Cryptococcus neoformansvertebral osteomyelitis

Cryptococcus neoformans osteomyelitis of the tibia: a case report and review of the literature

INTRODUCTION

Osteomyelitis is a bone inflammation that can be related to various infectious agents. As with any other type of inflammation, the prevailing symptoms and signs may include redness, swelling, pain, and heat. Fungal osteomyelitis is rare and usually found in immune-compromised patients.

CASE PRESENTATION

A non-human immunodeficiency virus immunocompromised Greek female patient, 82 years old, visited the emergency department due to a 3 day pain located mainly over the left tibia's anterior surface, accompanied by swelling and redness. There was also a subcutaneous lesion of her left breast. Medical history revealed that the patient had an unmasked close contact with pigeons, a main host of the disease. Initial x-ray imaging showed an osteolytic area in the upper third of the tibial diaphysis. The patient was admitted and underwent a computed tomography-guided biopsy. The specimen revealed a Cryptococcus neoformans infection of the bone and the breast. She was treated with 400 mg fluconazole twice a day for 3 weeks while in hospital and 200 mg twice a day upon discharge for 9 months. After that, she underwent surgical debridement because of lasting local irritation. She was closely monitored in our outpatient office, and in her last visit, 1 year after the initial admission, inflammatory signs had regressed vastly.

CONCLUSIONS

To our knowledge, this is the ninth cryptococcal osteomyelitis of the tibia to be recorded since 1974, and the most unusual finding was the bifocal nature of the infection, affecting both the tibia and the breast.

Isolated cryptococcal osteomyelitis of the sacrum in an immunocompetent patient: a case report and literature review

BACKGROUND

Cryptococcus neoformans, an opportunistic fungal pathogen, seldom causes infection in immunocompetent people. Cryptococcal osteomyelitis is an uncommon condition in which Cryptococcus invades the bone. It usually occurs as part of a disseminated infection and rarely in isolation. The spine has been reported as the most common site of cryptococcal osteomyelitis; however, isolated case of sacrum involvement in immunocompetent patients has never been reported.

CASE PRESENTATION

We report the case of a 37-year-old man without underlying disease who presented with progressive low back and sacrococcygeal pain. The patient was initially diagnosed with sacral tumour by a local doctor, and subsequently, after admission, was diagnosed with sacral tuberculosis. He was empirically treated with antitubercular drugs. The patient failed to respond to antitubercular drugs and complained of worsening low back pain. Additionally, he developed persistent radiating pain and numbness in his legs. For further diagnosis, we performed a computed tomography-guided puncture biopsy of the sacrum, which revealed granulomatous inflammation with massive macrophage infiltration and special staining revealed a fungal infection. We performed sacral debridement and drainage and obtained purulent specimens for pathological examination and microbial culture. Microbial identification and drug susceptibility tests revealed a Cryptococcus neoformans infection sensitive to fluconazole. Postoperatively, the persistent radiating pain and numbness in the legs resolved. After 12 consecutive weeks of antifungal therapy, all his symptoms resolved. The patient remained without any signs of recurrence at the 8-month follow-up.

CONCLUSION

We reported a rare case of isolated sacrum cryptococcal osteomyelitis in an immunocompetent patient. Furthermore, we identified and reviewed 18 published cases of spine cryptococcal osteomyelitis. Immunocompetent individuals are also at risk for cryptococcal osteomyelitis. Clinical manifestation and imaging are insufficient to diagnose cryptococcal osteomyelitis of the spine, and invasive examinations, such as puncture biopsy and fungal examinations, are needed. Antifungal therapy yields satisfactory results for the treatment of cryptococcal osteomyelitis of the spine, however, if the infective lesion is large, especially when it compresses the spinal cord and nerves, a regimen combining aggressive surgery with antifungal therapy is indispensable.

Isolated cryptococcosis of a lumbar vertebra in an immunocompetent patient: A case report and literature review

Background

Cryptococcus, a kind of fungus, can be found in soil, decayed wood, and avian excreta. Immunocompromised patients are prone to infection caused by Cryptococcus, and the lungs and central nervous system are the main target organs. Cryptococcosis rarely occurs in the lumbar vertebra or in immunocompetent patients.

Case presentation

A 40-year-old adult male with isolated lumbar vertebra cryptococcosis at the L4 vertebra underwent successful lesion removal surgery performed via the posterior approach and postoperative administration of an antifungal agent. At the 12-month follow-up, the patient's pain was relieved, and his motor function had improved. Isolated Cryptococcus vertebrae infection is a rare infectious disease.

Conclusions

A needle biopsy can confirm the diagnosis of Cryptococcus infection. When patients present with unbearable symptoms of nerve compression, posterior depuration combined with postoperative antifungal agents is a good option.

Cryptococcal Osteomyelitis of the First Metatarsal Head in an Immunocompetent Patient

Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.

Lumbar Cryptococcal Osteomyelitis Mimicking Metastatic Tumor

Cryptococcus is an encapsulated, yeast-like fungus that rarely causes infection in immunocompetent patients. We present the case report of a 66-year-old female patient with a history of rectal cancer with an isolated lumbar vertebral cryptococcosis proven by biopsy performed during operation. The patient was not an immunocompromised host and did not have any other risk factors except the history of cured rectal cancer. The presumptive diagnosis based on imaging studies was metastatic spine cancer, so operation was performed. However, cryptococcal osteomyelitis was diagnosed in the pathologic examination. This case report emphasizes that we should be aware that lumbar cryptococcosis can be a rare cause of mimicking lesions with metastatic cancer.

Skeletal cryptococcosis from 1977 to 2013

Skeletal cryptococcosis, an aspect of disseminated cryptococcal disease or isolated skeletal cryptococcal infection, is a rare but treatable disease. However, limited information is available regarding its clinical features, treatment, and prognosis. This systematic review examined all cases published between April 1977 and May 2013 with regard to the factors associated with this disease, including patient sex, age, and epidemiological history; affected sites; clinical symptoms; underlying diseases; laboratory tests; radiological manifestations; and delays in diagnosis, treatment, follow-up assessments, and outcomes. We found that immune abnormality is a risk factor but does not predict mortality; these observations are due to recent Cryptococcus neoformans var gattii (CNVG) outbreaks (Chaturvedi and Chaturvedi, 2011). Dissemination was irrespective of immune status and required combination therapy, and dissemination carried a worse prognosis. Therefore, a database of skeletal cryptococcosis cases should be created.

Cryptococcosis of lumbar vertebra in a patient with rheumatoid arthritis and scleroderma: case report and literature review

BACKGROUND

Although cryptococcosis mainly occurs in the central nervous system and lungs in immunocompromised hosts, it can involve any body site or structure. Here we report the first case of primary cryptococcosis of a lumbar vertebra without involvement of the central nervous system or lungs in a relatively immunocompromised individual with rheumatoid arthritis and scleroderma.

CASE PRESENTATION

A 40-year-old Chinese woman with rheumatoid arthritis diagnosed 1 year beforehand and with a subsequent diagnosis of scleroderma was found to have an isolated cryptococcal infection of the fourth lumbar vertebra. Her main complaints were severe low back and left leg pain. Cryptococcosis was diagnosed by CT-guided needle biopsy and microbiological confirmation; however, serum cryptococcal antigen titer was negative. After 3 months of antifungal therapy with fluconazole the patient developed symptoms and signs of scleroderma, which was confirmed on laboratory tests. After taking fluconazole for 6 months, the progressive destruction of the lumbar vertebral body had halted and the size of an adjacent paravertebral mass had decreased substantially. On discharge symptoms had resolved and at an annual follow-up there was no evidence of recurrence on the basis of symptoms, signs or imaging investigations.

CONCLUSION

Although cryptococcosis of the lumbar vertebra is extremely rare, it should be considered in the differential diagnosis for patients with lumbar vertebral masses to avoid missed diagnosis, misdiagnosis and diagnostic delay. Early treatment with antifungals proved to be a satisfactory alternative to surgery in this relatively immunocompromised patient. Any residual spinal instability can be treated later, once the infection has resolved.

Cryptococcus neoformans abscess and osteomyelitis in an immunocompetent patient with tuberculous lymphadenitis

Infection with Cryptococcus neoformans usually occurs in immunocompromised hosts and may occur in immunocompetent patients. Of all cryptococcal infections, 10-40% of patients have no apparent immune deficiency. Disseminated disease may occur in up to 62% of HIV-seronegative patients with cryptococcosis; however, cryptococcal osteomyelitis is rare. Here, we report an immunocompetent patient with cryptococcal vertebral osteomyelitis and concomitant tuberculous lymphadenitis. The patient received 12 weeks of fluconazole and a 1-year course of anti-tuberculous agents, with complete recovery.

The biology of the Cryptococcus neoformans species complex

Cryptococcus neoformans is a major cause of fungal meningoencephalitis in immunocompromised patients. Despite recent advances in the genetics and molecular biology of C. neoformans, and improved techniques for molecular epidemiology, aspects of the ecology, population structure, and mode of reproduction of this environmental pathogen remain to be established. Application of recent insights into the life cycle of C. neoformans and its different ways of engaging in sexual reproduction under laboratory conditions has just begun to affect research on the ecology and epidemiology of this human pathogenic fungus. The melding of these disparate disciplines should yield rich dividends in our understanding of the evolution of microbial pathogens, providing insights relevant to diagnosis, treatment, and prevention.

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.

Fluconazole treatment of cryptococcal rib osteomyelitis in an HIV-negative man. A case report and review of the literature

A 49-year-old, HIV-negative publican with single rib cryptococcal osteomyelitis was successfully treated with fluconazole 200mg per day for 10 weeks. This is a case report and a review of the relevant literature.

Isolated cryptococcal thoracic empyema with osteomyelitis of the rib in an immunocompetent host

Cryptococcal thoracic empyema is extremely rare and has been described almost always in immunocompromised patients with pulmonary or disseminated cryptococcosis. To our knowledge, isolated cryptococcal thoracic empyema with rib osteomyelitis has never been reported in an immunocompetent patient. We herein present such a case. Computed tomographic (CT) scan suggested the diagnosis of thoracic empyema in association with adjacent rib osteomyelitis, confirmed by postoperative histological examination. Surgical debridement followed by appropriate antifungal therapy achieved a complete eradication of the infection.

[Osteomyelitis from Cryptococcus neoformans]

A forty-three-year old patient suspected of having a bone tumor in his left femur, was submitted to the hospital. However, osteomyelitis caused by Cryptococcus neoformans has been demonstrated by culture. The history of the patient revealed a long-term therapy with corticosteroids due to sarcoidosis. The osteomyelitis was treated with fluconazole (200 mg daily p.o.) for three months. Under this therapy the infection resolved.