Spondylodiscitis Caused by Aspergillus Species

A case of invasive Aspergillus niger spondylodiscitis with epidural abscess following COVID-19 infection in an immunocompromised host with literature review

Introduction and Importance

Aspergillosis is defined as an opportunistic infection that may spread hematogenously. COVID-19 infection has not been reported as a direct cause or risk factor. Its treatment (e.g. corticosteroids) significantly increases the risk for invasive infections. The respiratory system remains the main target, and the Aspergillus fumigatus is the most responsible subtype. Other species like Aspergillus (A) flavus, A. niger, and A. nidulans follow in frequency. Other included sites are the skeletal muscular system and the entire spine leading to spondylodiscitis. Only a total of 118 cases of Aspergillus spondylodiscitis have been reported in the literature, and only 21 cases reporting spinal epidural abscess were identified.

Case Presentation

The authors report a new rare case of invasive A. Niger spondylodiscitis with epidural and iliopsoas abscesses in a 63-year-old North African female patient with a history of coronavirus infection (COVID-19) treated with high doses of corticosteroids. The patient had favorable medical and radiological outcomes after 6 months of antibiotic and antifungal therapy.

Clinical Discussion

Fungal spondylodiscitis is a rare pathology that may be lethal. Immunosuppression plays a determining role. Discovertebral contamination results from hematogenous dissemination, found in the majority of cases in adults. The main symptom is segmental spinal pain, with an inflammatory pattern most often predominating in the thoracolumbar spine. Clinical signs of spinal cord compression, such as paresthesias, radiculalgia, and paraplegia, can sometimes be associated. Diagnosis of such spondylodiscitis is based on cultures and/or histology, whereas in most cases, it was made by MRI. Epidural abscess remains a rare entity. The authors will explore the current literature in more detail to dissect and explain this rare entity.

Conclusion

Aspergillus spondylodiscitis remains a rare and very demanding clinical entity. Early diagnosis and well-targeted medical treatment seem the ideal solution given that this type of infection has a poor prognosis.

Aspergilloma Superinfection in the Spinal Canal of an 18-Year-Old Man: A Case Report

CASE

An 18-year-old immunocompetent man presented with symptomatic lumbar canal stenosis, discharging sinuses, and cold abscess for 3 years treated with multiple incision drainage procedures with cottonoid packing antibiotic therapy. Radiographic imaging showed a soft tissue mass in the canal causing bony destruction. Postoperative histopathological examination showed an Aspergillus fungal ball. Patient showed improvement at 6-month follow-up with medical management.

CONCLUSION

As far as we know, this is the first case report showing an aspergilloma involving the vertebral column. Inadequate antibiotic treatment and blind introduction of a foreign body into sinus tracts can lead to fungal infections mimicking tuberculosis, causing disastrous outcomes. Fungal cultures are recommended routinely.

Imaging of Spondylodiscitis: A Comprehensive Updated Review-Multimodality Imaging Findings, Differential Diagnosis, and Specific Microorganisms Detection

Spondylodiscitis is defined by infectious conditions involving the vertebral column. The incidence of the disease has constantly increased over the last decades. Imaging plays a key role in each phase of the disease. Indeed, radiological tools are fundamental in (i) the initial diagnostic recognition of spondylodiscitis, (ii) the differentiation against inflammatory, degenerative, or calcific etiologies, (iii) the disease staging, as well as (iv) to provide clues to orient towards the microorganisms involved. This latter aim can be achieved with a mini-invasive procedure (e.g., CT-guided biopsy) or can be non-invasively supposed by the analysis of the CT, positron emission tomography (PET) CT, or MRI features displayed. Hence, this comprehensive review aims to summarize all the multimodality imaging features of spondylodiscitis. This, with the goal of serving as a reference for Physicians (infectious disease specialists, spine surgeons, radiologists) involved in the care of these patients. Nonetheless, this review article may offer starting points for future research articles.

Diagnosis, Treatment, and Outcome of Coccidioidal Osseous Infections: A Systematic Review

Extrapulmonary infections by Coccidioides spp., though rare, can occur via dissemination, affecting singular or multiple sites, including the skin and musculoskeletal system. Skeletal involvement often manifests as osteomyelitis, particularly in the axial skeleton. The present systematic review evaluates all documented cases of skeletal coccidioidomycosis to assess the diagnostic and treatment strategies alongside the outcomes, drawing insights from an analysis of 163 verified cases. A systematic review following PRISMA guidelines identified all studies reporting skeletal infections by Coccidioides spp. up to 2023 from the PubMed and Scopus databases. Eligible studies evaluated osteoarticular infections from Coccidioides spp. Data extraction included demographics, microbiological data, diagnostic methods, and treatment outcomes. Of the 501 initially identified records, a total of 163 patients from 69 studies met the inclusion criteria. Most cases were from the USA, predominantly males, while the median age of the population was 36 years. Diabetes mellitus was the common comorbidity (14.7%). C. immitis was the most prevalent pathogen. The spine and hand were common sites of infection (17.5% and 15.1%, respectively). Osteomyelitis by Coccidioides spp. was diagnosed, in most cases, by positive cultures (n = 68; 41.7%), while, in 49 (30.9%), both the histological examination and cultures yielded the fungus. Surgical debridement was performed in 80.9% of cases. A total of 118 (72.3%) patients were treated with monotherapy, while combination therapy with two or more antifungal agents was reported in 45 (17.7%). Amphotericin B (either liposomal or deoxycholate) was the most commonly given agent as monotherapy in 51 (31.2%) patients, while 30 (18.4%) patients received itraconazole as monotherapy. The rate of infection's resolution was higher in patients undergoing surgical debridement (79.5%), compared to those treated only with antifungal agents (51.6%, p = 0.003). Treatment outcomes showed complete resolution in 74.2% of patients, with a mortality rate of 9.2%. Coccidioidal osseous infections present diagnostic and therapeutic challenges. Surgical intervention is often necessary, complementing antifungal therapy. Vigilance for Coccidioides spp. infections, especially in regions with endemicity, is crucial, particularly when bacterial cultures yield negative results.

An immunocompetent host with blood-disseminated Aspergillus versicolor spondylitis: a case report and literature review

Blood-disseminated Aspergillus spondylitis in immunocompetent individuals is rare. The clinical, imaging, and pathological manifestations of this condition are not specific. Therefore, this disease is prone to misdiagnosis and a missed diagnosis. Systemic antifungal therapy is the main treatment for Aspergillus spondylitis. We report a case of blood-disseminated Aspergillus versicolor spondylitis in a patient with normal immune function. The first antifungal treatment lasted for 4 months, but Aspergillus spondylitis recurred a few months later. A second antifungal treatment course was initiated for at least 1 year, and follow-up has been ongoing. Currently, there has been no recurrence.

Case series of aspergillus spondylodiscitis from a tertiary care centre in India

Aspergillus spondylodiscitis is a rare entity reported in the literature. In tuberculosis endemic regions like India, more often it could be misdiagnosed as tuberculous spondylodiscitis. Herein we report a case series of three patients with Aspergillus spondylodiscitis presenting with chronic low backpain and clinically diagnosed as tuberculosis spine. Culture and histopathological examination of the debrided tissue provided a definite diagnosis. Interestingly, one of the cases had coexisting tuberculosis spine. All three patients underwent surgical intervention-debridement, decompression and fusion of spine and combined medical management with voriconazole with successful outcome.

Spinal Infections Caused by Coccidioides Species

Introduction: Spinal Coccidioidomycosis, although rare, represents the most frequent osseous presentation of Coccidioides spp infection. The present review aims to describe the anatomical distribution, the epidemiological characteristics, and the diagnostic and therapeutic approach of this severe infection. Methods:A meticulous review of all published spinal Coccidioidomycosis cases was carried out. The studied population's demographics and the anatomical distribution of the infection were recorded. Furthermore, the medical and operative management as well as the disease outcome were studied. Results:Seventy-six cases (of which 78.9% males) with a mean age of 35.5 years were located. Regarding the anatomical distribution of the infection, the thoracic area was the most commonly affected spine region (26.3%). Among the studied patients, 14 (18.4%) were immunocompromised. Pain was the most commonly reported symptom (21.1%). Regarding the diagnostic approach of this infection, plain x-ray or CT scan indicated the disease in the majority of cases (44.7%). Pathology (48.7%), serology (42.1%) and microbiological examinations (35.5%) further established the firm diagnosis, with Coccidioides immitis being the most frequently isolated fungus. Medical management included mainly amphotericin B (in 57.9% of cases), followed by fluconazole (in 38.2% of cases). The disease required surgical intervention in the majority of cases (76.3%), while the infection had a successful outcome in 80.3% of cases. Conclusion:Spinal Coccidioidomycosis seems to require prolonged medical treatment, including proper antifungal therapy and, in most cases, operative management. Multidisciplinary approach, including infectious disease specialists, orthopaedic and/or spine surgeons, microbiologists and radiologists seems to be of utmost important for yielding favorable outcomes.

Skeletal Infections Caused by Coccidioides Species

Background: Coccidioidomycosis represents an endemic and challenging disease, with rare extrapulmonary manifestations. The present review of all published cases of core and extremities osseous coccidioidomycosis aims to describe epidemiology, patients’ characteristics, symptoms as well as medical and surgical treatment options and their effectiveness. Methods: A thorough review of all published skeletal core and extremity infections due to Coccidioides species was conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical management as well as the infection outcome was recorded. Results: A total of 92 cases of Coccidioides spp. skeletal infections were recorded in 87 patients. The patients’ mean age was 35.3 years. The most common site of infection was the spine (82.6%), followed by the foot (6.5%), while the predominant symptom upon presentation was pain (29.9%). Immunosuppressive conditions and/or medications were observed in 21 patients (24.1%). Regarding imaging methods, indicating diagnosis, plain X-rays or CT scans were performed in most patients (50.6%), followed by magnetic resonance imaging (MRI) (47.1%). Most cases were diagnosed through histopathology (62; 71.3%), followed by serology testing (36; 42.4%) and by cultures (35; 40.2%). In 32 cases (36.8%), Coccidioides immitis was cultured, while in the remaining 55 cases (63.2%) the fungus was not further characterized. Regarding AFT, amphotericin B was the preferred agent (52.9%), followed by fluconazole (43.3%). In most cases (78.2%) surgical treatment was also performed. Treatment was successful in 80.5% of cases. Conclusions: Skeletal core and extremity infections due to Coccidioides spp. represent a severe disease. With the available data, the combination of prolonged proper AFT with surgical intervention seems to be the optimal current therapeutic approach.

Osseous Infections Caused by Aspergillus Species

Background: Osteomyelitis caused by Aspergillus spp. is a severe, but rare, clinical entity. However, clear guidelines regarding the most effective medical management have not yet been established. The present study is a literature review of all such cases, in an effort to elucidate epidemiology, as well as the therapeutic management and the infection’s outcome. Methods: A thorough review of all reports of osteomyelitis of the appendicular and the axial skeleton, without the skull and the spine, caused by Aspergillus spp. was undertaken. Data about demographics, imaging techniques facilitating diagnosis, causative Aspergillus, method of mold isolation, antifungal treatment (AFT), surgical treatment, as well as the infection’s outcome were recorded and evaluated. Results: A total of 63 cases of osseous infection due to Aspergillus spp. were identified. The studied population’s mean age was 37.9 years. The most commonly affected site was the rib cage (36.8%). Most hosts suffered immunosuppressive conditions (76.2%). Regarding imaging methods indicating diagnosis, computer tomography (CT) was performed in most cases (42.9%), followed by plain X-ray (41.3%) and magnetic resonance imaging (MRI) (34.9%). The most frequent isolated mold was Aspergillus fumigatus (49.2%). Cultures and/or histopathology were used for definite diagnosis in all cases, while galactomannan antigen test was additionally used in seven cases (11.1%), polymerase chain reaction (PCR) in four cases (6.3%), and beta-d-glucan testing in three cases (4.8%). Regarding AFT, the preferred antifungal was voriconazole (61.9%). Most patients underwent surgical debridement (63.5%). The outcome was successful in 77.5%. Discussion: Osteomyelitis due to Aspergillus spp. represents a severe infection. The available data suggest that prolonged AFT in combination with surgical debridement is the preferred management of this infection, while identification of the responsible mold is of paramount importance.

Aspergillus fumigatus causing vertebral osteomyelitis in an immunocompetent patient: a case report and literature review

Aspergillus vertebral osteomyelitis causing deformity in immunocompetent patients is uncommon. We describe a previously healthy 68-year-old male who was referred after 2 years of lower thoracic back pain and gibbus. His inflammatory markers and HIV test were normal. Imaging demonstrated bony destruction of T12/L1 and L2 with vertebral collapse. Following inconclusive CT-guided biopsy, he underwent reconstructive spinal surgery. Histopathology showed fungi and Aspergillus fumigatus was cultured. He was treated with isavuconazole 200 mg once daily for 12 months with a satisfactory clinical outcome. We present a summary of recently published cases of atraumatic Aspergillus vertebral osteomyelitis in immunocompetent patients without risk factors. Fungal infection should be considered in culture-negative spondylodiscitis, even in the absence of risk factors.