Fungal Infections of the Spine

Differences in Haematological and Imaging Features of Lumbar Spine Fungal and Brucella Infections

Objective

To observe the clinical characteristics of fungal and Brucella infections of the lumbar spine and explore the key points for their differential diagnosis.

Methods

The clinical data of 12 patients with fungal infection (the fungal group) and 31 patients with Brucella infection (the Brucella group) of the lumbar spine confirmed by microbiological culture and antigen test were retrospectively analysed. The differences in the clinical characteristics and imaging manifestations were observed between the two groups.

Results

The peripheral blood neutrophil ratio, erythrocyte sedimentation rate, serum total protein and serum globulin levels in the fungal group were higher compared with the Brucella group, while the peripheral blood lymphocyte count, lymphocyte ratio and albumin-globulin ratio were lower in the fungal group compared with the Brucella group (P < 0.05). As for imaging examinations, the proportion of bone destruction centred on the intervertebral disc with surrounding osteosclerosis on computed tomography (CT) imaging showed a statistical difference between the Brucella group and the fungal group (P < 0.05). Fungal infection patients showed more osteosclerosis-free areas around the bone destruction on magnetic resonance imaging (MRI) than Brucella infection patients.

Conclusion

There are certain similarities in clinical manifestations between fungal and Brucella infections of the lumbar spine, but the haematological indices and image features of CT and MRI can effectively differentiate between them, providing guidance for the clinical differential diagnosis.

Cervical Intradural Fungal Infection Masquerading as a Meningioma in an Immunocompetent Patient: A Case Report and Systematic Review

BACKGROUND

Intradural spinal fungal infection is a rare phenomenon that can carry a significant increase in morbidity and mortality. This systematic review and case report provides a presentation of a 75-year-old male patient with an intradural cervical mass that was diagnosed as a fungal infection intraoperatively. We analyze and report on intradural spinal fungal infections in immunocompetent patients.

METHODS

We performed a systematic literature review following the PRISMA protocol for studies of intradural fungal infections published in the past 25 years. Original articles with a description of treatment outcomes of such patients were included.

RESULTS

A total of 8 studies were included in this review with the addition of the present case. There were 5 male and 4 female patients with an average age of 45.6 yeaers (range 24-75 years). Aspergillus and Candida species being the most isolated fungal organism. The origin of the lesions was identified and iatrogenic in 4 cases. Most patients underwent decompressive laminectomy with biopsy, abscess drainage, or resection of the identified lesion. There were 2 instances of cervical lesions, but most of the lesions were in the thoracic and lumbar spine. Half of the cases reported symptoms improvement, but 2 patients died from the infection or complications from the infections.

CONCLUSIONS

Intradural fungal infections are rare, with only 10 total cases reported in the past 25 years. Nonetheless, they can be associated with significant mortality and morbidity. Thus, the timeline from presentation to intervention should be evaluated and determined carefully.

Isolated Cryptococcal Infection of the Thoracic Spine in an Immunocompetent Patient

Cryptococcus neoformans is a type of fungal infection, which primarily affects the central nervous system and lungs of immunocompromised individuals. Spinal infections are known to be a rare manifestation of cryptococcosis. Herein, we report a case of a patient with isolated nonspecific spinal lesions at the T10 vertebra. The patient received non-surgical treatment with antifungal drugs, resulting in satisfactory clinical outcomes.

Malassezia restricta as an unexpected cause of infectious osteomyelitis diagnosed by metagenomic sequencing: a case report and literature review

BACKGROUND

Malassezia restricta, a lipophilic and lipodependent yeast belonging to the basidiomycetes group, is an opportunistic fungal pathogen associated with various skin diseases, including seborrheic dermatitis and dandruff. Typically, Malassezia infection in neonates manifests as fungemia or hematogenous dissemination to the bone or lungs. However, vertebral osteomyelitis caused by these fungi is rarely reported owing to non-specific clinical presentations and laboratory/imaging findings. The Pathogen Metagenomics Sequencing (PMseq) technique enables direct high-throughput sequencing of infected specimens, facilitating the rapid and accurate detection of all microorganisms in clinical samples through comprehensive reports.

CASE PRESENTATION

A 52-year-old male was admitted to our hospital on July 20, 2022 with a 3-month history of ambulatory difficulties and localized low back pain. Magnetic Resonance Imaging (MRI) examination of the spinal column revealed irregular bone destruction affecting the L2, L3, and L5 vertebral bodies. Additionally, low T1 and high T2 intensity lesions were observed at the intervertebral discs between L3 and L5. The presumptive diagnosis of tuberculous spondylitis was made based on the imaging findings, despite negative results in all mycobacterium tests. However, the patient exhibited no improvement after receiving regular anti-tuberculosis treatment for 3 months. Subsequent MRI revealed an expansive abnormal signal within the vertebral body, leading to progressive bone destruction. The absence of spinal tuberculosis or other infective microorganisms was confirmed through culture from blood and pathological tissue from the L4 vertebral body. Subsequently, PMseq was performed on the specimens, revealing M. restricta as the predominant pathogen with the highest relative abundance value. The pathological examination revealed the presence of fungal mycelium in the L4 vertebral body, with positive findings on periodic Schiff-methenamine and periodic acid-Schiff staining. The anti-tuberculosis treatment was discontinued, and an antifungal combination of fluconazole and voriconazole was administered. All symptoms were resolved after 7 consecutive months of treatment, and the patient was able to ambulate autonomously. Vertebral lesions were reduced on MRI during the 13-month follow-up.

CONCLUSIONS

M. restricta is not a commonly recognized pathogen associated with infectious vertebral osteomyelitis. However, PMseq can aid in diagnosis, timely treatment, and decision making for some non-specific infectious diseases.

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.

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.

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.

Fungal infections of spine: Case series during the COVID times

Fungal infections of the spine are a rare occurrence. We report three cases of Spondylodiscitis due to Aspergillus fumigatus, Candida albicans and Scedosporium apiospermum. Case 1:37 year old male, with history of COVID-19 infection one month prior presented with L1-2 Spondylodiscitis. Tissue showed growth of Aspergillus fumigatus. Case 2:75 year old male was admitted with swelling over low back. Pus aspirated from the swelling and tissue sent from operated site showed growth of Candida albicans. Case 3:56 year old known diabetic and end stage renal disease on hemodialysis presented with mid back pain since 2 months. Culture showed growth of Scedosporium apiospermum.

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.

A Quick and Comprehensive Guide to Differential Diagnosis of Neck and Back Pain: a Narrative Review

The list of diagnostic options when approaching a patient with axial pain is impressively complex. Many offer limited diagnostic workups, but we could not find a truly comprehensive diagnostic guide to assist in the diagnostic evaluation. In this short paper, we briefly described a long list of medical conditions, each of which can manifest as back or neck pain, and whose prevalence ranges from common to very rare. We then proposed an algorithm for classifying them into subgroups. Further referral to diagnostic tests and specialist consultations, after assignment to one of those subgroups, could save time and unnecessary tests. We believe that this review and the proposed diagnostic algorithm can be valuable for medical education and for use in the primary care setting for the diagnostic evaluation of any type of back or neck pain in all patient groups.

ACR Appropriateness Criteria® Suspected Spine Infection

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Infections of the Spine and Spinal Cord

PURPOSE OF REVIEW

Infections of the spine and spinal cord are associated with a high risk of morbidity and mortality and, therefore, require prompt clinical recognition, efficient diagnostic evaluation, and interdisciplinary treatment. This article reviews the pathophysiology, epidemiology, clinical manifestations, diagnosis, and treatment of infections of the spine and spinal cord to help practicing clinicians recognize, evaluate, and manage patients with such infections.

RECENT FINDINGS

Aging of the population, increasing use of immunosuppressive medications, and other factors have contributed to increasing rates of spinal infections. Although the most common agents responsible for spinal infections remain bacteria and viruses, fungal infections occur in individuals who are immunocompromised, and parasitic infections are common in endemic regions, but patterns are in evolution with migration and climate change. Recent outbreaks of acute flaccid myelitis in children have been associated with enteroviruses A71 and D68.

SUMMARY

Infections of the spine and spinal cord can be challenging to diagnose, requiring a thorough history and neurologic examination, laboratory studies of serum and CSF, neuroimaging (particularly MRI), and, in some instances, biopsy, to establish a diagnosis and treatment regimen. Interdisciplinary management including collaboration with experts in internal medicine, infectious disease, and neurosurgery is important to improve clinical outcomes.

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.

Aspergillus spondylitis: case series and literature review

BACKGROUND

Spinal fungal infections, especially spinal Aspergillus infections, are rare in the clinic. Here, we introduce the clinical features, diagnosis, treatment, and prognoses of 6 cases of Aspergillus spondylitis.

METHODS

We retrospectively analysed the complete clinical data of patients with Aspergillus spondylitis treated in our hospital from January 2013 to January 2020.

RESULTS

Aspergillus fumigatus was isolated in 4 cases, and Aspergillus spp. and Aspergillus niger were isolated in 1 case each. All six patients reported varying degrees of focal spinal pain; one patient reported radiating pain, one patient experienced bowel dysfunction and numbness in both lower limbs, and three patients had fever symptoms. One case involved the thoracic spine, one case involved the thoracolumbar junction, and 4 cases involved the lumbar spine. Three patients were already in an immunosuppressed state, and three patients entered an immunosuppressed state after spinal surgery. All six patients were successfully cured, and five required surgery. Of the 5 patients who underwent surgical treatment, 2 had spinal cord compression symptoms, and 3 had spinal instability. At the end of follow-up, 1 patient reported left back pain and 1 patient reported left limb numbness.

CONCLUSION

The clinical manifestations of Aspergillus spondylitis are non-specific, and the diagnosis depends on typical imaging findings and microbiological and histopathological examination results. When there is no spinal instability, spinal nerve compression symptoms, or progressive deterioration, antifungal therapy alone may be considered. If spinal instability, spinal nerve compression, or epidural abscess formation is present, surgery combined with antifungal therapy is recommended.

Lomentospora prolificans vertebral osteomyelitis with spinal epidural abscess in an immunocompetent woman: Case report and literature review

Lomentospora prolificans is a rare cause of vertebral osteomyelitis. We report a case of L. prolificans thoracic vertebral osteomyelitis with spinal epidural abscess in a patient without apparent immunodeficiency. Clinical manifestations and radiographic findings could not distinguish from other etiologic agents. Treatment is also challenging because L. prolificans is usually resistant to antifungal agents. The patient underwent surgical debridement and has been receiving a prolonged combination of antifungal therapy to prevent an infection relapse.

Diagnosis and treatment of nonadjacent cryptococcal infections at the L1 and S1 vertebrae

Cryptococcal spine infections are rare infections that are easy to misdiagnose and difficult to cure. Therefore, we report the case of a 25-year-old man who presented with nonspecific spinal lesions at L1 and S1. The patient underwent surgical removal of the lesions, and specimens were submitted for microbial identification, which identified a cryptococcal infection that was susceptible to amphotericin B. The patient exhibited marked improvement after receiving intravenous amphotericin B and remained asymptomatic (no back pain, fever, or other symptoms) at the 3‑ and 9‑month follow-ups. Similar cases of cryptococcal spine infections are rare, and we believe that our diagnostic findings and treatment experience may help improve the management of this rare disease.