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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
View Disclosures and Other Information
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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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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 “Infections of the spine in patients with Human Immunodeficiency Virus”(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 ‘unique’. Could the authors please clearly state as to what characterized these ‘unique’ 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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