Thoracic spinal cord intramedullary aspergillus invasion and abscess

Cervical Intramedullary Spinal Cord Abscess Secondary to Discitis and Osteomyelitis in an Immunocompromised Patient

Intramedullary spinal cord abscess is a rare neurological condition, not commonly suspected and often misdiagnosed. Even after a prompt diagnosis and treatment, most patients persist with permanent neurological deficits. In adults, factors such as immunocompromised, intravenous drug use, endocarditis, and sepsis could be associated with its development. In this study, we present the case of a 63-year-old male patient who developed a chronic cervical intramedullary spinal cord abscess after being treated for multiple abscesses in the paravertebral and psoas muscles. A diagnosis of cervical intramedullary spinal cord abscess secondary to osteomyelitis and discitis was made. He underwent a two-stage cervical surgery, with drainage of the abscess, spinal stabilization, and intravenous antibiotics. Although rare, vertebral osteomyelitis and discitis may be related to its development. Early diagnosis, prompt abscess drainage, and appropriate antibiotic therapy are of utmost importance to improve prognosis and minimize the long-term sequelae and complications of permanent neurological deficits.

Rapidly Progressing Intramedullary Spinal Cord Abscess: A Case Report

Intramedullary spinal cord abscess is a rare and severe infectious disease characterized by devastating neurological deficits. We report a case of cervical intramedullary spinal cord abscess in a 74-year-old diabetic male with a 3-day history of neck pain and weakness in the right lower extremity. Magnetic resonance imaging revealed a ring-shaped contrast lesion in C3-C6 of the cervical spinal cord with extensive edema. Further, 1 day after admission, he became comatose (Glasgow Coma Scale E1VtM1), and a computed tomography head scan revealed hydrocephalus. Despite emergency ventricular drainage, the patient's level of consciousness remained unchanged. Magnetic resonance imaging performed 1 day after surgery revealed bilateral intracranial extension of the abscess into the thalamus and caudate nucleus. The patient died 19 days after admission. Our report is the first case of extensive brain abscess development over a short period. Based on our experience, prompt administration of antibiotics and emergency abscess drainage of the cervical cord (and ventricular drainage, if necessary) are recommended in cases of neurological deterioration in patients with cervical intramedullary spinal cord abscess.

Acute lymphoblastic leukemia with central nervous system Aspergillus infection: A case report and literature review

Ubiquitous in nature, Aspergillus rarely invades the brain to induce infection in general. However, in clinical practice, some patients with hematological malignancies or immunosuppression may suffer from Aspergillus infection of the central nervous system, which arises most commonly as a result of hematogenous dissemination from a pulmonary focus or direct extension from the paranasal sinus infection. Treatment is clinically challenging and the mortality rate is relatively high. Recently, a case diagnosed with acute lymphocytic leukemia was admitted to the Department of Neurosurgery, The First People's Hospital of Huzhou (First Affiliated Hospital of Huzhou University, Huzhou, China). During chemotherapy, space-occupying lesions were observed in the right occipital lobe of the patient, and lesion progression was captured. After treatment with surgery, an analysis of specimens collected from the patient was performed and was suggestive of Aspergillus infection. Following the symptomatic therapy with voriconazole, the patient's disease prognosis was favorable. The focus of infection due to pulmonary aspergillosis or Aspergillus sinusitis was not detected in the patient and the focus was not a common site of hematogenous infection. In addition, the patient exhibited no obvious clinical symptoms. In view of the above observations, the possibility of hospital-acquired infection was considered, to which clinicians should be alert.

Cervico-Dorsal Intramedullary Spinal Cord Abscess with Aspergillus fumigates following Pulmonary Infection in an Immunocompetent Patient

Invasive forms of aspergillosis of the nervous system are relatively rare and are usually diagnosed in immunocompromised patients. We present the case of a young female patient, treated in the last two months with corticosteroids and antifungal drug for pulmonary aspergillosis, who developed progressive paraparesis. An intramedullary abscess at the C7-D1 level was identified and the lesion was treated with a combination of surgery and antifungal therapy. Histopathologic findings of surgical specimens showed myelomalacia with Aspergillus hyphae and a peripheral rim of neutrophils. We consider that the use of multiple drugs and corticosteroids for our patient's initial community pneumonia could be the factor that transformed her into a mildly immunocompromised individual and permitted the Aspergillus spp. to disseminate through the blood and into the spinal cord. Moreover, we highlight the fact that more attention should be paid to living and working conditions of the patients, as a simple colonization of the lung with Aspergillus spp. could develop, in a short time, into an invasive disease with a high risk of mortality.

Intramedullary Spinal Cord Abscess with Concomitant Spinal Degenerative Diseases: A Case Report and Systematic Literature Review

Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities. Traditionally it has been associated with significant mortality and neurological morbidities because it is often difficult to diagnose promptly, owing to its nonspecific clinical and neuroimaging features. The mortality rate and the outcome of these infections have been improved by the introduction into clinical practice of antibiotics, advanced neuroimaging modalities, and immediate surgery. We report the case of a 65-year-old male patient who presented with a progressive spastic gait and lumbar pain, predominantly in the left leg. An MRI image revealed an expansile intramedullary cystic mass in the thoracic spinal cord, which was initially diagnosed as a spinal tumor. He underwent laminectomy and myelotomy, and eventually the pus was drained from the abscess. The follow-up MRI showed improvement, but the patient’s paraplegia persisted. In light of his persistent hypoesthesia and paraplegic gait with developing neuropathic pain, he was readmitted, and an MRI of his lumbar spine revealed multilevel degenerative disease and tethered spinal cord syndrome with compression of the medulla at the L2–L3 level. The patient underwent central flavectomy with bilateral foraminotomy at the L2–L3 level, and the medulla was decompressed. Postoperatively, his neurological symptoms were significantly improved, and he was discharged from hospital on the third day after admission. In support of our case, we systematically reviewed the recent literature and analyzed cases published between 1949 and May 2022, including clinical features, mechanisms of infection, predisposing factors, radiological investigations, microbial etiologies, therapies and their duration, follow-ups, and outcomes. Initial clinical presentation can be misleading, and the diagnosis can be challenging, because this condition is rare and coexists with other spinal diseases. Hence, a high index of suspicion for making an accurate diagnosis and timely intervention is required to preclude mortality and unfavorable outcomes. Our case is a clear example thereof. Long-term follow-up is also essential to monitor for abscess recurrences.

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Isavuconazole Treatment of Spinal Cord Invasive Aspergillosis Guided by Cerebrospinal Fluid (1,3)-β-d-Glucan Levels in a Patient with Low Interferon-Gamma and Ulcerative Colitis

This case highlights the use of (1,3)-beta-d glucan to direct treatment of a cervical spinal cord Aspergillus fumigatus infection in a 22-year-old woman immunocompromised due to steroid and anti-TNF therapy in the context of ulcerative colitis and interferon gamma deficiency. A 4-year treatment course requiring neurosurgical intervention on four occasions and prolonged antifungal therapy, including isavuconazole, resulted in clinical cure with a corresponding decrease in CSF beta-d-glucan to <30 pg/mL. Serum and CSF galactomannan levels were not elevated at any point during the clinical course.

Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review

Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.

Aspergillus spinal epidural abscess: A case report and review of the literature

Aspergillus spinal epidural abscess (ASEA) is a rare entity that may mimic Pott's paraplegia as it commonly affects immunocompromised patients. We present one institutional case of ASEA with concomitant review of the literature. A 58-year-old female presented with intermittent low back pain for 10 years recently aggravated and with concurrent spastic paraparesis, fever, and weight loss. Emergent magnetic resonance imaging (MRI) showed T11–T12 epidural abscess with discitis and osteomyelitis. After empirical treatment with antibiotics, computed tomography-guided, percutaneous biopsy with drainage was performed, showing granulomatous tubercular-like collection. Antitubercular therapy was initiated, but after 1 month, the patient's condition deteriorated. Repeat MRI showed growth of the spinal epidural abscess with significant cord compression and vertebral osteomyelitis. T11–T12 laminectomy and tissue removal were performed with a posterior midline approach. Tissue histopathology showed necrotic debris colonies of Aspergillus spp. Antifungal therapy was started, and the patient rapidly improved. ASEA may mimic Pott's disease at imaging, leading to immediate start of antitubercular treatment without prior biopsy, leading to severe worsening of patients’ clinical status. Cases of ASEA should be considered at pretreatment planning, opting for biopsy confirmation before treatment initiation so to prevent the occurrence of fatal infection-related complications.

Aspergillosis of central nervous system in patients with leukemia and stem cell transplantation: a systematic review of case reports

Background

Aspergillosis of Central Nervous System (CNS) is a highly lethal infection in patients with leukemia and Stem Cell Transplantation (SCT).

Methods

Case reports of CNS aspergillosis in patients with leukemia and SCT published between 1990 and August 2020 were gathered using a structured search through PubMed/Medline.

Results

Sixty-seven cases were identified over the searches of the PubMed bibliographic database and then, 59 cases were included in the final analysis. Europe had the largest share of cases at 57.6% (34 reports), followed by Americas and Asia. Affected patients were predominantly males (58.6%) and the mean age of the patients was 36.1 years, while 62.7% of the patients were under the age of 50 years. The most common leukemia types include Acute Lymphoblastic Leukemia (ALL), Chronic Lymphocytic Leukemia (CLL), and Acute Myeloid Leukemia (AML) at 43.4%, 27.4%, and 23.5%, respectively. Furthermore, stem cell transplantation was reported in 11 cases. The overall mortality was 33%; however, the attributable mortality rate of CNS aspergillosis was 24.5%. Altered mental status, hemiparesis, cranial nerve palsies, and seizures were the clearest manifestations of infection and lung involvement reported in 57% of the patients. Histopathologic examination led to the diagnosis of infection in 57% of the patients followed by culture (23.7%), galactomannan assay (8.5%), and molecular method (3.3%). Amphotericin B and voriconazole were the most frequently used drugs for infection treatment. Good results were not obtained in one-third of the patients treated by voriconazole. Finally, neurosurgical intervention was used for 23 patients (39%).

Conclusion

CNS aspergillosis is a rapidly progressive infection in leukemic patients. Thus, these patients should be followed up more carefully. Furthermore, management of induction chemotherapy, use of different diagnostic methods, and use of appropriate antifungal can lead to infection control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12941-021-00452-9.

Spinal intramedullary abscess due to Candida albicans in an immunocompetent patient: A rare case report

Background:

A spinal intramedullary abscess is a rare clinical entity in which patients classically present with a subacute myelopathy and progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. We report the second case of spinal intramedullary abscess caused by Candida albicans to ever be published and the first case of its kind to be surgically managed.

Case Description:

A 44-year-old female presented with severe lumbar pain associated with paraparesis, incontinence, and paraplegia. She reported multiple hospital admissions and had a history of seizures, having already undergone treatment for neurotuberculosis and fungal infection of the central nervous system unsuccessfully. Nevertheless, no laboratory evidence of immunosuppression was identified on further investigation. Magnetic resonance imaging showed a D10-D11, well-circumscribed, intramedullary mass within the conus, which was hypointense on T1-weighted imaging and hyperintense on T2/STIR weighted. The patient underwent surgery for removal and biopsy of the lesion, which provided the diagnosis of an intramedullary abscess caused by C. albicans, a very rare condition with only one case reported in literature so far.

Conclusion:

C. albicans intramedullary abscess is a very rare clinical entity, especially in immunocompetent patients. We highlight C. albicans as an important etiology that must be considered in differential diagnosis. Critical evaluation of every case, early diagnosis, timely referral and surgical management of the abscess is essential to improve neurological outcome.

Acute infectious myelopathies

PURPOSE OF REVIEW

The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts.

RECENT FINDINGS

Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation.

SUMMARY

We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.

Spontaneous Vertebral Aspergillosis, the State of Art: A Systematic Literature Review

Objective

Vertebral aspergillosis is quite rare conditions, often misdiagnosed, that requires long-term antibiotic therapy, and sometimes, surgical treatments. The present investigations were aimed to investigate the epidemiology, clinical-radiological aspects, treatment protocols, and outcomes of Aspergillus-mediated vertebral osteomyelitis.

Methods

A systematic review of the pertinent English literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. The research was conducted on Cochrane library, MEDLINE, PubMed, and Scopus using as search-terms “Aspergillus,” “vertebral osteomyelitis,” “spondylodiscitis,” “spine infection.” A case of vertebral aspergillosis conservatively managed was also reported.

Results

Eighty-nine articles were included in our systematic review. Including the reported case, our analysis covered 112 cases of vertebral aspergillosis. Aspergillus fumigatus was isolated in 68 cases (61.2%), Aspergillus flavus in 14 (12.6%), Aspergillus terreus in 4 (3.6%), Aspergillus nidulans in 2 (1.8%). Seventy-three patients (65.7%) completely recovered at the last follow-up evaluation; in 7 patients (6.3%) radiological signs of chronic infection were reported, whereas 32 patients (28.8%) died during the follow-up.

Conclusion

This systematic review summarized the state of the art on vertebral aspergillosis, retrieving data on clinical features, diagnostic criteria and current limitations, treatment alternatives, and their outcomes.

Fusarium species intramedullary spinal cord fungus ball: case report

The Fusarium species are one of the most common opportunistic fungal infections occurring in immunocompromised patients and are associated with high morbidity and mortality. Common sites of infection include blood, skin, nasal passages, lungs, bone, and other visceral organs. There is a paucity of literature on Fusarium infections in the brain, and the true nature and extent of central nervous system involvement is not well described. To the authors' knowledge, there have been no reported cases of Fusarium infection of the spine. The authors report the case of a man with acute myeloblastic leukemia and resultant pancytopenia who presented with fungal sinusitis, upper- and lower-extremity weakness, and cardiopulmonary arrest. Imaging studies revealed a spinal cervical intramedullary ring-enhancing lesion. Because of the progressive nature of his symptoms, neurosurgical intervention involving a C2-3 laminectomy and drainage of the lesion was performed. Intraoperative cultures and histopathology results were positive for Fusarium species and, along with intraoperative findings, were consistent with a fungus ball. The patient was placed on a regimen of intravenous and intrathecal antifungal therapy. Unfortunately, his clinical condition declined postoperatively, and he ultimately died of disseminated infection.

Aspergillus spinal epidural abscess: case presentation and review of the literature

Study design

In this review, we present a case of Aspergillus spinal epidural abscess (ASEA) and review the literature.

Objectives

To provide further insight on a rare condition.

Setting

A description of a patient with ASEA in a 58-year-old woman that was successfully treated with conservative management is presented.

Methods

Following case presentation, a literature search (MedLine and PubMed) and assessment of epidemiology, presentation, diagnosis, treatments, and outcomes is performed.

Results

Review of the literature finds 26 reported cases. The infection occurs in males with a higher frequency (66.7%). The thoracic and lumbar regions are more likely afflicted (96.1%). Common symptoms are backache, neurological deficits, and fever. Most frequent comorbidities were malignancy, diabetes mellitus, and immunodeficiency. Complications were numerous and often catastrophic. Treatment entailed a combination of antibiotics and surgery. Overall, ASEA patients did poorly: death in majority (52%), minimal recovery in 22%, and others did attain full recovery (26%).

Conclusions

Generally, this infection has high morbidity and mortality. Early identification is important to a successful outcome. Appropriate management with antifungals is central and proves to be effective as seen in the reported case though surgical intervention is usually a necessity as the literature suggests. From an epidemiological and public health perspective, particularly with recent outbreaks, understanding the treatment of this rare CNS infection becomes even more imperative.

Streptococcus pneumoniae meningitis complicated by an intramedullary abscess: a case report and review of the literature

BACKGROUND

Intramedullary abscess is a rare neurosurgical condition that usually arises in the setting of penetrating trauma to the spinal cord, infected congenital dural sinuses, or tuberculosis.

CASE PRESENTATION

We describe a case of a 35-year-old African American male who presented with sepsis and a clinical picture of meningitis. The patient continued to have declining neurological status with decreasing sensation and worsening motor strength in all four extremities. He was found to have an intramedullary abscess in the cervical spinal cord that was treated with a decompressive posterior cervical laminectomy and drainage. The patient began to have a partial recovery of neurological function postoperatively. We also review the literature on intramedullary abscess that suggests the clinical presentation of our patient was a rare complication of acute meningitis.

CONCLUSIONS

Intramedullary abscess formation is a rare entity, and a high index of suspicion for intramedullary abscess is the key for making the diagnosis and expediting treatment for these patients.

Infections of the spine and spinal cord

Predisposing factors for developing spinal infections include: immunodeficiency; drug abuse; the widespread use of broad-spectrum antibiotics, corticosteroids, and immunosuppressive drugs; diabetes mellitus; and spinal surgery. Infections can be bacterial, fungal, parasitic, or viral in origin. This chapter reviews current knowledge in clinical and imaging findings in the most common spinal infections divided according to the compartment primarily involved.