The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 3

Scientific Articles | March 01, 2005

Infections of the Spine in Patients with Human Immunodeficiency Virus

Marc A. Weinstein, MD¹; Frank J. Eismont, MD²

¹ Center for Spinal Disorders, Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637-0925. E-mail address: mweinstein@floridaortho.com
² Department of Orthopaedics and Rehabilitation, University of Miami,P.O. Box 016960, Miami, FL 33101

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Miami Center for Orthopaedic Research and Education. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or non-profit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, Florida

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Mar 01;87(3):604-609. doi: 10.2106/JBJS.C.01062

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Abstract

Background: Musculoskeletal infections in patients with the human immunodeficiency virus (HIV) have been described. However, the prevalence, specific characteristics, and outcomes of spinal infections in these patients have not been studied in a large group of patients to our knowledge.

Methods: The computerized records of all patients discharged with the diagnosis of spinal osteomyelitis, discitis, epidural abscess, or tuberculosis from our institution from October 1994 through September 2000 were reviewed. Patients with the diagnosis of HIV were identified, and the charts were examined in detail.

Results: During the six-year period, 7338 unique patients who were HIV positive were admitted. Seventeen (0.23%) of them were treated for a spinal infection. The prevalence of spinal infection was 23.2 per 10,000 admissions of HIV-positive patients and 7.1 per 10,000 admissions of HIV-negative patients (p < 0.0001). Eight patients who had discitis and/or osteomyelitis had a mean CD4 T-cell count of 339.6 cells/mm³, and all eight had clinical resolution of the infection after six to twelve weeks of appropriate antibiotic therapy. In contrast, six patients who had spinal tuberculosis had a mean CD4 count of 75.7 cells/mm³ (p = 0.005), and one of them died during the hospitalization. The remaining three patients, who had epidural abscesses, had a mean CD4 count of 20.67 cells/mm³ (p = 0.001), and two of them died.

Conclusions: Discitis and/or osteomyelitis occurs in HIV-positive patients with a mild-to-moderate decrease (=200 cells/mm³) in the CD4 T-cell count, and the infection responds to appropriate antibiotics. Patients with a more severely decreased CD4 count (50 to 200 cells/mm³) may have spinal tuberculosis develop, and patients with the lowest CD4 counts are more likely to have epidural abscesses develop. The three fatalities in this study occurred in these two groups of patients. As a group, HIV-positive patients are significantly more likely to have a spinal infection develop than are HIV-negative patients (p < 0.0001). Although the CD4 count can be used as a predictor of the clinical course, identification of the organism remains paramount in the treatment of this complex patient population.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

With the ever-increasing number of individuals infected with the human immunodeficiency virus (HIV), orthopaedic surgeons are often confronted with complex issues involved in the care of these patients. In the United States, which has only 2.5% of the total worldwide reported caseload of acquired immunodeficiency syndrome (AIDS), the cases of more than 900,000 patients with an HIV infection have been documented¹.

Infectious diseases in patients who are HIV positive are common^2,3. Musculoskeletal infections in such patients have been described in various reports^4-8, but only a small percentage of these patients had osteoarticular infections. In several studies, osteoarticular infections were reported to be rare in HIV-positive patients when those who used intravenous drugs were excluded^9-11. Few studies have specifically examined osteoarticular infections in patients with AIDS, and the proportion of patients with a spinal infection has remained small. To our knowledge, the prevalence, characteristics, and clinical outcomes of HIV-positive patients with a spinal infection have not been reported in detail. The purpose of this study was to specifically evaluate these issues.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

After approval of the Office for Health Information Management was received, the computerized records of all patients admitted to the University of Miami/Jackson Memorial Hospital from October 1994 through September 2000 were made available for review for this study. Patients with the diagnosis of spinal osteomyelitis, discitis, epidural abscess, or spinal tuberculosis were identified by medical record number only, and the charts of those who also were HIV positive were examined in detail. In addition to demographic data, the following parameters were recorded: the HIV risk factor; the white blood-cell count, absolute lymphocyte count, and West-ergren erythrocyte sedimentation rate on admission; the most recent CD4 T-cell count; imaging studies; blood culture results; biopsy results; surgical procedures; type and duration of antibiotic treatments; the length of stay; hospital charges; and short-term outcome.

During the six-year period studied, 17,717 patients were admitted and 7338 of them represented unique patients who had been diagnosed as having HIV. Seventeen (0.23%) of the 7338 patients who were HIV positive were also treated for a spinal infection (Table I). These patients were separated into three groups that included eight patients with discitis and/or osteomyelitis, six patients with spinal tuberculosis, and three patients with an epidural abscess. For this same six-year period, there was a total of 346,874 admissions of which 265,635 represented unique patient admissions. After subtraction of the 7338 unique HIV-positive patients, 258,297 unique HIV-negative patients remained. The 183 HIV-negative patients with a spinal infection were separated into three similar groups, which included 109 patients with discitis and/or osteomyelitis, nineteen patients with spinal tuberculosis, and fifty-five patients with epidural abscesses.

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TABLE I Clinical Data on Seventeen HIV-Positive Patients with a Spinal Infection^*

Case	Gender, Age	Race	Diagnosis	HIV Risk Factor^*	Spinal Level	White Blood-Cell Count (×10⁹ cells/L)	Absolute Lymphocyte Count	CD4 T-Cell Count (cells/mm³)	Outcome
1	M, 40	White	Discitisosteomyelitis	MSM	Cervical	6.3	2142	194	Resolution
2	M, 53	White	Discitisosteomyelitis	Heterosex	Lumbar	9.3	2232	700	Resolution
3	F, 37	White	Discitisosteomyelitis	Intravenous drug use	Thoracic	3.7	851	391	Resolution
4	M, 36	Hispanic	Discitisosteomyelitis	Unknown	Thoracic	11.5		202	Resolution
5	M, 48	Black	Discitisosteomyelitis	Intravenous drug use	Lumbar	13.9	2919	457	Resolution
6	M, 45	Black	Discitisosteomyelitis	Intravenous drug use	Lumbar	9.4	2059	477	Resolution
7	M, 44	Black	Discitisosteomyelitis	MSM	Lumbar	3.1		282	Resolution
8	M, 34	Black	Discitisosteomyelitis	Heterosex	Thoracic	9.7	1261	14	Resolution
9	M, 57	Black	Spinal tuberculosis	Heterosex	Cervical	5.0	950	13	Died
10	M, 32	White	Spinal tuberculosis	Intravenous drug use	Lumbar	18.9	1323	24	Resolution
11	M, 29	White	Spinal tuberculosis	Heterosex	Lumbar	7.2	648	122	Resolution
12	M, 45	Black	Spinal tuberculosis	Unknown	Lumbar	5.6	896	73	Resolution
13	M, 41	Black	Spinal tuberculosis	MSM	Thoracic	7.4	814	168	Resolution
14	M, 41	White	Spinal tuberculosis	Intravenous drug use	Thoracic	15.0	300	54	Resolution
15	M, 48	Black	Epidural abscess	Heterosex	Lumbar	9.3	744	2	Resolution
16	M, 56	Black	Epidural abscess	Heterosex	Thoracic	20.5	1435	34	Died
17	M, 39	Asian	Epidural abscess	MSM	Thoracic	18.7	561	26	Died

HIV = human immunodeficiency virus, MSM = male-to-male sex, and Heterosex = unprotected male-to-female sex with multiple partners.

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TABLE I Clinical Data on Seventeen HIV-Positive Patients with a Spinal Infection^*

Case	Gender, Age	Race	Diagnosis	HIV Risk Factor^*	Spinal Level	White Blood-Cell Count (×10⁹ cells/L)	Absolute Lymphocyte Count	CD4 T-Cell Count (cells/mm³)	Outcome
1	M, 40	White	Discitisosteomyelitis	MSM	Cervical	6.3	2142	194	Resolution
2	M, 53	White	Discitisosteomyelitis	Heterosex	Lumbar	9.3	2232	700	Resolution
3	F, 37	White	Discitisosteomyelitis	Intravenous drug use	Thoracic	3.7	851	391	Resolution
4	M, 36	Hispanic	Discitisosteomyelitis	Unknown	Thoracic	11.5		202	Resolution
5	M, 48	Black	Discitisosteomyelitis	Intravenous drug use	Lumbar	13.9	2919	457	Resolution
6	M, 45	Black	Discitisosteomyelitis	Intravenous drug use	Lumbar	9.4	2059	477	Resolution
7	M, 44	Black	Discitisosteomyelitis	MSM	Lumbar	3.1		282	Resolution
8	M, 34	Black	Discitisosteomyelitis	Heterosex	Thoracic	9.7	1261	14	Resolution
9	M, 57	Black	Spinal tuberculosis	Heterosex	Cervical	5.0	950	13	Died
10	M, 32	White	Spinal tuberculosis	Intravenous drug use	Lumbar	18.9	1323	24	Resolution
11	M, 29	White	Spinal tuberculosis	Heterosex	Lumbar	7.2	648	122	Resolution
12	M, 45	Black	Spinal tuberculosis	Unknown	Lumbar	5.6	896	73	Resolution
13	M, 41	Black	Spinal tuberculosis	MSM	Thoracic	7.4	814	168	Resolution
14	M, 41	White	Spinal tuberculosis	Intravenous drug use	Thoracic	15.0	300	54	Resolution
15	M, 48	Black	Epidural abscess	Heterosex	Lumbar	9.3	744	2	Resolution
16	M, 56	Black	Epidural abscess	Heterosex	Thoracic	20.5	1435	34	Died
17	M, 39	Asian	Epidural abscess	MSM	Thoracic	18.7	561	26	Died

HIV = human immunodeficiency virus, MSM = male-to-male sex, and Heterosex = unprotected male-to-female sex with multiple partners.

When appropriate, quantitative variables were analyzed with the Student t test, and differences in group proportions were assessed with use of the two-tailed Fisher exact test. Alpha was set at 0.05.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

Patients who were HIV positive were 2.6 times more likely to be admitted to the hospital with osteomyelitis and/or discitis (p = 0.011), eleven times more likely to be admitted with spinal tuberculosis (p < 0.0001), and two times more likely to be admitted with epidural abscesses (p = 0.139) than were the patients without HIV (Table II). Epidemiological studies usually describe medical problems per 10,000 patient admissions. There were 23.2 patients with infections of the spine per 10,000 admissions of HIV-positive patients compared with 7.1 such patients per 10,000 admissions of HIV-negative patients (p < 0.0001).

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TABLE II Prevalence of the Three Types of Spinal Infection in 7338 HIV-Positive and 258,297 HIV-Negative Patients Admitted to the Hospital from October 1, 1994, to September 30, 2000^*

Infection Diagnosis	HIV-Positive Patients	HIV-Negative Patients	Prevalence per 10,000 Admissions for HIV-Positive Patients	Prevalence per 10,000 Admissions for HIV-Negative Patients	P Value†
Pyogenic discitis and/or osteomyelitis	8	109	10.9	4.2	0.011
Spinal tuberculosis	6	19	8.2	0.74	<0.0001
Pyogenic epidural abscess	3	55	4.1	2.1	0.139
Total no. of spinal infections	17	183	23.2	7.0	<0.0001

HIV = human immunodeficiency virus. †Two-tailed Fisher exact test.

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TABLE II Prevalence of the Three Types of Spinal Infection in 7338 HIV-Positive and 258,297 HIV-Negative Patients Admitted to the Hospital from October 1, 1994, to September 30, 2000^*

Infection Diagnosis	HIV-Positive Patients	HIV-Negative Patients	Prevalence per 10,000 Admissions for HIV-Positive Patients	Prevalence per 10,000 Admissions for HIV-Negative Patients	P Value†
Pyogenic discitis and/or osteomyelitis	8	109	10.9	4.2	0.011
Spinal tuberculosis	6	19	8.2	0.74	<0.0001
Pyogenic epidural abscess	3	55	4.1	2.1	0.139
Total no. of spinal infections	17	183	23.2	7.0	<0.0001

HIV = human immunodeficiency virus. †Two-tailed Fisher exact test.

In order to assess the importance of intravenous drug use on the occurrence of spinal infection in HIV-positive patients, the five patients who used intravenous drugs were eliminated from each subgroup of patients with a spinal infection and from the total number of patients who had a spinal infection, and the Fisher exact test was reapplied. Three of these patients were in the group with discitis and/or osteomyelitis, and two were in the group with spinal tuberculosis. After elimination of the patients who used intravenous drugs, the recalculated p values for pyogenic discitis and/or osteomyelitis (p = 0.111) and epidural abscess (p = 0.139) did not show a significant difference between the HIV-positive patients and the HIV-negative patients, but they did reveal a trend. The recalculated data showed a significant difference with respect to spinal tuberculosis (p = 0.003) and with respect to the total number of patients with a spinal infection (p = 0.008).

Of the total number of patients admitted to our institution with these diagnoses, patients with HIV infection represented 7% (eight) of the 117 patients with discitis and/or osteomyelitis, 24% (six) of twenty-five patients with spinal tuberculosis, and 5% (three) of fifty-eight patients with an epidural abscess (Table II). The demographic and clinical data for all patients with spinal infections are presented in Tables I and III. The mean length of hospital stay was 26.4 days.

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TABLE III Demographic Data on All Patients with Spinal Infections Seen from October 1, 1994, to September 30, 2000

	HIV-Positive Patients	HIV-Negative Patients	P Value
Discitis	8	109
Male	7	61
Female	1	48
White	3	68
Black	4	24
Hispanic	1	23
Mean age	42.1	51.3	0.005^*
Tuberculosis	6	19
Male	6	10
Female	0	9
White	3	3
Black	3	13
Hispanic	0	3
Mean age	40.8	43.9	NS^*
Epidural abscess	3	55
Male	3	35
Female	0	20
White	0	20
Black	2	23
Hispanic	0	11
Asian	1	1
Mean age	47.7	50.5	NS^*

Student t test. NS = not significant.

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TABLE III Demographic Data on All Patients with Spinal Infections Seen from October 1, 1994, to September 30, 2000

	HIV-Positive Patients	HIV-Negative Patients	P Value
Discitis	8	109
Male	7	61
Female	1	48
White	3	68
Black	4	24
Hispanic	1	23
Mean age	42.1	51.3	0.005^*
Tuberculosis	6	19
Male	6	10
Female	0	9
White	3	3
Black	3	13
Hispanic	0	3
Mean age	40.8	43.9	NS^*
Epidural abscess	3	55
Male	3	35
Female	0	20
White	0	20
Black	2	23
Hispanic	0	11
Asian	1	1
Mean age	47.7	50.5	NS^*

Student t test. NS = not significant.

Discitis or Osteomyelitis

Seven of the eight patients with discitis and/or osteomyelitis presented with a chief complaint of pain in the spine. Two of the eight patients had a temperature of >38.4°C on admission. Laboratory data revealed a mean white blood-cell count of 8.4 × 10⁹/L, a mean absolute lymphocyte count of 1910 cells/mm³, and a mean CD4 T-cell count of 339.6 cells/mm³. Only two of these patients had a CD4 count of <200 cells/mm³, and only one of the eight patients had a white blood-cell count of >12.0 × 10⁹/L. Blood cultures were obtained for six patients, and one of them had positive findings. Four patients underwent a computed tomography-guided needle biopsy. One of the four biopsy specimens was positive on culture. Two of the three patients with a negative result on the culture then underwent open surgical biopsy or débridement, and both had a positive finding on culture. The organism identified in all four patients with positive cultures was Staphylococcus aureus that was sensitive to oxacillin. The other patients were diagnosed as having discitis and/or osteomyelitis by the clinical history, positive findings on magnetic resonance imaging, or nuclear medicine studies, and by a favorable response to therapy. Seven patients had clinical resolution of the infection after six to twelve weeks of appropriate antibiotics. One patient (Case 7) improved clinically but was lost to follow-up after leaving the hospital against medical advice (Table I).

Spinal Tuberculosis

The chief complaint for all six patients with tuberculosis was pain in the spine, but patients in this group additionally presented with constitutional signs such as weight loss, night sweats, and fevers. In comparison with the group that had discitis and/or osteomyelitis, the mean white blood-cell count was 9.85 × 10⁹/L (p = 0.28), the mean absolute lymphocyte count was 822 cells/mm³ (p = 0.007), and the mean CD4 count was 75.7 cells/mm³ (p = 0.005) (Fig. 1). Two patients had a white blood-cell count of >12.0 × 10⁹/L (18.9 and 15 × 10⁹/L). Blood cultures were obtained from four patients, and none of the cultures grew bacteria. All patients had magnetic resonance imaging scans consistent with the diagnosis of spinal tuberculosis. Three patients underwent computed tomography-guided needle biopsy, and all demonstrated Mycobacterium tuberculosis on culture. Of the three patients who did not have a computed tomography-guided needle biopsy, one had been previously diagnosed as having disseminated tuberculosis, one had positive findings on a sputum culture, and one had a culture of pleural fluid that grew tuberculosis. All patients were treated with appropriate antituberculous medications, and, ultimately, four were discharged with symptom resolution. One patient (Case 10) was lost to follow-up after leaving the hospital against medical advice (Table I). One patient (Case 9) with a CD4 count of 13 cells/mm³ died during the hospitalization.

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Fig. 1: CD4 count in patients infected with the human immunodeficiency virus (HIV) who have a spinal infection. OM = osteomyelitis, and TB = tuberculosis.

Epidural Abscess

The three patients with epidural abscesses were acutely ill on admission. Two had pain in the spine, and the third patient presented with lower extremity weakness. All patients had temperatures of >38.3°C on admission.

The mean white blood-cell count of 16.17 × 10⁹/L in these three patients was significantly greater than the mean white blood-cell count in the patients in the discitis-osteomyelitis group (p = 0.01), but it was not significantly greater than that in the tuberculosis group (p = 0.10). Two of the three patients had white blood-cell counts of >12.0 × 10⁹/L (20.5 and 18.7 × 10⁹/L) on admission. The mean absolute lymphocyte count of 913.3 cells/mm³ and the mean CD4 count of 20.67 cells/mm³ were significantly less than those of the discitis-osteomyelitis group (p = 0.02 and p = 0.001, respectively). The mean CD4 count was also significantly less than that of the spinal tuberculosis group (p = 0.04). Two patients had blood cultures performed; one culture grew group-A Streptococcus, and the other grew methicillin-resistant Staphylococcus aureus. Two patients had an intrapleural abscess, which grew Nocardia species after biopsy, and both of these patients died during the hospitalization. The patient with the group-A streptococcus was treated with a third-generation cephalosporin (ceftriaxone) intravenously for six weeks and had clinical resolution of the infection.

Of the seventeen HIV-positive patients with a spinal infection, three died during hospitalization and all three had CD4 counts of <50 cells/mm³. Of the fourteen patients who were discharged, none were readmitted to the University of Miami/Jackson Memorial Hospital and diagnosed as having a spinal infection. However, we consider this a short-term report as none of the fourteen survivors were specifically evaluated for long-term results. Although we found no significant difference among any of the groups with regard to gender, race, or HIV risk factor, the number of patients was too small to have appropriate power.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Although the total number of HIV-positive patients with a spinal infection remains small, they represent >8% of all patients with a spinal infection who are admitted to our institution. This emphasizes the reality that spine surgeons must become familiar with the characteristics and treatment of infections of the spine in HIV-positive patients.

Spinal infections in HIV-positive patients at our institution occur at a rate of 0.23% per patient. The prevalence of spinal infection is 23.2 per 10,000 admissions of HIV-positive patients compared with 7.1 per 10,000 admissions of HIV-negative patients (p < 0.0001). We were able to demonstrate a difference with this large degree of certainty because of the large number of patients (265,635) reviewed over a six-year period. Even when these patients are subdivided into the three smaller groups of spinal infections (pyogenic discitis and/or osteomyelitis, spinal tuberculosis, and epidural abscess), there still is a distinctly greater predilection for spinal infection in HIV-positive patients.

In a review of 556 patients with HIV infection, twenty (3.6%) had an osteoarticular infection and one of the twenty had spinal tuberculosis⁸. The risk factor was intravenous drug use for all twenty patients, and twelve had Staphylococcus aureus infections¹⁰. Steinbach et al. reported on the cases of four patients with septic spondylitis in a group of forty-five patients with AIDS who had musculoskeletal symptoms⁷. The causative organisms in three patients were Escherichia coli, Cryptococcus neoformans, and Staphylococcus aureus. Three other combined reports examined more than 3100 HIV-infected patients who had musculoskeletal symptomatology and noted that none had a spinal infection^5,6,12.

Vassilopoulos et al. reported on three patients with a spine infection in a cohort of 3000 to 4000 HIV-positive patients⁴. In another report on 4023 patients infected with HIV, two had a spine infection⁹. Both patients had infection with Staphylococcus aureus, and the CD4 counts were 180 and 240 cells/mm³. In both patients, the HIV risk factor was intravenous drug use. The authors concluded that spinal infections in patients with AIDS are a result of intravenous drug use and that infection with HIV does not itself predispose to infectious spondylitis⁹. This conclusion was supported in another study that found osteoarticular infections in twenty-five (5%) of 482 HIV-positive intravenous drug users and in six (7%) of eighty-five HIV-negative intravenous drug users¹¹.

In the only other study we are aware of that specifically examined spinal infections in HIV-positive patients, Heary et al. compared the characteristics of spinal infections in thirteen patients with the HIV infection and in nineteen patients without the HIV infection¹³. All thirteen HIV-positive patients were intravenous drug users compared with only five of the nineteen HIV-negative patients who had a spinal infection. Staphylococcus aureus was the most common organism isolated, and tuberculosis was the second most frequently cultured organism in both groups. In addition, the clinical outcome was similar for both groups. The authors concluded that HIV status does not alter the microbiology or clinical outcome for patients with spinal infections.

Our data showed a highly significant predilection for spinal infection in HIV-positive patients as a group when those who are intravenous drug users are included (p < 0.0001). This significant predilection persisted even when the five patients who were intravenous drug users were eliminated from the analysis (p = 0.008). This suggests that HIV-positive patients have an increased susceptibility to spinal infection on the basis of the HIV disease itself rather than on external risk factors.

In our study, the eight HIV-positive patients who had nontuberculous discitis and/or osteomyelitis all responded to conventional treatments. The most common presenting symptom of pain is consistent with the presenting symptoms in patients who are not infected with HIV. All four patients with a positive culture were infected with Staphylococcus aureus, the most common causative organism historically in infectious spondylitis¹⁴. While there have been case reports of rare organisms causing infectious spondylitis in patients with HIV^15-17, the most common organism in our series as well as other published series^4,7-9,13 remained Staphylococcus aureus.

The health or progressive decline of HIV-positive patients is monitored by following a variety of laboratory data, and one of the most important is the CD4 T-cell count. The lower the CD4 count, the more prevalent are opportunistic infections and neoplasms. Studies in the pulmonary literature have also noted an association between the CD4 count and the type and severity of infection^18,19. Bacterial pneumonias are most common in patients with a mild decrease in the CD4 count; pulmonary tuberculosis is more common in patients with a moderately decreased CD4 count; Pneumocystis carinii pneumonia is more common in patients with more marked decreases in CD4 counts; and infections with cytomegalovirus, Mycobacterium avium complex, or fungal species are common in patients with a severe deficiency in the CD4 count¹⁹.

Our study showed a similar relationship between the CD4 count and the severity of the spinal infection. Pyogenic discitis and/or osteomyelitis occurred in patients infected with HIV who had a mild-to-moderate decrease in the CD4 count (=200 cells/mm³). The causative organism (Staphylococcus aureus) was consistent with that seen in the general population with a spinal infection, and, like the general population, the patients responded well to conventional treatment. Patients with markedly decreased CD4 counts (50 to 200 cells/mm³) were found to have spinal tuberculosis, and patients with the lowest CD4 counts (<50 cells/mm³) had development of epidural abscesses with more esoteric species, including two of three with Nocardia. The three inhospital deaths occurred in the latter two groups, and all three patients had CD4 counts of <50/mm³. Therefore, the CD4 count is important in the evaluation and treatment of HIV-positive patients who have a spinal infection.

Our current protocol for evaluating HIV-positive patients who have a suspected spinal infection begins with obtaining a CD4 count, white blood-cell count, erythrocyte sedimentation rate, and C-reactive protein level. Blood cultures are obtained in all patients. Appropriate imaging includes plain radiographs and magnetic resonance imaging with and without gadolinium. Isolation of the causative organism is imperative, and, if the blood cultures are negative, a biopsy should be performed under computed tomography guidance. Appropriate antibiotics are administered after the infecting organism has been identified. Surgical débridement with or without stabilization is indicated when antibiotic treatment is unsuccessful or when spinal stability or neurologic function is jeopardized. The general medical condition is also considered, and surgery is not recommended if the patient is too frail to tolerate appropriate surgical intervention or if the risk-benefit ratio for the patient is excessive.

This study demonstrates that HIV-positive patients are more likely than HIV-negative patients to have development of a spinal infection, including pyogenic discitis and/or osteomyelitis, spinal tuberculosis, and epidural abscesses. In addition, the type of infection and organism varies depending on the CD4 count. Patients with HIV infection who have a CD4 count of =200/mm³ are most likely to have development of pyogenic discitis and/or osteomyelitis with traditional bacteria, such as Staphylococcus aureus, which is the most common organism. These patients usually respond well to standard treatment. Patients with HIV infection who have a CD4 count of <200/mm³ are more likely to present with spinal tuberculosis or an epidural abscess with less common infecting organisms, such as Nocardia or combinations of bacteria. The identification of the organism and timely institution of treatment remain paramount in the management of the complex cases of these patients. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank Kathie Brookfield and Dr. Sanjay Khurana for their assistance with the statistical analysis.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Topics

hiv ; cd4 count determination procedure ; discitis ; epidural abscess ; hiv seropositivity ; osteomyelitis ; spinal tuberculosis ; infection ; spine ; spinal cord infection

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Robert Poss, MD

Posted on June 16, 2005

Editor's Note:

Journal of Bone and Joint Surgery

The corresponding author has been invited to respond to the letter by Dr. Upadhyay et al, but to date has not done so.

Ashish Upadhyay

Posted on April 08, 2005

Infections of the spine in patients with Human Immunodeficiency Virus

Wythenshawe Hospital, Manchester, United Kingdom

To the Editor:

Although spine infections are rare in HIV positive patients, they are important because a prompt medical treatment can prevent serious morbidity. We congratulate Drs. Weinstein & Eismont for their study â€œInfections of the spine in patients with Human Immunodeficiency Virusâ€(1). They have concluded from the study that there is a significantly higher risk of developing spine infections in patients who are HIV positive, that the CD4+ count has a positive correlation with pathogenicity of the infective organism, and that these patients usually respond well to standard treatment. May we ask the authors to clarify some questions?

There were 346,874 admissions during the 6 years of the study out of which 265,635 were â€˜uniqueâ€™. Could the authors please clearly state as to what characterized these â€˜uniqueâ€™ admissions?

Presumably, not all the patients classified as HIV negative were actually tested for HIV, either because there was no indication to do so or due to a lack of consent from patients. It would be helpful to know how many of the 183 HIV negative patients with spine infections were actually tested for HIV, especially the 74 patients with spinal tuberculosis and pyogenic epidural abscess. We know from the study that such infections usually develop in immunocompromised patients in the absence of other risk factors. If these patients were never tested, and if they did not have any other risk factors, then they could potentially add to the number on the HIV positive side, thereby further increasing the relevance of this study.

Belzunegni, et al, (2) reported that nearly half of their HIV positive patients (5 of 11) had osteoarticular tuberculosis as a result of a recurrence of a previous infection. It would be interesting to know how many patients in the present study had been treated for similar infections in the past and whether the CD4+ counts in such patients (if there were any) were high or low. Bearing in mind that the present study has refuted the previous claim (3) that the increased risk of osteoarticular infections is more directly related to parenteral drug abuse rather than presence of HIV infection, this assumes further importance. A patient developing infection due to intravenous drug abuse is more likely to get it as a result of fresh inoculation compared to the immunocompromised HIV positive patients who can develop infection due to latent foci or rejuvenation of previous inadequately treated infections.

Finally, it is unclear from the paper whether the CD4+ counts were recorded at the time when the spine symptoms occurred or at the time of making the diagnosis of HIV positivity. It is important to know this in view of the evidence (4) that prophylaxis against atypical mycobacteria is useful when CD4+ counts are low and can be stopped when the counts rise as a result of anti-retroviral therapy.

References

1. Weinstein MA, Eismont FJ. Infections of the Spine in Patients with Human Immunodeficiency Virus. J Bone Joint Surg Am. 2005;87:604-609.

2. Belzunegui J, Santisteban M, Gorordo M, Barastay E, Rodriguez- Escalera C, Lopez-Dominguez L, Gonzalez C, Figueroa M. Osteoarticular mycobacterial infections in patients with the human immunodeficiency virus. Clin Exp Rheumatol. 2004 May-Jun;22(3):343-5.

3. Ventura G, Gasparini G, Lucia MB, Tumbarello M, Tacconelli E, Caldarola G, Cauda R. Osteoarticular bacterial infections are rare in HIV- infected patients. 14 cases found among 4,023 HIV-infected patients. Acta Orthop Scand. 1997 Dec;68(6):554-8.

4. Currier JS, Feinberg J. Bacterial infections in HIV disease. AIDS Clin Rev.1995; 96:131 -52.

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Marc A. Weinstein, Frank J. Eismont; Infections of the Spine in Patients with Human Immunodeficiency Virus. The Journal of Bone & Joint Surgery. 2005 Mar;87(3):604-609.

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