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The incidence of endocarditis in large series of VO has been reported to range from selleck inhibitor Given previous knowledge about differences between Streptococcus species causing endocarditis [7], echocardiography was not routinely performed in all cases of SVO and this fact may be considered a limitation of our study. Thus, echocardiography was carried out in 81% of our viridans SVO cases with bacteraemia but it was only performed in 16% of non-viridans SVO with bacteraemia. However, it is very unlikely that this produced an important diagnostic bias, given the long follow-up of patients. Our comparison of vertebral osteomyelitis caused by S.?aureus with that caused by the viridans group also showed a significantly higher number of cases with endocarditis in the latter group, despite the fact that bacteraemia was even higher in the S.?aureus group. Once again, our results are in agreement with those of Mulleman et?al. [15], who reported endocarditis in only 3% of their patients with staphylococcal vertebral LMTK2 osteomyelitis. We believe that the association between endocarditis http://www.selleckchem.com/products/Romidepsin-FK228.html and vertebral osteomyelitis is especially due to the group of viridans Streptococcus, and thus, it is in this case that performing an echocardiography should be mandatory. When considering the presence of concomitant infection among non-viridans SVOs we noted that S.?pneumoniae was a significant contributor to these cases. Although all these infections have been previously described in relation to pneumococcal disease [12, 13], we noted that it was not only respiratory tract infections that were documented in our patients [8-12]. In the analysis of SVO caused by the viridans group we showed that patients with bacteraemia often suffered from endocarditis and their clinical presentation mimicked that for a sub-acute endocarditis caused by viridans Streptococcus [7, 32]. The clinical scenario of those patients without bacteraemia was close to that of VO caused by low-virulent bacteria and VO with no microbiological diagnosis (long diagnostic delay in older patients who were more likely to suffer from a debilitating disease with no concomitant infection) [3, 17, 18]. These data should be taken into account when seeking to identify the microorganism responsible for VO, or when initiating an empirical antimicrobial therapy. In conclusion, SVO presents a wide range of clinical patterns.