Nonsurgical treatment of lumbosacral blastomycosis involving L2-S1: a case report

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.

Spinal blastomycosis: unusual musculoskeletal presentation with literature review

We report a case of a 41-year-old male who presented to our institution with a large groin mass. CT, MRI and PET imaging was performed and was concerning for a soft tissue abscess likely originating in the lumbar spine. Differential considerations included infection, with atypical infections such as tuberculosis strongly considered. Biopsy revealed fungal elements preliminarily reported as consistent with Cryptococcus neoformans but later revealed to be Blastomyces dermatitidis. The patient responded positively following the introduction of appropriate treatment. This case illustrates the imaging similarities between spinal blastomycosis, spinal tuberculosis, and other fungal infections as well as the need for biopsy to differentiate.

Anterior cervical corpectomy and fusion for blastomycosis causing destruction of C6 vertebra: a case report

Introduction

We describe a patient who had cervical spine osteomyelitis caused by Blastomyces dermatitidis that resulted in cord compression and cervical spine instability.

Case presentation

A 25-year-old Hispanic woman presented with fever, sweats, neck pain, and an enlarging neck mass with purulent discharge after sustaining a C6 vertebral body fracture. Magnetic resonance imaging confirmed C6 vertebral osteomyelitis, demonstrated by vertebral body destruction, cervical spine instability, prevertebral abscess, and spinal cord compression. She underwent C6 anterior cervical corpectomy and fusion, with fungal cultures confirming Blastomyces dermatitidis.

Conclusions

Anterior cervical corpectomy and fusion successful debrided, decompressed, and restored cervical spine stability in a patient with vertebral osteomyelitis caused by Blastomyces dermatitidis. The patient was subsequently treated with a 1-year course of itraconazole and had no recurrence of infection 4 years postoperatively.

Fungal Infections of the Spine

STUDY DESIGN

Review of the literature.

OBJECTIVE

To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease.

SUMMARY OF BACKGROUND DATA

Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series.

METHODS

MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database.

RESULTS

A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles.

CONCLUSION

Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections.

LEVEL OF EVIDENCE

3.

Chronic pelvic pain reveals sacral osteomyelitis three years after abdominal hysterectomy

BACKGROUND

Deep pelvic abscess is a well-known infective complication in gynecologic practice. However, sacral osteomyelitis has been reported rarely. We describe sacral infection presenting three years after abdominal hysterectomy and point out the difficulty in management.

METHODS

Case report and review of the pertinent literature.

RESULTS

A 46-year-old woman who had undergone abdominal hysterectomy three years before presented with an 8-month history of abdominopelvic pain recently intensifying in the sitting position without fever. Gynecologic, urinary, and rectal examination did not yield positive findings. An abdominopelvic computed tomography (CT) scan was normal except for sacral osteolysis. A neoplasm was suspected, but magnetic resonance imaging revealed an S2-S4 cystic collection with presacral extension. Neurologic examination did not show any focal deficits. A posterior CT-guided biopsy-aspiration yielded purulent fluid. Pathologic examination revealed inflammatory granulations without any malignant tumor. Abscess cultures grew three microorganisms. The patient's symptoms resolved completely after 3 months of antibiotic therapy.

CONCLUSIONS

Sacral osteomyelitis has not been reported previously after abdominal hysterectomy. Early diagnosis was made difficult by the absence of neurologic findings. Such postoperative infection should be considered after pelvic surgery. Minimally invasive needle aspiration may confirm the diagnosis and reduce the necessary extent of surgical intervention.