Rare, post-periodontitis spondylodiscitis caused by Fusobacterium nucleatum in a patient with multiple sclerosis: challenge of diagnosis and treatment

Fusobacterium nucleatum is part of the commensal flora of the oral cavity, frequently associated with periodontal infections. We describe the case of a 49-year-old woman, on immunsuppressive therapy for multiple sclerosis, who presented with a 3-month history of debilitating back pain. She had a recent episode of periodontitis, and was under regular dental review. Her MRI scan demonstrated findings suggestive of L2–L3 spondylodiscitis. Her CT-guided biopsy yielded negative cultures and the patient failed two courses of empirical antibiotic treatment. With clinical and radiological disease progression, she underwent a percutaneous disc washout and biopsy, which subsequently grew F. nucleatum. Treatment with clindamycin and metronidazole was commenced orally for 6 weeks. She improved gradually, and at 1 year follow-up was asymptomatic. The diagnosis of spondylodiscitis caused by F. nucleatum is challenging. The perseverance on identification by surgical biopsy, minimally invasive washout and targeted antibiotics are the mainstay of effective treatment.

P5557Cardiac autoantibodies and ventricular arrhythmias in patients with biopsy-proved myocarditis

Background Cardiac autoandibodies have been associated with dilatative cardiomyopathy in subjects with inflammatory heart disease. However, their association with ventricular arrhythmias (VA) in patients with autoimmune myocardits has never been investigated so far. Purpose To evaluate the association between cardiac autoantibodies and both baseline and FU VA in patients with a de novo diagnosis of biopsy-proved autoimmune myocarditis. Methods We enrolled 44 consecutive patients (59% males, mean age 44±13y, mean LVEF 50±10%) presenting with symptomatic VA (VF, VT, NSVT, >1ehz746.0501 PVC/24h) and a de novo diagnosis of biopsy-proved autoimmune myocarditis according to the ESC criteria. Serum anti-heart (AHA) and anti-intercalated disk (AIDA) autoantibodies were assessed at a referral center at the time of the index hospitalization. Complete baseline data, including ECG, arrhythmia telemonitoring, echocardiogram, cardiac magnetic resonance (CMR) and blood biomarkers (T-troponin, NT-proBNP) were collected. The endpoint of the study was the occurrence of major VA (VT, VF, appropriate ICD shocks) at 5y FU, as assessed by 2/y Holter ECG monitoring and (when applicable) ICD interrogation. Results At baseline evaluation, 24 (55%) and 23 patients (52%) were AHA+ and AIDA+, respectively. Clinical onset with major VA was documented in 24 patients (55%): 9 AHA+ vs. 15 AHA- (p=0.017) and 13 AIDA+ vs. 11 AIDA- (p=0.547). At presentation, no significant differences were found between AHA+ vs. AHA- and AIDA+ vs. AIDA- patients in LVEDV, LVEF, T-troponin and NT-proBNP values (all p=n.s.). Positive (2/3) Lake Louise criteria at CMR were found in 33 patients (75%; p=n.s. among different subgroups). Before discharge, 27 subjects (61%) underwent ICD implant. Optimal medical treatment was started in all of the cases, with no significant differences in betablockers, antiarrhythmic drugs and immunsuppressive therapy, among different subgroups (all p=n.s.). Overall, 10 patients (23%) experienced major VA by 5y FU: 3 AHA+ vs. 7 AHA- (p=0.147) and 9 AIDA+ vs. 1 AIDA- (p=0.013). In particular, 18 events were documented (range 1–3 episodes per patient at 2.2±1.7 y mean FU), including 3 VT episodes and 15 appropriate ICD shocks. Taking together baseline and FU data, multiple (>1) major VA episodes occurred in 8 patients: 3 AHA+ vs. 5 AHA- (p=0.436) and 8 AIDA+ vs. 0 AIDA- (p=0.005). Of note, 3/3 AHA+ patients with multiple major VA espisodes were also AIDA+ (double positivity). Conclusion In biopsy-proved autoimmune myocarditis presenting with VA, major VA occurrence by 5y FU, as well as arrhythmias recurrences, are more common among AIDA+ patients. By converse, none of the isolated AHA+ cases experienced multiple episodes of major VA. These findings may suggest distinct pathophysiological mechanisms involving the different molecular targets of cardiac autoimmunity. Acknowledgement/Funding None

Unusual Presentation of Granulomatosis With Polyangitis (Wegener's Granulomatosis)

Objective: To present a case of unusual presentations of granulomatosis with polyangitis (Wegener’s granulomatosis) with parotid swelling and intractable otitis externa. Material and method: A 22-year-old male patient presented with left sided otitis externa with left sided parotid swelling and bilateral nasal obstruction for last two weeks. CT scan of paranasal sinuses showed homogenous mass in both maxillary antra and nasal cavities. FNAC from the parotid swelling was suggestive of granulomatous disease and endoscopic biopsy from the nasal mass showed features of granulomatosis with polyangitis (Wegener’s granulomatosis). CT scan of chest revealed multiple cysts within the lung parenchyma; urine examination showed RBC and pus cells. Renal biopsy showed focal segmental glomerulonephritis. c-ANCA was highly positive and thus the diagnosis of Wegener’s granulomatosis was made. Result: Patient received cyclophosphamide and prednisolone immunsuppressive therapy for one year, which showed marked clinical improvement. Conclusion: Granulomatosis with polyangitis (Wegener’s granulomatosis) is not an uncommon entity for otolarygologists. Its usual presentation mimics chronic rhinosinusitis; but presentations like otitis externa and parotid swelling are rare for this disease.