Can an infectious process cause abrupt levoscoliosis?

Can Infectious Processes Cause Abrupt Levoscoliosis?

Yes, infectious processes—particularly spinal infections such as discitis-osteomyelitis, epidural abscess, and tuberculous spondylitis—can cause abrupt levoscoliosis and should be urgently evaluated with MRI when suspected.

Key Infectious Etiologies to Consider

Spinal Infections (Discitis-Osteomyelitis and Epidural Abscess)

• Spinal infections commonly present with new or worsening back/neck pain, fever, and elevated inflammatory markers (ESR/CRP) 1
• These infections can cause structural changes and paraspinal muscle spasm leading to acute scoliotic deformity 1
• MRI without and with IV contrast is the imaging modality of choice for suspected spine infection, as it can identify marrow edema, paraspinal muscle abnormalities, epidural fluid collections, and spinal cord compression 1
• The use of IV contrast is critical to define the size and extent of epidural abscesses, which represent a feared complication that may result in spinal cord or cauda equina compression 1

Tuberculous Spondylitis

• Spinal tuberculosis characteristically causes destruction of 2 or more contiguous vertebrae with spread along the anterior longitudinal ligament 2
• MRI demonstrates sensitivity of 96%, specificity of 94%, and accuracy of 92% for diagnosing spinal TB 2
• Patients from TB-endemic regions should undergo tuberculin skin test (PPD) or interferon-γ release assay when spinal TB is suspected 2
• TB spine can present with disc infection and paraspinal masses or mixed soft tissue/fluid collections 2

Clinical Red Flags Requiring Urgent Evaluation

When evaluating abrupt levoscoliosis, immediately assess for:

• Fever or constitutional symptoms suggesting active infection 1
• Elevated ESR or CRP (highly suggestive when combined with back pain) 1
• Recent bacteremia (particularly Staphylococcus aureus within preceding 3 months) 1
• Neurologic deficits or signs of spinal cord compression 1
• Risk factors for spinal infection: immunosuppression, IV drug use, recent spinal procedures, decubitus ulcers overlying spine 1

Important Caveat: Levoscoliosis Pattern

Levoscoliosis (left-sided curvature) is inherently more concerning than dextroscoliosis 3:

• Only 6.6% of adolescent idiopathic scoliosis cases present as levoscoliosis 3
• In patients with Chiari malformation and syringomyelia, 50% had levoscoliosis 3
• The atypical pattern of levoscoliosis should prompt evaluation for underlying pathology including infection, tumor, or neurologic abnormalities 3

Diagnostic Algorithm for Abrupt Levoscoliosis

1. Obtain inflammatory markers (ESR, CRP) and complete blood count 1
2. Perform MRI of the spine without and with IV contrast emergently/urgently if infection suspected 1, 2
3. Do NOT delay imaging for empiric antibiotics unless patient is septic or has neurologic compromise 1
4. Obtain image-guided or intraoperative biopsy for microbiologic diagnosis before starting definitive antimicrobial therapy 1
5. Consider TB testing (PPD or interferon-γ release assay) in patients from endemic regions 2

Non-Infectious Causes of Secondary Scoliosis

While the question focuses on infection, recognize that secondary scoliosis from pleural infection/empyema is transient and benign 1:

• Commonly seen in children with empyema, with patient leaning toward the affected lung 1
• Caused by pleuritic pain and discomfort, not structural spinal pathology 1
• Resolves spontaneously without specific treatment and should be confirmed resolved on follow-up 1
• This represents a postural compensation, not true structural scoliosis from spinal infection

Critical Management Point

The combination of abrupt levoscoliosis with fever, elevated inflammatory markers, or neurologic symptoms mandates urgent MRI evaluation to exclude life-threatening spinal infections 1. Plain radiographs are insensitive for early diagnosis of spinal infection and should not delay advanced imaging 1.