Introduction: Infective endocarditis is related to a wide range of complications including septic embolizations such as spondylodiscitis. Risk factors associated with systemic include left-sided vegetation, large vegetation size, microbiology, age, diabetes, etc (1). Endocarditis masked by such complications might be difficult to diagnose and lead to invalid and late treatment which in turn results in increased morbidity and mortality (2).
Case report: During one year period we observed three cases of endocarditis complicated with severe form of spondylodiscitis leading to immobilization and prolonged rehabilitation. Two out of three patients underwent surgical procedure. First patient, a 66-year-old female was admitted to our department due to E. faecalis aortic valve endocarditis and consequently moderate aortic regurgitation (Figure 1 A). Few years preceding the initial presentation, patient was hospitalized in our institution because of non-ischemic cardiomyopathy and implantable cardioverter defibrillator (ICD) was implanted for primary prevention of sudden cardiac death. During routine follow-up patient complained about general weakness, weight loss, fever and chills and limited walking ability caused by lumbar back pain. On echocardiogram, ICD lead-associated thrombus was described, although patient was already receiving oral anticoagulant therapy for atrial fibrillation. Three months after that, patient was hospitalized once again and endocarditis was confirmed. Clinical presentation was complicated not only with spondylodiscitis and paraparesis but also with septic emboli to the right kidney which was initially believed to be tumor. Following PET CT and MR scan, infection of ICD electrodes together with L3/L4 spondylodiscitis were revealed (Figure 1 B, C). Second patient, a 48-year-old male was evaluated because of recurrent fever, hypergammaglobulinemia and sacral pain. Multiple myeloma was suspected and investigated to be the cause of patient’s disability, when blood cultures, along with echocardiography, confirmed diagnosis of Aggregatibacter aphrophilus mitral valve endocarditis resulting in severe mitral regurgitation (Figure 2 A). MR scan was performed due to long standing lumbar pain - L5-S1 spondylodiscitis was described and treated with prolonged antibiotic therapy (Figure 2 B). Third patient, a 52-year-old man is still hospitalized in our institution due to Gemella morbillorum sepsis, aortic valve endocarditis and thoracic spondylodiscitis (Figure 3 A). He was initially treated for 6-weeks with antibiotics, however, clinical course was complicated by vancomycin-induced DRESS syndrome along with acute kidney injury which required renal replacement therapy. PET CT scan reported resolution of aortic valve inflammation, but active metabolism was detected in thoracic spine in Th6 (Figure 3 B). Even though tremendous effort is exerted to improve patient’s condition, his full recovery is very uncertain.
Conclusion: Septic embolism due to infective endocarditis warrants multidisciplinary team approach, prolonged antimicrobial therapy and surgery as a definitive treatment in most of the cases. Early diagnosis and treatment are highly important because any delay may lead to life-threatening, long-term sequelae and prolonged rehabilitation.