Fungal infections of the spine

The IFSD Score-A Practical Prognostic Model for Invasive Fungal Spondylodiscitis

Objectives: Invasive fungal spondylodiscitis (IFSD) is rare and could be lethal in certain circumstances. The previous literature revealed limited data concerning its outcomes. This study aimed to establish a risk-scoring system to predict the one-year mortality rate of this disease. Methods: A total of 53 patients from a multi-centered database in Taiwan were included in this study. All the clinicopathological and laboratory data were retrospectively analyzed. Variables strongly related to one-year mortality were identified using a multivariate Cox proportional hazards model. A receiver operating characteristic (ROC) curve was used to express the performance of our IFSD scoring model. Results: Five strong predictors were included in the IFSD score: predisposing immunocompromised state, the initial presentation of either radiculopathy or myelopathy, initial laboratory findings of WBC > 12.0 or <0.4 103/µL, hemoglobin < 8 g/dL, and evidence of candidemia. One-year mortality rates for patients with IFSD scores of 0, 1, 2, 3, and 4 were 0%, 16.7%, 56.3%, 72.7%, and 100%, respectively. The area under the curve of the ROC curve was 0.823. Conclusions: We developed a practical scoring model with easily obtained demographic, clinical, and laboratory parameters to predict the probability of one-year mortality in patients with IFSD. However, more large-scale and international validations would be necessary before this scoring model is commonly used.

Advances in diagnosis and management of atypical spinal infections: A comprehensive review

Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

Changes of the microbiological spectrum and antibiotic resistance pattern in postoperative spinal implant infections with multiple culture-positive revision surgeries

BACKGROUND CONTEXT

In severe cases of postoperative spinal implant infections (PSII) multiple revision surgeries may be needed. Little is known if changes in the microbiological spectrum and antibiotic resistance pattern occur between revision surgeries.

PURPOSE

Analysis of the microbiological spectrum and antibiotic resistance pattern in patients with multiple revision surgeries for the treatment of PSII STUDY DESIGN: Retrospective database analysis.

PATIENT SAMPLE

Between 01/2011 and 12/2018, 103 patients underwent 248 revision surgeries for the treatment of PSII. Twenty patients (19.4%) who underwent multiple revision surgeries for PSII were included in this study.

OUTCOME MEASURES

Microbiological spectrum, antibiotic resistance pattern.

METHODS

A retrospective analysis of a prospectively maintained single center spine infection database was performed with a minimum follow-up of 3 years. Overall, 20 patients (six male/14 female) underwent 82 revisions for PSII (median 3; range 2-12). There were 55 of 82 (67.1%) procedures with a positive microbiological result. Microbiological analysis was performed on tissue and implant sonication fluid. Changes in microbial spectrum and antibiotic resistance pattern between surgeries were evaluated using Chi-Square and Fisher's exact test.

RESULTS

In total, 74 microorganisms (83.3% gram-positive; 10.8% gram-negative) were identified. The most common microorganisms were Staphylococcus epidermidis (18.9%) and Cutibacterium acnes (18.9%). All S. epidermidis identified were methicillin-resistant (MRSE). Overall, there were 15 of 55 (27.3%) polymicrobial infections. The microbiological spectrum changed in 57.1% (20/35) between the revision stages over the entire PSII period. In 42.9% (15/35) the microorganism persisted between the revision surgeries stages. Overall, changes of the antibiotic resistance pattern were seen in 17.4% (8/46) of the detected microorganisms, comparing index revision and all subsequent re-revisions. Moreover, higher resistance rates were found for moxifloxacin and for ciprofloxacin at first re-revision surgery compared with index PSII revision. Resistances against vancomycin increased from 4.5% (1/23) at index PSII revision to 7.7% (2/26) at first re-revision surgery.

CONCLUSIONS

Changes of the microbiological spectrum and the resistance pattern can occur in patients with severe PSII who require multiple revision surgeries. It is important to consider these findings in the antimicrobial treatment of PSII. The microbiological analysis of intraoperative tissue samples should be performed at every revision procedure for PSII.

Fungal Arthritis of a Lumbar Facet Joint Because of Candida albicans: A Case Report

CASE

A 73-year-old man who was treated in our hospital for pyelonephritis because of left ureteral stones and fungemia was referred to our orthopaedic department for persistent right lower-back pain. Magnetic resonance imaging and computed tomography findings showed pyogenic arthritis of the right L4/5 facet joint with a paraspinal muscle abscess. Based on cultures of samples aspirated from the lesions, we diagnosed the patient with fungal arthritis of the lumbar facet joint. We treated him conservatively with an antifungal agent for a year, and the infection resolved.

CONCLUSION

This is the first report of hematogenous fungal arthritis of a lumbar facet joint.

Sequential endoscopic and robot-assisted surgical solutions for a rare fungal spondylodiscitis, secondary lumbar spinal stenosis, and subsequent discal pseudocyst causing acute cauda equina syndrome: a case report

Background

Fungal spondylodiscitis is a rare infectious disease. The secondary lumbar spinal stenosis and postoperative discal pseudocyst were even rarer. The surgical interventions were disputed, yet endoscopic and robot-assisted techniques may be helpful under different circumstances.

Case presentation

A 62-year-old female was diagnosed as infectious spondylodiscitis at the L4/5 level and a posterolateral endoscopic debridement was performed after invalid conservative therapy. Causative organism culture revealed a rare fungus, Candidatropicalis. A secondary spinal stenosis with refractory radiculopathy occurred almost 3 years after the first surgery and a successful endoscopic surgery was implemented aiming to decompress the nerve in a minimally invasive way. However, 2 months later, the patient manifested severe acute cauda equina syndrome and radiological examinations suggested a rare postoperative discal pseudocyst. A laminectomy followed by a pseudocystectomy was applied to achieve thorough decompression. An innovative double trajectory system (simultaneous traditional pedicle screw and cortical bone trajectory screw) accompanied by posterolateral fusion was designed and executed by the professional robot-assisted system.

Conclusion

Endoscopic and robot-assisted techniques may provide alternative solutions for fungal spondylodiscitis and accompanied sequelae.

Case Report: SARS-CoV-2 Infection-Are We Redeemed? A Report of Candida Spondylodiscitis as a Late Complication

Background: We describe a case of candida spondylodiscitis secondary to coronavirus disease (COVID-19). Case report: A 47-year-old man diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) required prolonged admission to the intensive care unit (ICU). Four months later, he was diagnosed with thoracic candida spondylodiscitis. Medical management was insufficient, so he eventually underwent surgery. Discussions: Fungal infections seem to be more likely in patients with COVID-19, but it is unknown whether they are directly attributed to COVID-19 or other surrounding factors. Regardless of the answer, the diagnosis is complicated, and the mortality rate is high. Lessons: COVID-19 is posing a challenge to the society, and new and unexpected diseases that had once disappeared have risen again. It is our duty to suspect them and to treat them in the most effective way possible.

An unusual case of childhood osteoarticular tuberculosis from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (Győr-Moson-Sopron county, Hungary)

Ancient human remains exhibiting bony changes consistent with osteoarticular tuberculosis (OATB) indicate that the disease has afflicted mankind for millennia. Nonetheless, not many pediatric OATB cases have been published in the paleopathological literature–from Hungary, only three cases have been described up to now. In our paper, we demonstrate a child (S0603) from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (northwestern Hungary), who represents a unique case of OATB regarding both the pattern and severity of the observed bony changes. During the macromorphological and radiological investigations, the most serious alterations were discovered in the upper thoracic spine–the development of osteolytic lesions led to severe bone loss and consequent collapse and fusion of several adjacent vertebrae. The pathological process terminated in a sharp, rigid angular kyphosis. Disruption of the normal spine curvature resulted in consequent deformation of the whole thoracic wall–it became “rugby-ball-shaped”. The overall nature and pattern of the detected alterations, as well as their resemblance to those of described in previously published archaeological and modern cases from the pre-antibiotic era indicate that they are most consistent with OATB. Based on the severity and extent of the lesions, as well as on the evidence of secondary healing, S0603 suffered from TB for a long time prior to death. Besides body deformation, OATB resulted in consequent disability in daily activities, which would have required regular and significant care from others to survive. It implies that in the Árpádian Age community of Győrszentiván-Révhegyi tag, there was a willingness to care for people in need. Detailed archaeological case studies can give us a unique insight into the natural history and different presentations of OATB. Furthermore, they can provide paleopathologists with a stronger basis for diagnosing TB and consequently, with a more sensitive means of assessing TB frequency in past populations.

Minimally invasive debridement and drainage using intraoperative CT-Guide in multilevel spondylodiscitis: a long-term follow-up study

Background

Spondylodiscitis is an unusual infectious disease, which usually originates as a pathogenic infection of intervertebral discs and then spreads to neighboring vertebral bodies. The objective of this study is to evaluate percutaneous debridement and drainage using intraoperative CT-Guide in multilevel spondylodiscitis.

Methods

From January 2002 to May 2017, 23 patients with multilevel spondylodiscitis were treated with minimally invasive debridement and drainage procedures in our department. The clinical manifestations, evolution, and minimally invasive debridement and drainage treatment of this refractory vertebral infection were investigated.

Results

Of the enrolled patients, the operation time ranged from 30 minutes to 124 minutes every level with an average of 48 minutes. Intraoperative hemorrhage was minimal. The postoperative follow-up period ranged from 12 months to 6.5 years with an average of 3.7 years. There was no reactivation of infection in the treated vertebral segment during follow-up, but two patients with fungal spinal infection continued to progress by affecting adjacent segments prior to final resolution. According to the classification system of Macnab, one patient had a good outcome at the final follow-up, and the rest were excellent.

Conclusions

Minimally invasive percutaneous debridement and irrigation using intraoperative CT-Guide is an effective minimally invasive method for the treatment of multilevel spondylodiscitis.

Spinal blastomycosis: unusual musculoskeletal presentation with literature review

We report a case of a 41-year-old male who presented to our institution with a large groin mass. CT, MRI and PET imaging was performed and was concerning for a soft tissue abscess likely originating in the lumbar spine. Differential considerations included infection, with atypical infections such as tuberculosis strongly considered. Biopsy revealed fungal elements preliminarily reported as consistent with Cryptococcus neoformans but later revealed to be Blastomyces dermatitidis. The patient responded positively following the introduction of appropriate treatment. This case illustrates the imaging similarities between spinal blastomycosis, spinal tuberculosis, and other fungal infections as well as the need for biopsy to differentiate.

Invasive pulmonary aspergillosis with Aspergillus vertebral osteomyelitis in an HIV-infected adult: a case report

We report the case of a 29-year-old man with human immunodeficiency virus infection and irregular adherence to antiretroviral therapy who initially presented with pulmonary symptoms and subsequently developed spinal cord compromise symptoms. After many different diagnostic tests, invasive aspergillosis with pleuroparenchymal involvement and vertebral osteomyelitis by Aspergillus spp. was diagnosed. The patient was treated with amphotericin B deoxycholate without improvement and a fatal outcome ensued. Differential diagnoses of vertebral osteomyelitis in immunosuppressed patients should be taken into account for early detection and prompt treatment.

Dual Invasive Fungal Infection Presenting with Cervical Myelopathy

Disseminated fungal infections are often seen in immunocompromised patients. Here we present a case of a previously healthy woman presenting with cervical myeloradiculopathy found to have two separate fungal infections in the setting of depressed CD4 cell counts and a genetic mutation predisposing to invasive fungal infections.

Treatment algorithm for spontaneous spinal infections: A review of the literature

Background:

Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

Methods:

A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus.

Results:

Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment.

Conclusion:

A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.

Fungal spondylodiscitis in a patient recovered from H7N9 virus infection: a case study and a literature review of the differences between Candida and Aspergillus spondylodiscitis

To report a rare case of fungal spondylodiscitis in a patient recovered from H7N9 virus infection and perform a literature review of the different characteristics of Candida and Aspergillus spondylodiscitis, we reviewed cases of spondylodiscitis caused by Candida and Aspergillus species. Data, including patients' information, pathogenic species, treatment strategy, outcomes, and relapses, were collected and summarized. The characteristics of Candida and Aspergillus spondylodiscitis were compared to see if any differences in clinical features, management, or consequences could be detected. The subject of the case study was first misdiagnosed as having a vertebral tumor, and then, following open biopsy, was diagnosed as having fungal spondylodiscitis. The patient made a good recovery following radical debridement. Seventy-seven additional cases of Candida spondylodiscitis and 94 cases of Aspergillus spondylodiscitis were identified in the literature. Patients with Candida spondylodiscitis tended to have a better outcome than patients with Aspergillus spondylodiscitis (cure rate 92.3% vs. 70.2%). Candida was found more frequently (47.8%) than Aspergillus (26.7%) in blood cultures, while neurological deficits were observed more often in patients with Aspergillus spondylodiscitis (43.6% vs. 25.6%). Candida spinal infections were more often treated by radical debridement (60.5% vs. 39.6%). Patients with Candida spondylodiscitis have better outcomes, which may be associated with prompt recognition, radical surgical debridement, and azoles therapy. A good outcome can be expected in fungal spondylodiscitis with appropriate operations and anti-fungal drugs.

Multidetector Computed Tomography and MR Imaging Findings in Mycotic Infections

Fungal infections constitute a diverse spectrum of infections with variable clinical and imaging features. They are commonly opportunistic infections that affect immunocompromised individuals secondary to inherited or acquired disorders. Fungal infections may affect multiple organ systems and contribute to significant morbidity and mortality. Although the imaging features of some fungal infections are characteristic and permit their diagnosis, many mycotic infections manifest nonspecific findings. Definitive diagnosis often depends on histopathological analysis. Early diagnosis requires both clinical suspicion and supporting radiological evidence. Early treatment results in reduced morbidity and mortality. This article reviews the imaging findings in opportunistic and endemic fungal infections.

Neurosurgical approaches to spinal infections

Spinal infection is rare. Clinical suspicion is important in patients with nonmechanical neck and/or back pain to make the proper diagnosis in early disease. Before planning surgery, a thorough evaluation of the spinal stability, alignment, and deformity is necessary. Timing of surgery, side of approach, appropriate surgical technique, and spinal instruments used are crucial. Biomechanical preservation of the spinal column during and after the infection is a significant issue. Postoperative spine infection is another entity of which spinal surgeons should be aware of. Proper septic conditions with meticulous planning of surgery are essential for successful spine surgery and better outcome.

Pathologic basis of pyogenic, nonpyogenic, and other spondylitis and discitis

Pyogenic spondylitis and discitis are usually seen following a recent infection or surgery. A septic embolus causes an infarcted area within the bone. Pyogenic spondylitis is characterized by edema, vascular leakage, and supportive inflammatory reaction characterized with polymorphonuclear leukocytes. In tuberculosis of the spine, active lesions are characterized by formation of epithelioid granulomas with central caseating necrosis. Mycobacterium tuberculosis can be shown by histochemical stains for acid-fast bacteria or by immunochemistry. In brucella spondylitis, microgranulomatous proliferation composed of histiocytes containing numerous bacilli without caseating necrosis is characteristic. Brucella melitensis can be shown on histochemical Gram stain.

Anterior cervical corpectomy and fusion for blastomycosis causing destruction of C6 vertebra: a case report

Introduction

We describe a patient who had cervical spine osteomyelitis caused by Blastomyces dermatitidis that resulted in cord compression and cervical spine instability.

Case presentation

A 25-year-old Hispanic woman presented with fever, sweats, neck pain, and an enlarging neck mass with purulent discharge after sustaining a C6 vertebral body fracture. Magnetic resonance imaging confirmed C6 vertebral osteomyelitis, demonstrated by vertebral body destruction, cervical spine instability, prevertebral abscess, and spinal cord compression. She underwent C6 anterior cervical corpectomy and fusion, with fungal cultures confirming Blastomyces dermatitidis.

Conclusions

Anterior cervical corpectomy and fusion successful debrided, decompressed, and restored cervical spine stability in a patient with vertebral osteomyelitis caused by Blastomyces dermatitidis. The patient was subsequently treated with a 1-year course of itraconazole and had no recurrence of infection 4 years postoperatively.

Fungal Infections of the Spine

STUDY DESIGN

Review of the literature.

OBJECTIVE

To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease.

SUMMARY OF BACKGROUND DATA

Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series.

METHODS

MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database.

RESULTS

A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles.

CONCLUSION

Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections.

LEVEL OF EVIDENCE

3.

Postoperative initial single fungal discitis progressively spreading to adjacent multiple segments after lumbar discectomy

OBJECTIVE

To report multiple cases and investigate etiology of initially single fungal spondylodiscitis that progressively spread to adjacent segments following lumbar discectomy, resulting in multiple spinal involvements.

METHODS

From January 2005 to May 2013, ten adult patients were admitted or referred to our institution with postoperative discitis. Fungal infections were confirmed by microbiologic and pathologic examinations. The clinical appearance, radiographic features, and treatments of this pathology were investigated.

RESULTS

All the patients were previously healthy. The average interval between the occurrence of symptoms and primary lumbar discectomy was 61 days (range, 15-120 days). All the patients were treated with anterior surgical debridement, interbody fusion, and prolonged antifungal therapy. Three patients additionally received combined posterior instrumented fusion. Despite aggressive surgical debridement and antifungal therapy, spread of the infections to adjacent multiple discs was observed. No deaths, severe neurologic deficits, or deterioration of neurologic status were noted. The infections were completely resolved in all cases with spontaneous fusion within an average follow-up of 32.4 months.

CONCLUSION

Fungal spondylodiscitis after surgery represents an intractable and troublesome complication, and surgical debridement may not impede the progression of the infection in cases where an insufficient course of antifungal treatment is administered. Such cases may require prolonged antifungal treatment with regular consultation by an infectious disease specialist.

Thoracic spinal cord intramedullary aspergillus invasion and abscess

Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12-L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases.

Candida albicans spondylodiscitis following an abdominal stab wound: forensic considerations

Candida albicans spondylodiscitis is a fungal infection of the spine which is still unusual in spite of the increasing frequency of predisposing factors. A 22-year-old man received an abdominal stab wound during a physical assault. Initial medical care included surgery, prolonged use of indwelling vascular catheters with administration of broad-spectrum antibiotics, and hospitalization in intensive care. Two months after the event, the victim experienced back pain in the right lumbar region and septic spondylodiscitis secondary to C. albicans was diagnosed three weeks later. This case is noteworthy because of its clinical forensic context. In France, the public prosecutor orders a medico-legal assessment after an assault for all living victims in order to establish a causal relationship between the assault and its complications. In our case, the patient presented numerous risk factors for candidemia and the forensic specialist reasonably accepted that the causal relationship was certain but indirect. We have only found one published case of spondylodiscitis after an abdominal penetrating injury and the pathogenic agent was not mentioned. We have found no case reported in a forensic context. This unusual observation shows that it may be genuinely difficult to prove the causal relationship between an abdominal penetrating injury and an unusual infectious complication such as fungal spondylodiscitis.

Candida spondylitis: Comparison of MRI findings with bacterial and tuberculous causes

OBJECTIVE

Candida spondylitis is relatively uncommon and is usually encountered as an opportunistic infection. We analyzed the MRI characteristics of biopsy-proven cases of Candida spondylitis, and compared the findings with bacterial or tuberculous spondylitis.

MATERIALS AND METHODS

The study included patients with infectious spondylitis who underwent MRI and biopsy from 1998 to 2011 (60 patients; mean age 56 ± 18 years). MR images were analyzed with respect to the number of involved vertebrae, contrast enhancement pattern, signal intensity of spinal inflammatory masses on T2-weighted imaging, paraspinal abscess size, intervertebral disk destruction, subligamentous spread, and skip lesions. The Fisher exact test and analysis of variance were used for statistical analysis.

RESULTS

There were 10 cases of Candida spondylitis, and 29 and 21 cases of bacterial and tuberculous spondylitis, respectively. On MRI, disk destruction was seen in 50%, 93%, and 30% of Candida, bacterial, and tuberculous cases, respectively. Subligamentous spread of infection was noted in 22%, 10%, and 85%. Paraspinal inflammatory masses were seen in 100%, 100%, and 76%, and abscesses in 100%, 66%, and 90%, of Candida, bacterial, and tuberculous cases, respectively. Paraspinal inflammatory masses contained low T2 signal intensity portions in 80%, 21%, and 67%, and skip lesions were seen in 0%, 10%, and 14%, respectively. Small abscesses were noted in 100%, 76%, and 35% of Candida, bacteria, and tuberculosis infections, respectively. Candida involved 2.3 ± 0.4 vertebrae compared with 2.3 ± 0.9 and 3.0 ± 1.7 in bacterial and tuberculous, respectively. Differences in the three groups were statistically significant (p < 0.05) except for the number of involved vertebrae, and skip lesions.

CONCLUSION

Candida spondylitis can be suspected when infectious lesions contain low-signal spinal inflammatory masses on T2-weighted imaging, small paraspinal abscesses, and in immunocompromised patients.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

Evaluación de una nueva sistematización de estudios para el diagnóstico del síndrome de destrucción vertebral

OBJETIVO: Explorar la efectividad de un conjunto de pruebas de diagnósticos, sistematizadas en hoja de protocolo, para la determinación del Síndrome de Destrucción Vertebral en pacientes de nuestro servicio. MÉTODOS: Analizamos una propuesta de sistematización mediante un estudio piloto de 20 pacientes a quienes se realizaron 10 diferentes pruebas de laboratorio y gabinete, además del estudio histopatológico de biopsia percutánea. Se describieron las características demográficas y clínicas, con los resultados obtenidos mediante estadística descriptiva, media y desviación estándar para las variables cuantitativas y porcentajes para las cualitativas. RESULTADOS: Edad promedio de 53,3 años ± 16,56 años; 10 hombres y 10 mujeres. 30 vértebras afectadas en los 20 pacientes, 8 de ellos tuvieron afección de dos o más vértebras. El nivel más afectado fue el Lumbar en 18 casos, seguido por el Torácico en 12. El Mal de Pott se diagnosticó en 7 casos (35%), Osteomielitis en 4 (20%), Mieloma Múltiple en 2 (10%), y Espondilodiscitis, Metástasis de Adenocarcinoma, Linfoma y Osteoporosis en un caso respectivamente (5%). En 3 casos (15%) no se obtuvo un diagnóstico específico. CONCLUSIONES: Esta propuesta de sistematización fue útil para llegar al diagnóstico etiológico definitivo del SDV en 85% de los casos, con la reducción en la cantidad de estudios realizados. Es necesario mayor número de pacientes para aumentar la evidencia de su utilidad.

Treatment of spondylodiscitis

PURPOSE

Pyogenic infections of the spine are relatively rare with an incidence between 1:100,000 and 1:250,000 per year, but the incidence is increasing due to increases in average life-expectancy, risk factors, and medical comorbidities. The mean time in hospital varies from 30 to 57 days and the hospital mortality is reported to be 2-17%. This article presents the relevant literature and our experience of conservative and surgical treatment of pyogenic spondylodiscitis.

METHOD

We have performed a review of the relevant literature and report the results of our own research in the diagnosis and treatment of pyogenic spondylodiscitis. We present a sequential algorithm for identification of the pathogen with blood cultures, CT-guided biopsies and intraoperative tissue samples. Basic treatment principles and indications for surgery and our surgical strategies are discussed.

RESULTS

Recent efforts have been directed toward early mobilisation of patients using primary stable surgical techniques that lead to a further reduction of the mortality. Currently our hospital mortality in patients with spondylodiscitis is around 2%. With modern surgical and antibiotic treatment, a relapse of spondylodiscitis is unlikely to occur. In literature the relapse rate of 0-7% has been recorded. Overall the quality of life seems to be more favourable in patients following surgical treatment of spondylodiscitis.

CONCLUSION

With close clinical and radiological monitoring of patients with spondylodiscitis, conservative and surgical therapies have become more successful. When indicated, surgical stabilisation of the infected segments is mandatory for control of the disease and immediate mobilisation of the patients.

Spondylodiscitis: update on diagnosis and management

Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

Multiple osseous involvements in a case of disseminated cryptococcosis

Osseous involvement occurs in 5-10% of patients with disseminated cryptococcosis. We are reporting an unusual case of disseminated cryptococcosis involving the sternum and lumbar vertebra with the formation of psoas abscess with pulmonary tuberculosis. The patient presented with fever for 3 months. A diagnosis of pulmonary tuberculosis was made on thoracic contrast-enhanced computerized tomography and she was put on antituberculosis treatment. She was immunocompetent with negative human immunodeficiency virus. She conceived subsequently and had complaints of backache and swelling over the sternum. Magnetic resonance imaging showed destruction of L5 vertebra with psoas abscess. Vertebral cryptococcosis may mimic tuberculosis and malignancy. She had a bad obstetric history and experienced five, first-trimester spontaneous abortions in each successive year since 2001. This pregnancy again resulted in spontaneous abortion. Cryptococcus neoformans was isolated from two different sites: pus-involving the sternum and ultrasound-guided psoas abscess aspirate. Serum latex agglutination test for cryptococcal capsular polysaccharide antigen was positive. The diagnosis of cryptococcosis was delayed because the patient was diagnosed as a case of pulmonary tuberculosis, wherein clinical signs, symptoms and radiological findings in both the conditions are similar. Amphotericin B was started but she developed varicella infection and expired due to cardiac failure.

Treatment for multiple Aspergillus spondylitis including a hip joint

Multiple aspergillus spondylitis (AS) is a life threatening infection that occurs more commonly in immunocompromised patients, and is commonly treated with antifungal agents. However, there is relatively little information available on the treatment of multiple AS. The authors encountered a 46-year-old man suffering from low back and neck pain with radiculomyelopathy after a liver transplant. The patient had concomitant multiple AS in the cervico-thoraco-lumbar spine and right hip joint, as confirmed by radiologic imaging studies. The pathological examination of a biopsy specimen revealed fungal hyphae at the cervical and lumbar spine. Anterior decompression and interbody fusion were performed for the cervical and lumbar lesions, which showed instability and related neurological symptoms. Additional antifungal therapy was also performed. The patient was treated successfully with remission of his symptoms.

Treatment of spondylodiscitis in human immunodeficiency virus-infected patients: a comparison of conservative and operative therapy

STUDY DESIGN

Multicenter retrospective case series.

OBJECTIVE

To determine relevant clinical presentation and outcome of human immunodeficiency virus (HIV)-positive patients with spondylodiscitis as a function of the treatment.

SUMMARY OF BACKGROUND DATA

This is the first study comparing the clinical outcome of HIV-positive patients with spondylodiscitis as a function of the treatment.

METHODS

We performed a national multicenter retrospective case series comparing operatively versus conservatively treated HIV-positive patients with spondylodiscitis presenting between 1991 and 2007.

RESULTS

Twenty patients were included in the study. The average age of the patients at the time of admission was 43.0 years. The sex ratio m:w resulted in 2.3:1. On admission, 50% of the patients were in CDC stage C3. The CD4 T-cell count was determined as being 237.5/microL on average. At the occurrence of spondylodiscitis HIV had been known for a mean 8.5 years. In altogether 75% of the cases a pathogen was found. In 3 cases, mixed infections were present. Half of the patients received surgery. In none of these patients a wound infection or a delay of wound healing could be observed. One patient died during in-patient stay. Eleven of the 19 patients could be followed up a mean 13 months after discharge. In the follow-up period further 3 patients died on an average of 45 months after discharge.

CONCLUSION

The occurrence of spondylodiscitis in HIV-positive patients is associated with a low CD4 T-cell count. The probability of mixed infections rises with a CD4 T-cell count <100/microL. The occurrence of spondylodiscitis in HIV-positive patients is accompanied by high mortality. Operative therapy of spondylodiscitis in HIV-positive patients is not associated with an increased surgical complication rate. HIV infection or AIDS should not have an influence on decision-making regarding conservative or operative therapy of spondylodiscitis.

Nonsurgical treatment of lumbosacral blastomycosis involving L2-S1: a case report

STUDY DESIGN

A case report and clinical discussion.

OBJECTIVE

To discuss the diagnosis and treatment of Blastomyces dermatitidis in the spine.

SUMMARY OF BACKGROUND DATA

Blastomycosis, like other fungal organisms, has a nonspecific appearance on radiographs, and is often mistaken for TB or a neoplasm. Nonsurgical treatment of this infection is possible, however, as seen in this case. The difficulty in diagnosing fungal infections often leads to a delay in treatment.

METHODS

We report on a 37-year-old Arabian woman who presented initially with progressive low back and anterior thigh pain without precipitating trauma. She was found to have 2 draining fistulas. Computed tomography-guided percutaneous drainage of the paravertebral phlegmon yielded purulent material that was pan cultured. The KOH preparation was consistent with a fungal pathogen, which was later identified as Blastomyces dermatitidis by polymerase chain reaction.

RESULTS

Radiologic studies of the lumbar spine and sacrum performed revealed extensive involvements with osseous destruction of L2-S1. The destruction was most severe at L3 with mild boney retropulsion at that level. Throughout the patient's treatment course, she complained of mild-to-moderate lower back pain and had no neurologic symptoms. Therefore, surgery was deferred.

CONCLUSION

There are no pathognomonic findings of blastomycosis on magnetic resonance imaging. Fungal osteomyelitis is rarely identified in this country, and blastomycosis is even less often diagnosed. This case illustrates that fungal osteomyelitis should be considered in the radiographic differential diagnosis until a definitive diagnosis is made through biopsy.

Current diagnosis and treatment of spondylodiscitis

INTRODUCTION

Infection of the spinal column is rare, and often recognized and treated too late. Spondylodiscitis is osteomyelitis of the spine and can cause severe symptoms. Hospital mortality is in the region of 2% to 17%.

METHODS

Selective literature review and results of the authors' own research.

RESULTS

The incidence of pyogenic spondylodiscitis is around 1 : 250 000, which represents around 3% to 5% of osteomyelitis as a whole. 10% to 15% of all vertebral infections can be ascribed to exogenous spondylodiscitis, with Staphylococcus aureus as the commonest pathogen, 2% to 16% of which are reported to be MRSA (methicillin-resistant S. aureus). Catheter-related, nosocomial infection with MRSA is a key cause for spondylodiscitis. 50% of all skeletal tuberculoses are found in the spine.

DISCUSSION

Spondylodiscitis should be borne in mind in cases of diffuse back pain and non-specific symptoms. MRI is the diagnostic modality of choice for detecting spondylodiscitis. Thanks to precise monitoring of conservative treatments and primarily stable surgical techniques, prolonged immobilization of the patient is no longer necessary nowadays.

Postoperative Trichosporon asahii spondylodiscitis after open lumbar discectomy: a case report

STUDY DESIGN

A case report of Trichosporon asahii spondylodiscitis.

OBJECTIVE

To report the first case of T. asahii spondylodiscitis that developed in a healthy woman at the site of an open lumbar discectomy.

SUMMARY OF BACKGROUND DATA

Trichosporon is a genus of basidiomycetous yeasts that is common in nature and a member of the normal flora of the mouth, skin, and nails. It causes deep infections and fungemia mainly in immunocompromised patients or patients with underlying hematologic malignancies. To our knowledge, there is no reported case of bone and joint infections caused by T. asahii.

METHODS

A 42-year-old female gynecologist was transferred to our hospital with a chief complaint of severe lower back pain after an open L4-L5 discectomy. The infection indexes showed an elevated erythrocyte sedimentation rate and the C-reactive protein. Despite bed rest and antibiotic therapy, the lower back pain and tingling sensation on both lower extremities continued to worsen. The magnetic resonance imaging showed an abscess-like fluid collection compressing the thecal sac and showed a signal change in the bone marrow of the L4 and L5 vertebral bodies, suggesting spondylodiscitis. Laminectomy, curettage, and debridement of the infected discs were performed. Cultures of the abscess yielded yeasts that were sensitive to fluconazole. The yeast was identified as T. asahii.

RESULTS

She received fluconazole therapy for 5 months, and returned to her work after the fourth postoperative month. She has remained in a satisfactory condition since.

CONCLUSION

We present the first case of T. asahii spondylodiscitis, which developed unexpectedly in a healthy woman at the site of an open lumbar discectomy. We successfully treated the patient with surgical debridement and 5 months of fluconazole therapy.

Recent advances: Infections of the spine

The global increase of spinal infections is concomitant with the rise of its risk factors, including HIV/AIDS, diabetes mellitus, intravenous drug use, advanced age, and gunshot wounds to the spine. Because spinal infections have a wide span of presentation, early detection and differentiation are notoriously challenging. Current advances in laboratory and imaging techniques, such as polymerase chain reaction, fluorodeoxyglucose positron emission tomography, and 99mTc-ciprofloxacin scintigraphy, allow for better diagnostic rendering of the infection and its degree of spinal involvement. Less invasive surgical procedures and preventive surgical management have helped reduce spinal infection morbidities such as deformity and neurologic deficit. Although proper antibiotic regimen and correct surgical management are of vital importance to successful patient outcome, early detection remains the most critical factor.