, bone erosion of the vertebral body and variable degrees of
bone sclerosis can be detected. One can also see hypo-intensity
of the disc and vertebral body in T1 weighted images, with non-
homogenous signs of the vertebral body and hyperintensity on
T2 weighted images.
4
Epistaxis can occur due to local causes such as irritation,
trauma and septal abnormalities, as well as systemic causes such
as uncontrolled hypertension, blood dyscrasias and arteriosclero-
sis. The treatment of epistaxis can be achieved by nasal packing
or cauterisation. If anterior packing fails to control the epistaxis,
posterior nasal packing is done. Currently, most nasal packing
materials are coated with antibiotics. Petroleum jelly gauze
coated with antibiotics is frequently used in clinical practice.
5
In the literature search, we found two cases reported. In
1994 one report mentioned
Staphylococcus aureus
endocarditis
involving a prosthetic aortic valve subsequent to anterior nasal
packing, and in 2006 another report of
Staphylococcus aureus
endocarditis involving a native mitral valve.
5,6
The last updated guidelines of IE by the American Heart
Association and the European Society of Cardiology recommend
antibiotic prophylaxis only after dental procedures in high-risk
patients. Our patient developed endocarditis despite nasal pack-
Fig. 1. TEE image showing a vegetation of 0.7
×
0.3 cm
in diameter on the LVOT side of the bioprosthetic non-
coronary aortic cusp (arrow).
Fig. 2. MRI of the lumbar spine with typical signs of acute
spondylodiscitis, hypodensity of the vertebrae between
L5 and S1 in a T1-weighted image and hyperdensity in a
T2-weighted image (arrow).
