Candida spondylodiscitis and epidural abscess: management with shorter courses of anti-fungal therapy in combination with surgical debridement

Candida spondylodiscitis: a systematic review and meta-analysis of seventy two studies

OBJECTIVES

Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors.

METHODS

A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed.

RESULTS

In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival.

CONCLUSION

Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Lumbar cistern Candida intradural abscess following epidural anesthesia

Background:

This report describes a case of an immunocompetent patient with an intradural abscess from Candida dubliniensis. The majority of fungal spine infections, although rare in general, are due to Aspergillus or C. albicans through systemic fungemia. To date, there have only been two reports of spondylodiscitis from C. dubliniensis.

Case Description:

A 37-year-old immunocompetent female patient presented to the neurosurgical service for worsening headaches with nausea, vomiting, vision changes, and weight loss. MRI studies showed diffuse leptomeningeal enhancement of the distal spinal cord, conus medullaris, and nerve roots of the cauda equina extending beyond the neural foramina bilaterally. She had persistent symptoms and no clear diagnosis on lumbar puncture or systemic testing therefore L5-S1 laminectomy for an intradural tissue biopsy was performed. During surgery, cultures were taken and grew colonies of C. dubliniensis.

Conclusion:

This organism has been reported rarely in the literature as being an infectious agent, thus diagnosing remains a challenge but should be considered in patients with a suggestive history.

One-stage oblique lateral corridor antibiotic-cement reconstruction for Candida spondylodiscitis in patients with major comorbidities: Preliminary experience

Fungal spondylodiscitis is rare (0.5%-1.6% of spondylodiscitis) and mainly caused by Candida albicans. Surgical intervention in spondylodiscitis patients is indicated for compression of neural elements, spinal instability, severe kyphosis, failure of conservative management and intractable pain. However, there is no evidence-based optimal surgical approach for spondylodiscitis. There have been only case reports of surgical treatment for Candida spondylodiscitis. We evaluated the preliminary results of the efficacy and safety of one-stage debridement via oblique lateral corridor with interbody fusion (OLIF) using stand-alone cement reconstruction after debridement for the treatment of Candida spondylodiscitis in patients with major co-morbidities. Five patients (4 males, 1 female, mean age: 64.2 years) suffering from Candida albicans lumbar spondylodiscitis who underwent this procedure were studied. Their predominant symptoms were unremitting back and leg pain and all had pre and postoperative anti-fungal therapy under microbiologist supervision. The operative time ranged from 137minutes to 260minutes (mean: 213.4minutes). The mean blood loss was 160mL (range: 100-200mL). There were no perioperative complications. At follow-up all showed major improvement in pain and ambulatory status. CT scan showed radiological stability for all patients at 6-12 months. Our preliminary results showed stand-alone anterior debridement and spinal re-construction with cement through mini-open OLIF approach might be a safe and effective option for patients with spinal fungal infection and major comorbidities.

Azole-resistant Candida albicans Spondylodiscitis After Bariatric Surgery: A Case Report

CASE

We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up.

CONCLUSION

Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.

Fungal cauda equina lesion with delayed cord compression and treatment response

This is a 24 year old man with profound chronic hydrocephalus found to have a cauda equina abscess composed of Candida albicans. Prior literature reveals a paucity of central nervous system candidiasis. In these previously reported cases, there was evidence of local invasion of surrounding structures; however, this case is a sentinel report of a fungal abscess without evidence of local structural invasion. The patient's course was complicated by clinical and radiographic worsening to cauda equina syndrome, requiring emergent surgical decompression, despite appropriate antifungal treatment. This case illustrates the diagnostic challenge of this rare entity and the need for close follow up with this patient population.

Intrathecal spinal abscesses due to Candida albicans in an immunocompetent man

Infections of the central nervous system due to Candida albicans are uncommon and are usually only observed in special circumstances, such as following neurosurgery or penetrating head trauma, in immunosuppressed patients, premature infants or in patients with ventriculoperitoneal shunts. The author reports a case of an immunocompetent man who presented with a thoracic intraspinal abscess due to C. albicans Despite surgical drainage and 6 weeks of high-dose fluconazole therapy, the abscess extended and recurred in the cervical spine, requiring a second operation to arrest the infection.

[Vertebral osteomyelitis due to Candida tropicalis secondary to candidemia. A case report]

Candida spp. vertebral osteomyelitis is rare. Clinical presentation is unspecific. Diagnosis requires mycological culture of a biopsy specimen. Therapeutic management is based on prolonged course of azole or liposomal amphotericin B. We report the case of Candida tropicalis vertebral osteomyelitis with epidural involvement in a 27 years-old male patient, followed for S-β-thalassemia and with a history of candidemia. The fungus was isolated from a needle biopsy of the vertebral disk. The outcome was favorable under antifungal treatment by amphotericin B and voriconazole.

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.

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

The incidence of spinal infections has increased in the past two decades, owing to the increasing number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use. Conventional MRI is the gold standard for diagnostic imaging; however, there are still a significant number of misdiagnosed cases. Diffusion-weighted imaging (DWI) with a b-value of 1000 and apparent diffusion coefficient (ADC) maps provide early and accurate detection of abscess and pus collection. Pyogenic infections are classified into four types of extension based on MRI and DWI findings: (1) epidural/paraspinal abscess with spondylodiscitis, (2) epidural/paraspinal abscess with facet joint infection, (3) epidural/paraspinal abscess without concomitant spondylodiscitis or facet joint infection and (4) intradural abscess (subdural abscess, purulent meningitis and spinal cord abscess). DWI easily detects abscesses and demonstrates the extension, multiplicity and remote disseminated infection. DWI is often a key image in the differential diagnosis. Important differential diagnoses include epidural, subdural or subarachnoid haemorrhage, cerebrospinal fluid leak, disc herniation, synovial cyst, granulation tissue, intra- or extradural tumour and post-surgical fluid collections. DWI and the ADC values are affected by susceptibility artefacts, incomplete fat suppression and volume-averaging artefacts. Recognition of artefacts is essential when interpreting DWI of spinal and paraspinal infections. DWI is not only useful for the diagnosis but also for the treatment planning of pyogenic and non-pyogenic spinal infections.

Disseminated Fusarium oxysporum neurospinal infection

We report a case of disseminated meningospondylodiscitis in an elderly diabetic patient caused by Fusarium oxysporum. As the clinical presentation was nonspecific, the diagnosis of the condition could only be arrived at after laboratory and imaging studies. The diagnosis of the condition requires a high index of suspicion. Patient underwent thorough surgical debridement along with a short course of variconazole and remained asymptomatic after 36 months of diagnosis. Fusarium is a large genus of filamentous fungi widely distributed in soil and in association with plants. It is known to cause local infections (nail, cornea) in healthy humans and disseminated infection only in the immunocompromised.

Candida dubliniensis spondylodiscitis in an immunocompetent patient. Case report and review of the literature

We describe what appears to be the first case of spondylodiscitis due to Candida dubliniensis. Our case adds to the current literature of the importance of C. dubliniensis as a cause of fungemia and subsequent deep seated infections. It highlights the importance of taking fungal as well as bacterial culture from biopsy specimens in patients with spondylodiscitis. We also review the literature covering the reported cases of Candida spondylodiscitis, which amount to about 100 over the last 5 decades.

Candida osteomyelitis: analysis of 207 pediatric and adult cases (1970-2011)

BACKGROUND

The epidemiology, pathogenesis, clinical manifestations, management, and outcome of Candida osteomyelitis are not well understood.

METHODS

Cases of Candida osteomyelitis from 1970 through 2011 were reviewed. Underlying conditions, microbiology, mechanisms of infection, clinical manifestations, antifungal therapy, and outcome were studied in 207 evaluable cases.

RESULTS

Median age was 30 years (range, ≤ 1 month to 88 years) with a >2:1 male:female ratio. Most patients (90%) were not neutropenic. Localizing pain, tenderness, and/or edema were present in 90% of patients. Mechanisms of bone infection followed a pattern of hematogenous dissemination (67%), direct inoculation (25%), and contiguous infection (9%). Coinciding with hematogenous infection, most patients had ≥2 infected bones. When analyzed by age, the most common distribution of infected sites for adults was vertebra (odds ratio [OR], 0.09; 95% confidence interval [CI], .04-.25), rib, and sternum; for pediatric patients (≤18 years) the pattern was femur (OR, 20.6; 95% CI, 8.4-48.1), humerus, then vertebra/ribs. Non-albicans Candida species caused 35% of cases. Bacteria were recovered concomitantly from 12% of cases, underscoring the need for biopsy and/or culture. Candida septic arthritis occurred concomitantly in 21%. Combined surgery and antifungal therapy were used in 48% of cases. The overall complete response rate of Candida osteomyelitis of 32% reflects the difficulty in treating this infection. Relapsed infection, possibly related to inadequate duration of therapy, occurred among 32% who ultimately achieved complete response.

CONCLUSIONS

Candida osteomyelitis is being reported with increasing frequency. Localizing symptoms are usually present. Vertebrae are the most common sites in adults vs femora in children. Timely diagnosis of Candida osteomyelitis with extended courses of 6-12 months of antifungal therapy, and surgical intervention, when indicated, may improve outcome.

Clinical characteristics of infectious spondylodiscitis

Spondylodiscitis represents an inflammatory process, localized in the vertebrae body and in the intervertebral discs. The goals of this research were to identify subjective complaints, clinical findings, and laboratory characteristics in patients with spondylodiscitis, as well as to establish the importance of magnetic resonance imaging in diagnosing this disease. The data of 40 patients treated at the Clinic for Infectious diseases of the Clinical Center of Vojvodina from 2003 till 2007 were reviewed. Majority of the patients had low back pain (90%). Fever was present in 37.5% of patients (chi2 = 2.5; p > 0.05). Laboratory parameters of inflammation were higher than normal in most of the patients before the treatment. Diagnosis of spondylodiscitis was made using MRI in 97.5% of the patients. Keeping in mind unspecific subjective complaints and clinical findings in patients with spondylodiscitis, a health professional should always suspect spondylodiscitis when back pain occurs, in order to diagnose and treat this severe disease as early as possible. Magnetic resonance imaging is the most advantageous method in diagnosing spondylodiscitis.

Clinical assessment and medical treatment of spine infections

Spinal infections affect the vertebral bodies, the intervertebral disks, the spinal canal, and the paravertebral soft tissues and structures. A delay in diagnosis can result in spine deformity, substantial neurologic complications, and even death. Because of this, a high level of awareness is required by physicians in order to diagnose infections of the spine promptly. Advances in medical microbiologic testing and newer imaging methods have contributed considerably to the medical treatment of these infections. Through careful followup, less invasive approaches orchestrated by a multidisciplinary team that includes a spine surgeon, an infectious diseases specialist, and a neuroradiologist may be sufficient to treat patients with these infections. Research done through multidisciplinary collaborations will further advance our knowledge for the successful treatment of spinal infections.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.