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\begin{document}

\title{Epidural abscess and spondylitis caused by Veillonella parvula in a man
on hemodialysis}



\author[1]{Masaru Kurihara}%
\author[1]{Itaru Tamaki}%
\author[2]{Yasuharu Tokuda}%
\affil[1]{Urasoe General Hospital}%
\affil[2]{Muribushi Okinawa Teaching Hospitals}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Veillonella species rarely cause serious infections, but the incidence
of infection has been increasing among immunocompromised individuals.
This case of an epidural abscess and spondylitis caused by Veillonella
parvula in a hemodialysis patient illustrates the importance of
performing anaerobic blood culture in immunocompromised patients with
signs of infection.%
\end{abstract}%



\sloppy


Clinical Case Report

\textbf{Epidural abscess and spondylitis caused by \emph{Veillonella
parvula} in a man on hemodialysis}

\textbf{Running title:} Epidural abscess and spondylitis caused by

\emph{Veillonella parvula}

Masaru Kurihara, Itaru Tamaki, Yasuharu Tokuda

{[}Institutions{]}

Correspondence: Masaru Kurihara

Department of Hospital Medicine, Urasoe General Hospital

Okinawa, Japan

Tel: +81-98-878-0231

Fax: +81-98-878-0231

E-mail: masarukurihara1025@gmail.com

\textbf{Key Clinical Message}

\emph{Veillonella} species rarely cause serious infections, but the
incidence of infection has been increasing among immunocompromised
individuals. This case of an epidural abscess and spondylitis caused by
\emph{Veillonella parvula} in a hemodialysis patient illustrates the
importance of performing anaerobic blood culture in immunocompromised
patients with signs of infection.

Keywords: Infectious diseases, Opportunistic
infections,\emph{Veillonella} infections, Gram-negative bacteria,
epidural abscess, hemodialysis

\textbf{Introduction}

\emph{Veillonella} is an anaerobic gram-negative coccus that inhabits
the oral cavity, gastrointestinal tract, and female genital
tract.\textsuperscript{1-3} Thirteen species of the genus have been
identified, of which six species have been isolated from the human oral
cavity.\textsuperscript{4} \emph{Veillonella} species were formerly
considered to be non-pathogenic and to rarely cause serious infections,
but in recent years, there has been an increasing number of reports of
human infections among immunocompromised
individuals.\textsuperscript{5}Here, we report a rare case of an
epidural abscess and spondylitis caused by \emph{Veillonella parvula} .

\textbf{Case History}

A 52-year-old Japanese man presented to the emergency department of our
hospital with a 1-week history of low back pain. He had also developed
difficulty in walking over the previous 2 days. He had a 10-year history
of chronic renal failure caused by glomerulonephritis and was on
hemodialysis three times a week. He had smoked 20 cigarettes/day for 30
years and was an occasional drinker. On examination, he was alert, with
a temperature of 37.0, blood pressure of 105/74 mmHg, respiratory rate
of 32 breaths/min, and heart rate of 180 beats/min. No abnormalities
were detected on respiratory or cardiac examination. Abdominal
examination showed tenderness over an area from the right buttock to the
right thigh. There was no redness or tenderness at the dialysis shunt
site, located on the left forearm. Laboratory test results on admission
showed a white blood cell count of 16,200 cells/\selectlanguage{greek}µ\selectlanguage{english}L, hemoglobin level of
11.8 g/dL, and platelet count of 102,000 /\selectlanguage{greek}µ\selectlanguage{english}L. His serum potassium (8.0
mmol/L) and C-reactive protein (41.7 mg/dL) levels were elevated. His
other blood test results are shown in Table 1.

\textbf{Differential diagnosis, investigations, and treatment}

He was admitted to the hospital and underwent emergency hemodialysis to
correct the hyperkalemia, and his serum potassium level decreased to 4.5
mmol/L. On day 2 of admission, he developed a fever (40.1\selectlanguage{ngerman}°C), and his
right lower back pain worsened. Pelvic magnetic resonance imaging (MRI)
revealed findings suggestive of an epidural abscess and spondylitis at
the L5/S1 intervertebral disc (Figure 1). Blood culture revealed
anaerobic gram-negative cocci. Based on these findings, the patient's
condition was diagnosed as spondylitis and epidural abscess caused by
anaerobic bacteria. Antimicrobial therapy was initiated with intravenous
ampicillin/sulbactam (3 g 6-hourly). Testing using a VITEK-ANC Card®
identified the pathogen as a \emph{Veillonella} species. and 16S rRNA
polymerase chain reaction identified the species as
\emph{Veillonellaparvula} . Based on the susceptibility by the micro
liquid dilution method (Table 2), the antimicrobial agent was changed to
ampicillin (2 g 6-hourly).

\textbf{Outcome and follow-up}

After initiation of ampicillin, the clinical and imaging signs of
inflammation gradually improved. Antibiotics were administered for 58
days, and the patient was discharged on day 60. He has been followed up
further for 6 months since his discharge, and has not experienced a
recurrence.

\textbf{Discussion}

This is a rare case of epidural abscess and spondylitis caused by
V\emph{. parvula} . Hirai et al.\textsuperscript{6} reviewed the
literature from 1976 to October 2015 and found 31 cases
of\emph{Veillonella} infection in humans. Of these cases, five were
musculoskeletal infections caused by \emph{V. parvula} , including four
spinal infections. There has been only one case of an epidural abscess
caused by \emph{V. parvula} reported previously.\textsuperscript{7} To
our knowledge, the current case is the first report of human \emph{V.
parvula} infection in Japan. The previously reported case of an epidural
abscess caused by \emph{V. parvula} \textsuperscript{7} was in a cancer
patient, and our patient was on hemodialysis; therefore, \emph{V.
parvula} appears to be an opportunistic pathogen that affects
immunocompromised patients. Previous reports have indicated the
importance of anaerobic culture for identifying this
pathogen;\textsuperscript{6} in our case, anaerobic culture isolated the
organism, and further investigation revealed the species, suggesting
that anaerobic culture should be considered in patients with signs of an
epidural abscess, especially in immunocompromised patients.

Most \emph{Veillonella} spinal infections reported to date have been
associated with a subacute course of lower back pain from 1 week to 4
months.\textsuperscript{1,8,9} Spinal infections may develop serious
complications if the diagnosis is delayed.\textsuperscript{10} Our case
was diagnosed early using MRI. MRI should be considered in
immunocompromised patients with signs of musculoskeletal infection with
low back pain, such as our case.

In conclusion, this is the first case of epidural abscess and
spondylitis caused by \emph{V. parvula} reported in Japan.
Musculoskeletal infection caused by \emph{Veillonella} can lead to
chronic back pain in immunocompromised patients, and early diagnosis
using MRI and anaerobic culture are recommended.

\textbf{Author Contributions:}

All authors critically revised the report, commented on drafts of the
manuscript, and approved the final report.

\textbf{Conflict of Interest:} None declared.

\textbf{Funding:} This study was supported by a grant that was provided
by the Japan Primary Care Association project for Developing Future
Leaders in Research (grant number: 2019B002).

\textbf{Consent for Publication:} The patient has provided informed
consent for publication.

\textbf{References}

1. Kishen, T. J., S. T. Lindstrom, G. Etherington, and A. D. Diwan.
2012. \emph{Veillonella} spondylodiscitis in a healthy 76-year-old lady.
Eur Spine J 21(Suppl~4):413-417.

2. Chen, Y. C., P. H. Ko, C. J. Yang, Y. C. Chen, C. J. Lay, C. C. Tsai,
et al. 2016. Epidural abscess caused by \emph{Veillonella parvula} :
case report and review of the literature. J Microbiol Immunol Infect
49:804\selectlanguage{english}-808.

3. Baker, S., and R. Allyn. 2017. Lytic lesions: looking lethal but
leaving room for a simple cure? A case of \emph{Veillonella} spinal
osteomyelitis. JMM Case Rep 4:e005108.

4. Mashima, I., and F. Nakazawa. 2015. Interaction
between\emph{Streptococcus} spp. and \emph{Veillonella tobetsuensis} in
the early stages of oral biofilm formation. J Bacteriol 197:2104-2111.

5. Gouze, H., L. Noussair, I. Padovano, E. Salomon, M. de Laroche, C.
Duran, et al. 2019. \emph{Veillonella parvula} spondylodiscitis. Med Mal
Infect 49:54-58.

6. Hirai, J., Y. Yamagishi, T. Kinjo, M. Hagihara, D. Sakanashi, H.
Suematsu, et al. 2016. Osteomyelitis caused by
\emph{Veillonella}species: case report and review of the literature. J
Infect Chemother 22:417-420.

7. Chen, Y.C., P. H. Ko, C. J. Yang, Y. C. Chen, C. J. Lay, C. C. Tsai,
et al. 2016. Epidural abscess caused by \emph{Veillonella parvula} :
case report and review of the literature. J Microbiol Immunol Infect
49:804-808.

8. Marriott, D., D. Stark, and J. Harkness. 2007. \emph{Veillonella
parvula} discitis and secondary bacteremia: a rare infection
complicating endoscopy and colonoscopy? J Clin Microbiol 45:672-674.

9. Isner-Horobeti, M. E., J. Lecocq, A. Dupeyron, S. J. De Martino, P.
Froehlig, and P. Vautravers. 2006. \emph{Veillonella} discitis. A case
report. Joint Bone Spine 73:113-115.

10. Jean, M., J. O. Irisson, G. Gras, F. Bouchand, D. Simo, C. Duran, et
al. 2017. Diagnostic delay of pyogenic vertebral osteomyelitis and its
associated factors. Scand J Rheumatol 46:64-68.

\textbf{Table 1} . Laboratory data of the patient\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Variable & Reference range & Value on admission\tabularnewline
\midrule
\endhead
Red blood cell (per \selectlanguage{greek}μ\selectlanguage{english}L) & 3860 000--4920 000 & 4620 000\tabularnewline
Hemoglobin (g/dL) & 11.6--14.8 & 11.8\tabularnewline
Hematocrit (\%) & 35.1--44.4 & 37.7\tabularnewline
White blood cell (per \selectlanguage{greek}μ\selectlanguage{english}L) & 3300--8600 & 16200\tabularnewline
Platelets (per \selectlanguage{greek}μ\selectlanguage{english}L) & 158 000--348 000 & 1020000\tabularnewline
Sodium (mmol/L) & 135--145 & 136\tabularnewline
Potassium (mmol/L) & 3.6--4.8 & 8.0\tabularnewline
Chloride (mmol/L) & 101--108 & 100\tabularnewline
Urea nitrogen (mg/dL) & 8.0--20.0 & 80.6\tabularnewline
Creatinine (mg/dL) & 0.46--0.79 & 14.46\tabularnewline
Alanine aminotransferase (U/L) & 13--30 & 86\tabularnewline
Aspartate aminotransferase (U/L) & 7--23 & 21\tabularnewline
Alkaline phosphatase (U/L) & 106--322 & 378\tabularnewline
C-reactive protein (mg/dL) & 0.0--0.1 & 41.7\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Antimicrobial susceptibility of this patient\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Antimicrobial & Minimal inhibitory concentration (\selectlanguage{greek}µ\selectlanguage{english}g/mL)\tabularnewline
\midrule
\endhead
Ampicillin & [?]0.5\tabularnewline
Piperacillin & 8\tabularnewline
Cefaclor & [?]8\tabularnewline
Cefotiam & 16\tabularnewline
Cefotaxime & 16\tabularnewline
Ceftazidime & [?]1\tabularnewline
Ceftriaxone & 4\tabularnewline
Flomoxef & [?]1\tabularnewline
Azithromycin & 16\tabularnewline
Imipenem and cilastatin & 2\tabularnewline
Ampicillin and sulbactam & [?]0.5\tabularnewline
Piperacillin and tazobactam & 4\tabularnewline
Gentamycin & \textgreater{}16\tabularnewline
Clindamycin & \textgreater{}4\tabularnewline
Minocycline & [?]2\tabularnewline
Levofloxacin & [?]0.5\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure 1.}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\textbf{Figure Legend}

Figure 1. Lumbar magnetic resonance imaging on the second day of
hospitalization. The image shows an extensive epidural abscess with
evidence of discitis in the L5/S1 region.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/2-5/2-5}

\end{center}
\end{figure}

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