Vancomycin Resistant Enterococcal Endocarditis Presenting as Spondylodiskitis
Introduction: Enterococcal endocarditis generally manifests as classical subacute infection and when metastatic events occur, the embolic events are almost always bland in nature rather than causing metastatic infection. We present a patient with vancomycin-resistant Enterococcus faecalis (VRE) aortic valve endocarditis which presented with lumbar spondylodiskitis, a very unusual manifestation of enterococcal endocarditis. Case Report: A 87 year old man with diabetes and a recent cerebrovascular event was evaluated for increasing lumbar spine pain without fever, chills or other constitutional symptoms. An outpatient MRI revealed fluid in the L2-L3 disk space with enhancement of the L2 and L3 vertebrae and bilateral adjacent psoas muscle. An Interventional Radiology-facilitated aspirate showed many PMNs on Gram stain and culture of the aspirate as well as 4 blood cultures revealed vancomycin-resistant E. faecalis. Retrospectively, the patient had had several urine cultures in the past 2 months which also revealed the same organism. He gave a history of IgE-mediated hypersensitivity to penicillin. Because of the unusual cause of the diskitis and multiple positive blood cultures, a trans-esophageal echocardiogram was performed which revealed a vegetation on the right coronary cusp of the patient's aortic valve. A diagnosis of VRE aortic valve endocarditis was made associated with secondary lumbar spondylodiskitis. He was begun on intravenous daptomycin and the blood cultures became negative. A review of the literature found only several cases of this scenario previously reported and none were linked to VRE as the etiology. Conclusion: Extravalvular secondary infections associated with enterococcal endocarditis as in this case are quite rare. This case is the first known of endocarditis with secondary spondylodiskitis caused by VRE.