Diagnosis and treatment of Candida vertebral osteomyelitis: Clinical experience with a short course therapy of amphotericin B lipid complex

Vertebral Candidiasis, the State of the Art: A Systematic Literature Review

OBJECTIVE

In recent years, Candida spondylodiscitis has represented an increasingly emerging disease in clinical practice. This condition requires long-term antibiotic therapy and sometimes surgical treatments. The main purpose of this study is to investigate the epidemiology, clinical and radiological aspects, treatment protocols, and outcomes of Candida-mediated vertebral osteomyelitis.

METHODS

A systematic review of the English literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The research was conducted on Medline, Cochrane library, PubMed, and Scopus using as search terms "vertebral"; "spinal"; "infection"; "spondylodiscitis"; "discitis"; "osteomyelitis"; "Candida"; and "Candidosis." A case of vertebral candidiasis that was surgically managed was also reported.

RESULTS

In total, 88 articles were included in our systematic review. Including the reported case, our analysis covered 113 cases of vertebral candidiasis. Candida albicans was isolated in 64 cases (56.1%), Candida tropicalis in 21 (18.4%), Candida glabrata in 14 (12.3%), and Candida parapsilosis in five (4.4%). The mean duration of the follow-up was 395 days. Finally, 87 (82%) patients completely recovered, ten (9.4%) died, and nine (8.5%) reported sequelae.

CONCLUSION

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

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.

Candida parapsilosis osteomyelitis following dog bite: a case report and review of the literature

Candida osteomyelitis is uncommon, especially after dog bites. We describe a case of a 63-year-old man without significant comorbidities presenting progressing swelling of the distal interphalangeal joint (DIJ) of right index finger following a dog bite. Despite empiric antibiotic therapy and local medications, there were no clinical signs of improvement. Clinical examination revealed fistula with purulent drainage on the volar region. Even though laboratory data showed inflammatory markers on range, magnetic resonance imaging (MRI) demonstrated signs of osteomyelitis. The patient was taken to exploration and debridement of the bite wound. Culture of the bone biopsy showed growth of Candida parapsilosis. Therefore, the patient was diagnosed with isolated fungal osteomyelitis and was initiated on fluconazole therapy. The treatment was effective and all symptoms were resolved in 8 weeks after the surgery. There were no signs of recurrence after 20 months of follow-up. The patient had no cosmetic abnormalities or sequelae. Concurrently with the description of the case report a review of the literature was provided. According to the authors, there are three main etiopathogenesis for this infection. The first pathogenic mechanism is direct inoculation into the deep tissues through the dog bite. The second hypothesis is direct translocation of the pathogen from the skin to the deep tissue and to the bone. The last mode of transmission is hematogenous dissemination. Fungal osteomyelitis are really rare conditions, especially after dog bites, but nevertheless it should be considered as a possible diagnosis when there is no response to antibiotics.

Fungal spondylodiscitis: imaging findings and brief review of the literature

A 57-year-old man was admitted to our department reporting persistent low back and leg pain; this patient had undergone chemotherapy 1 year earlier for acute myeloid leukaemia (AML). During chemotherapy, he exhibited bilateral pneumonia due to Candida tropicalis, which was treated by specific antibiotic therapy, and septicaemia by Enterococcus faecalis MRI showed the presence of spondylodiscitis. A CT-guided needle biopsy was performed and the culture from the excised material tested positive for C. tropicalis We report a rare case of spondylodiscitis by C. tropicalis in a patient treated for AML, which, in turn, was followed by sepsis from E. faecalis and C. tropicalis Without adequate treatment, the disease is progressive, and leads to vertebral destruction with secondary kyphosis and neural or spinal cord compression. Although MRI has high sensitivity in the diagnosis of spondylodiscitis, open or needle biopsy allows to identify the aetiology.

Vertebral osteomyelitis due to Candida species

OBJECTIVE

We have noted an increased number of cases of vertebral osteomyelitis secondary to Candida species over the past few years at our facility. Our aim was to identify and review these cases to elucidate risk factors, treatment regimens and outcomes.

METHODS

We performed a retrospective chart review using our electronic medical record and microbiology laboratory database to identify cases of vertebral osteomyelitis due to Candida at a single teaching hospital from 2006-2018.

RESULTS

We found 15 cases of Candida vertebral osteomyelitis. The majority of cases were due to Candida albicans and affected either the lumbar or the thoracic spine. Injection drug use and previous spine surgery were the two most common risk factors identified. Treatment was largely with intravenous antifungal induction followed by prolonged therapy with oral fluconazole. There was no short-term mortality though we lacked long-term follow-up on most patients.

CONCLUSIONS

The number of vertebral infections due to Candida may be increasing. This may be partially driven by both a rise in intravenous drug use as well as the growing rate of spine surgery. Management following currently available guidelines seems favorable, though further studies are necessary to determine the optimal treatment regimen.

Vertebral infection with Candida albicans failing caspofungin and fluconazole combination therapy but successfully treated with high dose liposomal amphotericin B and flucytosine

A patient with Candida spondylitis failed two weeks of fluconazole combined with caspofungin, and the infection relapsed despite six weeks of liposomal amphotericin B followed by two months of fluconazole. Six months therapy with high dose liposomal amphotericin B combined with flucytosine effectively cured the patient.

Shoulder Joint Infectious Arthritis and Acromioclavicular Joint Osteomyelitis due to Candida

Candida species inhabit the skin and mucous membranes of healthy individuals with low virulence, and osteomyelitis due to candida is very rare. However, the incidence of invasive candidal infection caused by intravenous drug use, broad-spectrum antibiotics, and indwelling central venous catheter is increasing. A 73-year old man visited the outpatient clinic complaining of right shoulder pain that radiated to the right acromioclavicular joint. He had undergone multiple injection procedures followed by nonsteroidal anti-inflammatory drug therapy for several weeks. The ultrasonographic findings showed a heterogeneous mass around the right acromioclavicular joint, while the right shoulder MRI and the overall findings of the body bone scan were suggestive of osteomyelitis. Pathologic findings of ultrasonographically guided joint aspiration fluid showed acute and chronic nonspecific inflammation, while the tissue culture and staining revealed Candida parapsilosis.

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.

A real-time PCR assay for the differentiation of Candida species

AIMS

We established a real-time PCR assay for the detection and strain identification of Candida species and demonstrated the ability to differentiate between Candida albicans the most common species, and also Candida parapsilosis, Candida glabrata, Candida tropicalis and Candida dubliniensis by LightCycler PCR and melting curve analysis.

METHODS AND RESULTS

The DNA isolation from cultures and serum was established using the QIAmp Tissue Kit. The sensitivity of the assay was ≥ 2 genome equivalents/assay. It was possible to differentiate all investigated Candida species by melting curve analysis, and no cross-reaction to human DNA or Aspergillus species could be observed.

CONCLUSIONS

The established real-time PCR assay is a useful tool for the rapid identification of Candida species and a base technology for more complex PCR assays.

SIGNIFICANCE AND IMPACT OF THE STUDY

We carried out initial steps in validation of a PCR assay for the detection and differentiation of medically relevant Candida species. The PCR was improved by generating PCR standards, additional generation of melting curves for species identification and the possibility to investigate different specimens simultaneously.

Candida parapsilosis spondylodiscitis after lumbar discectomy

Candida is a relatively rare cause of spinal infections that commonly affects immunocompromised patients. A 70-year-old woman, who underwent a lumbar discectomy on L5-S1 two months earlier, was admitted to our department complaining of persistent back and leg pain. Magnetic resonance imaging showed irregular enhancing mass lesion in L5-S1 intervertebral space, suggest of pyogenic discitis with epidural abscess. The surgery was performed via retroperitoneal approach and the infected material at L5-S1 intervertebral space was removed. The histological examination of the specimen revealed chronic inflammation involving the bone and soft tissue, and a culture of the excised material was positive for Candida parapsilosis. The patient received intravenous fluconazole for 4 weeks after surgery and oral fluconazole 400 mg/day for 3 months after surgery. The patient made a full recovery with no symptoms 6 months after surgery. We present a rare case of spondylodiscitis after a lumbar discectomy due to Candida parapsilosis and discuss treatment option with a review of the literatures.

Les spondylodiscites à Candida; à propos de deux cas

In recent years, the incidence of systemic infections due to Candida increased, but the incidence of spondylodiscitis remained low, and epidural involvement during such infection was seldom reported. The purpose of this study was to report the cases of 2 young male heroin addicts who developed spondylodiscitis due to Candida sp., with epidural involvement. In one case, a microbiological diagnosis was obtained after biopsy. In the other case, the diagnosis was based on serological data and Candida antigenemia. In both cases, an oral fluconazole based therapy was administered at first (because of a poor peripheral venous system), but proved to be inefficient. A secondary therapy by liposomal amphotericin B proved efficient allowing a favourable evolution. This pathology raised a number of problems concerning diagnosis and treatment. The clinical data was non-specific the paraclinical diagnosis required MRI, and biopsy. When microbiological assessment is negative, serology and the antigenemia can be useful. The treatment pattern suggested for the management of bone and joint infections is: intravenous amphotericine B for 2-3 weeks, followed by oral administration of fluconazole or voriconazole for 6-12 month. Surgical treatment is recommended only to patients ay risk of neurological disorders or severe epidural abscess.

Die Candida-albicans-induzierte Spondylodiszitis der Halswirbelsäule bei einem polytraumatisierten Patienten

With the increasing occurrence of predisposing factors, invasive candidiasis is being diagnosed more frequently. Based on a review of only a few previous reported cases, we describe and discuss the unusual case of candidal cervical spondylodiscitis in a 36 year old man who had sustained a polytrauma, complicated through a Candida albicans pneumonia. The main symptom was disabling neck pain. Clinical, laboratory and radiological findings were unspecific. The definitive diagnosis was determined by MRI imaging and biopsy. The early diagnosis and surgical treatment with a sufficient debridement and stabilisation of the affected segment combined with a prolonged antifungal therapy lead to good results.

Spondylodiscitis caused by Candida krusei: case report and susceptibility patterns

A 62-year-old man with amphotericin B-resistant Candida krusei spondylodiscitis, following an episode of candidemia caused by the same strain, was successfully treated with caspofungin plus voriconazole. Amphotericin B fungicidal concentrations were better predictors of the clinical outcome than were MICs. This is the first case of C. krusei spondylodiscitis reported in the literature.

Spectrum of spine infections in patients with HIV: a case report and review of the literature

Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy.

LEVEL OF EVIDENCE

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

Candida vertebra osteomyelitis in a girl with factor X deficiency

Candidal vertebra osteomyelitis is a rare condition which occurs primarily in immunocompromised patients. We report a 14-year-old girl with factor X deficiency who developed candida vertebra osteomyelitis during home therapy. The microorganism was probably from a contaminated peripheral cannula used for infusion of factor concentrate. This is the first such case in bleeding disorders to our knowledge.

Surgical strategies for vertebral osteomyelitis and epidural abscess

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.