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Spondylodiskitis after Dilatation of Esophageal Radiation Stenosis: A Suspect for Metastasis

Open ArchivePublished:March 27, 2017DOI:https://doi.org/10.1016/j.jtho.2017.03.016

      Case Description

      A 56-year-old woman underwent concurrent chemoradiotherapy for a T3N2M0 adenocarcinoma in the right superior sulcus. Four months after chemoradiation, restaging with endoscopic endobronchial ultrasound revealed no N2 disease. A lobectomy of the right upper lobe with lymph node dissection followed. No vital tumor was found.
      The treatment was complicated by severe radiation esophagitis requiring long-term tube feeding. Hitherto, she underwent 15 esophageal dilatations with a Savary-Gilliard bougie dilator because of radiation stenosis.
      Three years after therapy for NSCLC she was admitted for moderate back pain located between the shoulders and persistent low-grade fever for more than 2 months. The complaints started within days after her last esophageal dilatation.
      Physical examination revealed no abnormalities. Her C-reactive protein level was 47 mg/L. Positron emission tomography showed uptake of fludeoxyglucose in thoracic vertebrae 2 and 3 and in the intervertebral disk continuous with mediastinal soft tissue adjacent to the esophagus (Fig. 1A).
      Figure thumbnail gr1
      Figure 1(A) Positron emission tomography scan showing uptake of fludeoxyglucose in thoracic vertebrae 2 and 3 and in the intervertebral disk continuous with mediastinal soft tissue adjacent to the esophagus. (B) Positron emission tomography scan showing a marked decrease in fludeoxyglucose uptake after 1 month of antibiotic treatment.
      Computerized tomography (CT) showed wedge-shaped widening of the adjacent vertebral bodies with a regular sclerotic aspect (Fig. 2).
      Figure thumbnail gr2
      Figure 2Wedge-shaped widening of the adjacent thoracic vertebral bodies with a sclerotic aspect.
      With endoscopic ultrasound performed by a thin endobronchial ultrasound scope, fine-needle aspirates were obtained from the diseased intervertebral region. Different species of bacteria were cultured (Escherichia coli, Rothia mucilaginosa, and various anaerobic species) and no malignancy was found.
      After 4 weeks of treatment with amoxicillin/clavulanic acid and flucloxacillin, repeat positron emission tomography showed a marked decrease in fludeoxyglucose uptake (Fig. 1B).
      Invasive diagnostic procedures, treatments, and trauma of the esophagus have been described as causes of infectious spondylodiskitis.
      • Park S.Y.
      • Chung H.K.
      • Yoon K.W.
      • et al.
      Infectious spondylodiscitis caused by esophageal injury after blunt chest trauma.
      • Giger A.
      • Yusuf E.
      • Manuel O.
      • Clerc O.
      • Trampuz A.
      Polymicrobial vertebral osteomyelitis after oesophageal biopsy: a case report.
      This case report describes infectious spondylodiskitis as a complication of esophageal dilatation. The findings of imaging of this patient are confusing, as the vertebral damage has to be differentiated from metastatic disease. The central mediastinal and anterior vertebral location seems difficult to approach, but endoscopic ultrasound is appropriate to guide aspiration of thoracic vertebral and paravertebral disease.
      • Stigt J.A.
      • Wolfhagen M.J.
      • Boomsma M.F.
      • Mostert A.K.
      • Groen H.J.
      Diagnosing infectious spondylodiscitis with endoscopic ultrasound.
      Several months of treatment with antibiotics is advised, although recurrence is not uncommon.
      • Cottle L.
      • Riordan T.
      Infectious spondylodiscitis.

      References

        • Park S.Y.
        • Chung H.K.
        • Yoon K.W.
        • et al.
        Infectious spondylodiscitis caused by esophageal injury after blunt chest trauma.
        Gastrointest Endosc. 2010; 72: 1095-1097
        • Giger A.
        • Yusuf E.
        • Manuel O.
        • Clerc O.
        • Trampuz A.
        Polymicrobial vertebral osteomyelitis after oesophageal biopsy: a case report.
        BMC Infect Dis. 2016; 16: 141
        • Stigt J.A.
        • Wolfhagen M.J.
        • Boomsma M.F.
        • Mostert A.K.
        • Groen H.J.
        Diagnosing infectious spondylodiscitis with endoscopic ultrasound.
        J Bronchology Interv Pulmonol. 2012; 19: 82-84
        • Cottle L.
        • Riordan T.
        Infectious spondylodiscitis.
        J Infect. 2008; 56: 401-412