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Chronic Obstructive Pneumonia Caused by a Vertebral Body Osteophyte

      Osteophytes associated with spondylosis have been implicated as a cause of multiple extraspinal manifestations. Symptoms are more likely to occur with the large osteophytes associated with diffuse idiopathic skeletal hyperostosis. In the thoracic region, osteophytes have been reported infrequently as a cause of extraspinal complications. We report a case in which an anterior thoracic vertebral osteophyte was responsible for chronic obstructive pneumonia due to obstruction of the right main stem bronchus. The patient's condition improved considerably after surgical resection of the compressing thoracic osteophyte.
      DISH (diffuse idiopathic skeletal hyperostosis)
      Thoracic spondylosis has been implicated as a cause of several extraspinal manifestations, including myelopathy
      • Smith DE
      • Godersky JC
      Thoracic spondylosis: an unusual cause of myclopathy.
      • Reisner A
      • Stiles RG
      • Tindall SC
      Diffuse idiopathic skeletal hyperostosis causing acute thoracic myelopathy: a ease report and discussion.
      • Wilson FM
      • Jaspan T
      Thoracic spinal cord compression caused by diffuse idiopathic skeletal hyperostosis (DISH).
      radiculopathy.
      • Taillandier J
      • Alcmanni M
      • Manigand G
      Radiculalgie dorsale et hyperostose vertébrale.
      • Silben PL
      • Radhakrishnan K
      • Litchy WJ
      The spectrum of thoracic radiculopathy: what is an appropriate evaluation? [abstract].
      Horner syndrome,
      • Bemad PG
      • Perlo VP
      Homer syndrome with causalgia.
      and esophageal food impaction.
      • Underberg-Davis S
      • Levine MS
      Giant thoracic osleophyte causing eosphageal food impaction.
      Some of these manifestations are associated with diffuse idiopathic skeletal hyperostosis (DISH).
      • Reisner A
      • Stiles RG
      • Tindall SC
      Diffuse idiopathic skeletal hyperostosis causing acute thoracic myelopathy: a ease report and discussion.
      • Wilson FM
      • Jaspan T
      Thoracic spinal cord compression caused by diffuse idiopathic skeletal hyperostosis (DISH).
      • Taillandier J
      • Alcmanni M
      • Manigand G
      Radiculalgie dorsale et hyperostose vertébrale.
      We report a case in which a thoracic vertebral body osteophyte caused several clinical, radiological, and laboratory manifestations associated with chronic obstructive pneumonia. Although the presence of large thoracic vertebral osteophytes is common, to our knowledge, the association with obstructive pneumonia has not been previously reported.

      Report Of A Case

      An 85-year-old man presented to our internal medicine clinic because of a 6-month history of intermittent fever, chills, generalized weakness, and a cough productive of white sputum. He had received a course of trimethoprimsulfamethoxazole with no improvement. Three days before consultation, the patient's symptoms worsened, with a temperature up to 39°C. His sputum became purulent, and he developed generalized weakness to the point that he was unable to drive.
      The patient had a 3-year history of daily cough productive of whitish sputum, which had been attributed to postnasal drip. Because of a history of normochromic, normocytic anemia, he recently underwent upper and lower gastrointestinal endoscopy, which revealed mild gastritis and a benign colonic polyp. He had chronic obstructive pulmonary disease and a 120-pack-year history of cigarette smoking. In addition, he had a 3-year history of progressive, generalized weakness and a weight loss of 13.6 kg over the past year. Previously, laparotomy had been done for an “ileal abscess,” and lumbar vertebral fusion had been performed. The patient was semiretired and traveled throughout the United States in a motor home.
      On physical examination, the patient was mildly cachectic and in no acute distress. His blood pressure was 130/60 mm Hg, pulse rate was 80/min with frequent extrasystoles, respirations were I8/min, and temperature was 37.5°C. Lung auscultation revealed bilateral expiratory wheezing and bilateral coarse inspiratory crackles, greater on the right than on the left.
      Laboratory results were remarkable for a hemoglobin concentration of 11.7 g/dL., mean corpuscular volume of 90.2 fL, and leukocyte count of 8.7 × 10
      • Jonathan D
      • Baer S
      Cervical osteophytes: their significance in ENT practice (ankylostng vertebral hyperostosis-Forestier's disease).
      /L with 83% neutrophils and 8.2% lymphocytes. The erythrocyte sedimentation rate was 87 mm in 1 hour. The purified protein derivative skin test was negative. Chest radiography (Figure 1) revealed hyperinflated lungs, an infiltrate in the right lower lobe region, and a small right pleural effusion. Blood cultures were negative. Sputum cultures revealed many leukocytes but no organisms. Serum protein electrophoresis was clinically important only for a low albumin level. Bone marrow biopsy and aspirate revealed a reactive hypercellular marrow, and iron stains were compatible with anemia of chronic disease.
      Figure thumbnail gr1
      Figure 1Chest radiogram demonstrating an infiltrate in the right lower lobe of the lung medially (arrow).
      The patient was treated initially with intravenous antibiotics, and his condition improved slowly. However, symptoms recurred after his regimen was changed to oral agents. Computed tomography of the chest revealed a right basilar nodular infiltrate, platelike atelectasis in the left base, and prominent lymphadenopathy in the left axilla and left subpectoral area. An anterior thoracic vertebral body osteophyte was producing a mass effect on the posterior wall of the right main stem bronchus (Figure 2). Fiberoptic bronchoscopy showed almost complete obstruction of the right main stem bronchus, which appeared as an extrinsic compression from its posterior aspect (Figure 3). The obstruction was not fixed and could be bypassed easily to allow the passage of the bronchoscope. Transbronchial biopsy revealed chronic inflammation. Bronchial washing cytology and cultures were negative. An excisional biopsy specimen of an enlarged lymph node in the left axilla revealed reactive inflammation.
      Figure thumbnail gr2
      Figure 2Computed tomogram depicting the large anterior thoracic vertebral body osteophyte producing some mass effect on the posterior wall of the right main stem bronchus (arrow).
      Figure thumbnail gr3
      Figure 3Fiberoptic bronchoscopy at the level of the carina, showing the posterior extrinsic mass effect on the right main stem bronchus (arrowhead).
      The patient underwent thoracotomy, with resection of a 6 × 6 × 5-cm osteophyte arising from the anterior aspect of the T7 vertebral body (Figure 4) and another smaller osteophyte arising from the anterior aspect of the T6 vertebral body. The procedure was well tolerated by the patient.
      Figure thumbnail gr4
      Figure 4Intraoperative photograph demonstrating the large osteophyte (arrowheads) arising from the anterior aspect of the T7 vertebral body (arrow).
      Four months later, the patient's symptoms had diminished considerably, with complete resolution of the infiltrate. His hemoglobin concentration had improved to 14.1 g/dL, and the erythrocyte sedimentation rate had decreased to 3 mm in 1 hour. On follow-up fiberoptic bronchoscopy, the area of narrowing in the right main stem bronchus had improved to less than 50% of the lumen (Figure 5).
      Figure thumbnail gr5
      Figure 5Fiberoptic bronchoscopy after resection of the anterior thoracic vertebral body osteophytes, showing reduction in the extrinsic posterior mass effect on the right main stem bronchus (arrowhead).

      Discussion

      Cervical spondylosis is recognized as a rare cause of dysphagia,
      • Kibel SM
      • Johnson PM
      Surgery for osteophyte-induced dys-phagia.
      • Jonathan D
      • Baer S
      Cervical osteophytes: their significance in ENT practice (ankylostng vertebral hyperostosis-Forestier's disease).
      • Brandenburg G
      • Leibrock LG
      Dysphagia and dysphonia secondary to anterior cervical osteophytes.
      aspiration pneumonia.
      • Warniek C
      • Sherman MS
      • Lesser RW
      Aspiration pneumonia due to diffuse cervical hyperostosis.
      • Babores M
      • Finnerty JP
      Aspiration pneumonia secondary to giant cervical osteophyte formation (diffuse idiopathic skeletal hyperstosis or Foresiier's disease): a case report.
      myelopathy,
      • Ebersold MJ
      • Pare MC
      • Quasi LM
      Surgical treatment for cervical spondytitic myelopalhy.
      upper airway obstruction,
      • Demuynck K
      • Van Calenbcrgh F
      • Goffin J
      • Verschakelen J
      • Demedts M
      • Van de Woeslijne K
      Upper airway obstruction caused by a cervical osteophyte.
      dysphonia,
      • Brandenburg G
      • Leibrock LG
      Dysphagia and dysphonia secondary to anterior cervical osteophytes.
      and vertebral artery compression.
      • Alexandrov AV
      • Norris JW
      Recurrent stroke caused by spondy-lotic compression of the vertebral artery [letter].
      Symptoms are particularly apt to occur in DISH, which may be associated with large cervical osteophytes.
      • Eviatar E
      • Harell M
      Diffuse idiopathic skeletal hyperostosis with dysphagia (a review).
      • Hughes TA
      • Wiles CM
      • Lawrie BW
      • Smith AP
      Case report: dysphagia and sleep apnoea associated with cervical osleophytes due to diffuse idiopathic skeletal hyperostosis [letter].
      • Rotes-Querol J
      Clinical manifestations of diffuse idiopathic skeletal hyperostosis [editorial].
      • Stechison MT
      • Tator CH
      Cervical myelopathy in diffuse idiopathic skeletal hyperostosis: case report.
      • Singh NK
      • Gupta SK
      • Agrawal A
      • Srivastava PK
      Cervical myelopathy in diffuse idiopathic skeletal hyperosteosis.
      • Chavaillon JM
      • Perrin C
      • Vivona P
      Detresse respiratoire par compression tracheale au cours d'une maladie de Forestier [letter |.
      • Marks B
      • Schober E
      • Swoboda H
      Diffuse idiopathic skeletal hyperostosis causing obstructing laryngeal edema.
      Warnick et al
      • Warniek C
      • Sherman MS
      • Lesser RW
      Aspiration pneumonia due to diffuse cervical hyperostosis.
      described a patient whose symptoms progressed from dysphagia to choking and finally aspiration pneumonia secondary to cervical body osteophytes and who underwent surgical excision of the osteophytes.
      Thoracic spondylosis has been cited as a cause of myelopathy
      • Smith DE
      • Godersky JC
      Thoracic spondylosis: an unusual cause of myclopathy.
      Horner syndrome,
      • Bemad PG
      • Perlo VP
      Homer syndrome with causalgia.
      radiculopathy.
      • Taillandier J
      • Alcmanni M
      • Manigand G
      Radiculalgie dorsale et hyperostose vertébrale.
      • Silben PL
      • Radhakrishnan K
      • Litchy WJ
      The spectrum of thoracic radiculopathy: what is an appropriate evaluation? [abstract].
      and esophageal food impaction.
      • Underberg-Davis S
      • Levine MS
      Giant thoracic osleophyte causing eosphageal food impaction.
      These symptoms are more likely to occur in patients with DISH, who have large bridging osteophytes.
      • Reisner A
      • Stiles RG
      • Tindall SC
      Diffuse idiopathic skeletal hyperostosis causing acute thoracic myelopathy: a ease report and discussion.
      • Wilson FM
      • Jaspan T
      Thoracic spinal cord compression caused by diffuse idiopathic skeletal hyperostosis (DISH).
      • Taillandier J
      • Alcmanni M
      • Manigand G
      Radiculalgie dorsale et hyperostose vertébrale.
      To our knowledge, the occurrence of obstructive pneumonia due to a large thoracic vertebral osteophyte has not been previously reported. The frequency of this complication cannot be determined, but because the occurrence of large osteophytes in this region is occasionally detected radiographically, we suspect this complication may occur in other patients.
      Lumbar osteophytes in patients with DISH have been implicated in lumbar spinal stenosis
      • Leroux JL
      • Legeron P
      • Moulinier L
      • et al.
      Stenosis of the lumbar spinal canal in vertebral ankylosing hyperostosis.
      and in inferior vena caval obstruction.
      • Scapinelli R
      Compression of the inferior vena cava due to diffuse idiopathic skeletal hyperostosis.
      In our patient, an anterior thoracic vertebral osteophyte produced a 3-year history of cough, weight loss, and associated manifestations of chronic pneumonia secondary to mechanical compression of the right main stem bronchus. He had no history of gastroesophageal reflux disease or history suggestive of aspiration pneumonia. These entities should be included in the differential diagnosis of chronic lower lobe pneumonia. The patient presented with right lower lobe pneumonia, although the obstructing lesion was at the proximal aspect of the right main stem bronchus. We hypothesize that this was most likely because this obstruction was not fixed and varies with such factors as patient position. Any abnormal secretions or possibly aspirated bacteria would preferentially accumulate in the most dependent lobe of the right lung.
      Although follow-up fiberoptic bronchoscopy showed residual obstruction, it was approximately 50% less than that seen on the previous examination. The persistent mild degree of obstruction is likely explained by remodeling of that portion of the bronchial tree by the chronic pressure, spanning decades, produced by the compressing osteophyte. At follow-up 21/2 years after surgery, the patient continued to experience fatigue and symptoms related to chronic bronchitis, but he had no recurring episodes of pneumonia.
      We propose that vertebral body osteophytes, although rare, be considered in the differential diagnosis of chronic obstructive pneumonia.

      References

        • Smith DE
        • Godersky JC
        Thoracic spondylosis: an unusual cause of myclopathy.
        Neurosurgery. 1987; 20: 589-593
        • Reisner A
        • Stiles RG
        • Tindall SC
        Diffuse idiopathic skeletal hyperostosis causing acute thoracic myelopathy: a ease report and discussion.
        Neurosurgery. 1990; 26: 507-511
        • Wilson FM
        • Jaspan T
        Thoracic spinal cord compression caused by diffuse idiopathic skeletal hyperostosis (DISH).
        Clin Radiol. 1990; 42: 133-135
        • Taillandier J
        • Alcmanni M
        • Manigand G
        Radiculalgie dorsale et hyperostose vertébrale.
        Rev Rhum Mal Osteoariic. 1991; 58: 471-472
        • Silben PL
        • Radhakrishnan K
        • Litchy WJ
        The spectrum of thoracic radiculopathy: what is an appropriate evaluation? [abstract].
        Neurology. 1994; 44: A307
        • Bemad PG
        • Perlo VP
        Homer syndrome with causalgia.
        Neurology. 1980; 30: 534-535
        • Underberg-Davis S
        • Levine MS
        Giant thoracic osleophyte causing eosphageal food impaction.
        AJR Am J Roentgenol. 1991; 157: 319-320
        • Kibel SM
        • Johnson PM
        Surgery for osteophyte-induced dys-phagia.
        J Laryngol Otol. 1987; 101: 1291-1296
        • Jonathan D
        • Baer S
        Cervical osteophytes: their significance in ENT practice (ankylostng vertebral hyperostosis-Forestier's disease).
        J Laryngol Otol. 1990; 104: 236-238
        • Brandenburg G
        • Leibrock LG
        Dysphagia and dysphonia secondary to anterior cervical osteophytes.
        Neurosurgery. 1986; 18: 90-93
        • Warniek C
        • Sherman MS
        • Lesser RW
        Aspiration pneumonia due to diffuse cervical hyperostosis.
        Chest. 1990; 98: 763-764
        • Babores M
        • Finnerty JP
        Aspiration pneumonia secondary to giant cervical osteophyte formation (diffuse idiopathic skeletal hyperstosis or Foresiier's disease): a case report.
        Chest. 1998; 114: 1481-1482
        • Ebersold MJ
        • Pare MC
        • Quasi LM
        Surgical treatment for cervical spondytitic myelopalhy.
        J Neurosurg. 1995; 82: 745-751
        • Demuynck K
        • Van Calenbcrgh F
        • Goffin J
        • Verschakelen J
        • Demedts M
        • Van de Woeslijne K
        Upper airway obstruction caused by a cervical osteophyte.
        Chest. 1995; 108: 283-284
        • Alexandrov AV
        • Norris JW
        Recurrent stroke caused by spondy-lotic compression of the vertebral artery [letter].
        Ann Neurol. 1994; 35: 126
        • Eviatar E
        • Harell M
        Diffuse idiopathic skeletal hyperostosis with dysphagia (a review).
        J LaryngoS Oiol. 1987; 101: 627-632
        • Hughes TA
        • Wiles CM
        • Lawrie BW
        • Smith AP
        Case report: dysphagia and sleep apnoea associated with cervical osleophytes due to diffuse idiopathic skeletal hyperostosis [letter].
        J Neurol Neurosurg Psychiatry. 1994; 57: 384
        • Rotes-Querol J
        Clinical manifestations of diffuse idiopathic skeletal hyperostosis [editorial].
        Br J Rheumatol. 1996; 35: 1193-1194
        • Stechison MT
        • Tator CH
        Cervical myelopathy in diffuse idiopathic skeletal hyperostosis: case report.
        J Neurosurg. 1990; 73: 279-282
        • Singh NK
        • Gupta SK
        • Agrawal A
        • Srivastava PK
        Cervical myelopathy in diffuse idiopathic skeletal hyperosteosis.
        Autralas Radiol. 1986; 30: 137-138
        • Chavaillon JM
        • Perrin C
        • Vivona P
        Detresse respiratoire par compression tracheale au cours d'une maladie de Forestier [letter |.
        Presse Med. 1991; 20: 1230
        • Marks B
        • Schober E
        • Swoboda H
        Diffuse idiopathic skeletal hyperostosis causing obstructing laryngeal edema.
        Eur Arch Otorhinolaryngol. 1998; 255: 256-258
        • Leroux JL
        • Legeron P
        • Moulinier L
        • et al.
        Stenosis of the lumbar spinal canal in vertebral ankylosing hyperostosis.
        Spine. 1992; 17: 1213-1218
        • Scapinelli R
        Compression of the inferior vena cava due to diffuse idiopathic skeletal hyperostosis.
        Rev Rhum Engl Ed. 1997; 64: 198-211