Literature Review and Clinical Presentation of Cervical Spondylitis Due to Salmonella Enteritidis in Immunocompetent
A 48-year-old woman was presented to our clinic with some fever and neck pains for about one month. She had no significant neck injury history. Her neck pains occurred after days of low degree fever and fatigue, with shoulder and arm pains. She rated the neck pain 7 out of 10 points (visual analogue scale). The pain, with dizziness and headaches, increased at night. Although the neck pain involved both shoulders and arms, there were no specific distributions of arm pains. She did not have any numbness in either arms. She felt a low fever everyday but denied a contact with tuberculosis. She walked normally and continued her work at home. She had no bowel and bladder problems.\nPhysical examinations revealed restricted neck rotations and obvious tenderness on her shoulders. For her neurological examination of the upper limb, no abnormality was found. Spurling signs and Lhermitte's test were not detected. Hoffman's sign and Babinski's sign were negative. Her tandem gait was normal. Her body temperature was 38.2℃.\nThe laboratory tests revealed that white blood cell (WBC) was counted as 3.8×109/L, with 57% neutrophils, and 30.1% leukocyte. C-reactive protein (CRP) level was 7.29 mg/L and erythrocyte sedimentation rate (ESR) was 28 mm/hr. Both purified protein derivative tests and tuberculosis antibody colloidal gold diagnostic tests were negative.\nLateral radiograph revealed a loss of lordosis on the cervical spine by destructions of the fifth cervical vertebrae (C5) and narrowing of the intervertebral disk space between C5 and the sixth cervical vertebrae (C6). In addition, magnetic resonance imagings (MRIs) of the cervical spine demonstrated uneven compressions of the intervertebral disk spaces between C5 and C6. Endplates and vertebrae were moth-eaten damaged. This was combined with well-defined paraspine and intraspine abnormal signals wrapped with smooth walls, all in parallel with tuberculous spondylitis which is inconsistent with the pyogenic ().\nAn empirical diagnosis of tuberculosis (TB) cervical spondylitis was made and the patient underwent classic anti-tuberculosis therapy with isoniazid, rifampicin, and ethambutol, and anti-infective treatments with penicillin and gentamicin. Yet, the chemotherapy for TB received no improvements in neck pain after 3 weeks. Repeated lab tests revealed that WBC was 7.2×109/L, with 70% of neutrophils and 17% of leukocyte, while CRP was 2.68 mg/L and ESR 23mm/hr. Based on the limited responses of anti-TB therapy, we realized that TB might not be the pathogen. Therefore, an exploration of the C4/5 through the anterior medial approach was recommended to evaluate the germ and debridement.\nIn the surgery, hypertrophic and edematous prevertebral fascia was noticed. On the right edge of C5 vertebral body, there was an abscess in the size of about 1×1×0.6 cm3. Needle puncture containing about 1 mL yellow feculent abscess was sent for culture. The abscess was drained and adjacent inflammatory tissues were removed. The C5/6 disc and its adjacent vertebral endplates were damaged. Scattered local bone destructions and hyperplastic granulations were found in C5 vertebral body. Frozen pathological section examinations of the pre-vertebral tissues revealed infiltration of neutrophils and tissue cells, but no evidences of malignancy and tuberculosis. Acid-fast bacillus test of purulent specimen smear was negative. The C5 corpectomy was then performed, and C4/5 and C5/6 discs were removed, followed by auto-iliac grafts and anterior plate instrumentations (InterTan, Smith & Nephew, Memphis, TN, USA). Gel foams filled with streptomycin were used to cover the plate and screws.\nHistological study revealed chronic infections of C5 vertebra, with apparent neutrophils infiltration and granulation tissues hyperplasia. No evidences of tuberculosis, such as epithelioid cell hyperplasia and langhan's cell, were detected. Instead, bacteriology study showed that the pathogen was SE. She was diagnosed as having cervical spondylitis caused by SE. Based on sensitivity test, levofloxacin was administrated through intravenous injection for 3 weeks, followed by oral antibiotic for another 2 weeks. At 1 month follow-up, her neck pain completely disappeared and radiography showed signs of bone growth. At 1.5 year of follow-up, C4-6 fusion was obtained. At 5-year of follow-up, she was symptoms-free and magnetic resonance showed a fine fusion from C4 to C6. However, accelerated degeneration was observed in the adjacent C3/4 discs ().