IE can mimic a variety of manifestations: neurologic, systemic, and rheumatic. The frequency of rheumatic manifestations (RM) ranges from 19 to 44% [1-3], they are not specific of EI and are particularly hard to diagnose. Moreover, they often precede the diagnosis of EI; patients often present first to a rheumatology clinic; causing a delay up to 4 weeks in the diagnosis.

In the recent years, many studies have emphasized the prevalence of these manifestations in patients with IE [4-7]. The RM can be symmetric polyarthritis, arthralgia, myalgia, osteitis, or spondylodiscitis; [2,8]. The incidence of spondylodiscitis as a complication of endocarditis varies widely, ranging from 0,02% to up to 16% [5,9], those numbers show that spondylodiscitis remain rare and has only been described as case reports in the past few years. Ninet et al [10] found the prevalence of spondylodiscitis in patients with IE to be 5,9% and Thomas et al. [11] reported a prevalence of 3,7% among 108 with IE. The rarity of this association contrasts with frequency of back pain as a clinical finding in patient with IE. In many studies on IE back pain was reported in up to 43% of patients [12]. In our case report the two patients had backpain as main clinical manifestation like the results shown in most of the studies. However, in their study Myers and al found that all the patients presenting with back pain had kidney manifestations related to endocarditis (muscular abscess, renal infarction discovered post-mortem).

As concerning the pathophysiology of this complication many mechanisms have been suggested, such as bacterial emboli, immune dysfunction [2,4] or hematogenous dissemination.

Gender in published reports was predominantly masculine and age was mainly above 55 years [10,13,14], our patients were male and age respectively 50 and 60. A large variety of bacteria are found in cases of IE associated with spondylodiscitis. However, in most studies as in our described cases, group D streptococcus is the most frequent causative agent [10,15]. There have also been reported cases of IE caused by coagulase negative staphylococci especially in patient with pacemaker [4]. In a study published by Churchill and al. about bacteria found in patients with endocarditis and RM; streptococcus was first in line (49%), followed by staphylococcus (19%), group D streptococcus (15%) and Gram-negative bacteria, those results were comparable to the classical germs responsible of endocarditis with no complications. However, Vlahakis and al. [1] showed in a recent published report that among   nine described cases of patients with enterococcus and RM complicating IE, seven had spondylodiscitis confirmed on MRI.

The treatment does not differ from IE without complications except for duration of treatment. Patient with the association spondylodiscitis and IE should have 6 weeks of treatment and up to 3 months (this duration is explained by spondylodiscitis) is often based on antibiotic therapy and is extended to 6 weeks.

The rheumatic manifestations of IE have in most cases a good outcome under the effect of antibiotic therapy [1] and the overall prognosis depends on the cardiac complications. The treatment does not differ from IE without complications regarding antibiotic except for duration of treatment. Patient with the association spondylodiscitis and IE receive 6 weeks of treatment and up to 3 months.