Vertebral Aspergillus osteomyelitis and acute diskitis in patients with chronic obstructive pulmonary disease

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.

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Spondylodiscitis Caused by Aspergillus Species

Background: Spondylodiscitis caused by Aspergillus spp. is a rare but life-threatening clinical entity. However, a consensus on diagnostic criteria and most effective medical management is still missing. The present study is a review of all published cases of spondylodiscitis caused by Aspergillus spp., in an effort to elucidate epidemiology, patients’ characteristics, andand the medical and surgical treatment options and their effectiveness. Methods: A thorough review of all existing spondylodiscitis cases caused by Aspergillus was performed. Data regarding demographics, responsible fungus, time between symptoms’ onset and firm diagnosis, antifungal treatment (AFT), surgical intervention, andand the infection’s outcome were investigated. Results: A total of 118 Aspergillus spondylodiscitis cases, yielding 119 Aspergillus spp. isolates, were identified in the literature. The patients’ mean age was 40.6 years. Magnetic resonance imaging (MRI) (after its introduction) indicated the diagnosis in most cases (66.7%), while definite diagnosis was established through cultures in the majority of cases (73.7%). Aspergillus fumigatus was isolated in most cases (73; 61.3%), followed by Aspergillus flavus (15; 12.6%) andand Aspergillus nidulans and terreus (7; 5.9%, each). The mean time between symptoms’ onset and diagnosis was 5.7 months. Amphotericin B was the preferred antifungal regiment (84 cases; 71.2%), followed by voriconazole (31; 26.3%), and the mean AFT duration was 6.1 months. The final outcome was successful in 93 cases (78.8%). Furthermore, 77 patients (65.3%) underwent surgery. Conclusions: Spondylodiscitis caused by Aspergillus spp. represents a clinical challenge, requiring a multidisciplinary approach. The present review has shown that prolonged AFT has been the standard of care of the studied cases, while surgical treatment seems to play an important role in selected patents.

Spontaneous Vertebral Aspergillosis, the State of Art: A Systematic Literature Review

Objective

Vertebral aspergillosis is quite rare conditions, often misdiagnosed, that requires long-term antibiotic therapy, and sometimes, surgical treatments. The present investigations were aimed to investigate the epidemiology, clinical-radiological aspects, treatment protocols, and outcomes of Aspergillus-mediated vertebral osteomyelitis.

Methods

A systematic review of the pertinent English literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. The research was conducted on Cochrane library, MEDLINE, PubMed, and Scopus using as search-terms “Aspergillus,” “vertebral osteomyelitis,” “spondylodiscitis,” “spine infection.” A case of vertebral aspergillosis conservatively managed was also reported.

Results

Eighty-nine articles were included in our systematic review. Including the reported case, our analysis covered 112 cases of vertebral aspergillosis. Aspergillus fumigatus was isolated in 68 cases (61.2%), Aspergillus flavus in 14 (12.6%), Aspergillus terreus in 4 (3.6%), Aspergillus nidulans in 2 (1.8%). Seventy-three patients (65.7%) completely recovered at the last follow-up evaluation; in 7 patients (6.3%) radiological signs of chronic infection were reported, whereas 32 patients (28.8%) died during the follow-up.

Conclusion

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

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.

A rare case of spontaneous Aspergillus spondylodiscitis with epidural abscess in a 45-year-old immunocompetent female

Vertebral osteomyelitis and discitis are mainly due to bacterial infections though fungal infections are one of the important causes of morbidity and mortality in immunocompromised patients. Aspergillus involving intervertebral disc space is extremely rare. We report a case of aspergillosis of intervertebral L5-S1 disc space with spinal epidural abscess in an immunocompetent 45-year-old female which can add on to a few case reports described in literature as well as an insight for clinicians regarding this rare spontaneous infection in an immunocompetent patient.

Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome

BACKGROUND

The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.

METHODS

Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.

RESULTS

Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).

CONCLUSIONS

Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.

Osteomyelitis caused by Aspergillus species: a review of 310 reported cases

Aspergillus osteomyelitis is a rare infection. We reviewed 310 individual cases reported in the literature from 1936 to 2013. The median age of patients was 43 years (range, 0-86 years), and 59% were males. Comorbidities associated with this infection included chronic granulomatous disease (19%), haematological malignancies (11%), transplantation (11%), diabetes (6%), pulmonary disease (4%), steroid therapy (4%), and human immunodeficiency virus infection (4%). Sites of infection included the spine (49%), base of the skull, paranasal sinuses and jaw (18%), ribs (9%), long bones (9%), sternum (5%), and chest wall (4%). The most common infecting species were Aspergillus fumigatus (55%), Aspergillus flavus (12%), and Aspergillus nidulans (7%). Sixty-two per cent of the individual cases were treated with a combination of an antifungal regimen and surgery. Amphotericin B was the antifungal drug most commonly used, followed by itraconazole and voriconazole. Several combination or sequential therapies were also used experimentally. The overall crude mortality rate was 25%.

MRI findings of Aspergillus spondylitis

OBJECTIVE

The aim of this retrospective study is to report the MRI findings of biopsyproven Aspergillus spondylitis.

CONCLUSION

Aspergillus spondylitis should be suspected when multiple disk levels are involved with skip lesions or subligamentous spread on MRI. A serrated appearance of the vertebral endplates and subchondral T2 hypointensity are suggestive of Aspergillus spondylitis.

Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature

BACKGROUND

There are increasing reports describing invasive pulmonary aspergillosis (IPA) in patients with chronic obstructive pulmonary disease (COPD) without the classic risk factors for this severe infection. The available literature on this association is based on case reports or small case series. The aim of this review is to systematically review these cases and describe the clinical features, diagnostic studies and outcome.

METHODS

We identified all the cases of IPA and COPD reported in the literature and had enough clinical information. We also included five cases of IPA in patients with COPD identified by the authors. These cases were systematically reviewed for clinical features, diagnostic studies and outcome.

RESULTS

There were 60 cases of IPA in patients with COPD identified from the literature. The total number of cases reviewed was 65. The mean age was 65.1 years, the mean FEV1 was 39% of predicted (n = 17, range 19-56%). Forty-nine patients were documented to be on systemic corticosteroids. The mean dose was 24 mg/day (range 15-65 mg/day). Five patients were only on inhaled corticosteroids and in 11 patients there was no documentation of corticosteroid therapy. The clinical and radiological findings were nonspecific. Thirteen patients had documented evidence of disseminated IPA. Sputum examination was positive for Aspergillus in 76% and bronchoscopy with bronchoalveolar lavage that was positive in 70%. The diagnosis of IPA was definite in 43 patients and probable in 22 patients. Forty-six patients were treated with anti-fungal therapy. Fifty-nine patients (91%) died with IPA.

CONCLUSION

Invasive pulmonary aspergillosis is an emerging serious infection in patients with COPD. The majority of these patients have advanced COPD and/or on corticosteroid therapy. The clinical and radiological presentation is nonspecific. High index of suspicion is necessary for the timely treatment of these patients.

Recommendations for managing Aspergillus osteomyelitis and joint infections based on a review of the literature

OBJECTIVES

To produce recommendations for the management of Aspergillus osteomyelitis and joint infections.

METHODS

Published literature was surveyed to identify both case reports of Aspergillus osteomyelitis and joint infections and anti-fungal pharmacology of anti-fungal agents. Included in the pharmacological review was an assessment of new and investigational anti-fungals to consider their potential role in the management of this infection.

RESULTS

Successful treatments, identified from the cases reviewed, were based on combination anti-fungal therapy with one agent having good bone penetration and one having reliable anti-Aspergillus activity.

CONCLUSIONS

For the management of serious Aspergillus osteomyleitis/joint infections amphotericin B in combination with flucytosine is recommended. A number of second line treatment combinations are identified. Monotherapy is appropriate with an azole in clinically stable patients.

Spinal infections

Spinal infections can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy and myelitis. Radiological evaluations have gained importance in the diagnosis, treatment planning, treatment and treatment monitoring of the spinal infections. Conventional radiographs are usually the initial imaging study. The sensitivity and specificity of the plain radiographs are very low. The sensitivity of CT is higher while it lacks of specificity. Conventional CT has played minor role for the diagnosis of early spondylitis and disc space infection and for follow-up, researches are going on the value of MDCT. MRI is as sensitive, specific and accurate as combined nuclear medicine studies and the method of choice for the spondylitis. Low signal areas of the vertebral body, loss of definition of the end plates and interruption of the cortical continuity, destruction of the cortical margins are typical on T1WI whereas high signal of affected areas of the vertebral body and disc is typical on T2WI. Contrast is mandatory and increases conspicuity, specificity, and observer confidence in the diagnosis and facilitates the treatment planning. Contrast enhancement is the earliest sign and pathognomonic in the acute inflammatory episode and even in the subtle infection then persists to a varying degree for several weeks or months. The outcome of the treatment is influenced by the type of infection and by the degree of neurologic compromise before treatment. There is an increasing move away from surgical intervention towards conservative therapy, percutaneous drainage of abscess or both. It is therefore critical to monitor treatment response, particularly in the immuno-deficient population.

Spontaneous corynebacterium discitis in a patient with chronic renal failure

STUDY DESIGN

Case report describing spontaneous Corynebacterium diptheria discitis in a patient with chronic renal failure.

OBJECTIVES

To describe this very rare form of discitis and the results of surgical and antibiotic therapy.

SETTING

University Department of Neurosurgery, Turkey.

CASE REPORT

A 55-year-old man with chronic renal failure presented with acute low-back pain. Lumbar magnetic resonance imaging (MRI) suggested discitis and osteomyelitis at the L5-S1 level. The L5-S1 disc was operated upon and the discectomy material was sent for pathological and microbiological analysis.

RESULTS

Pathological examination revealed infection and bacterial culture grew C. diptheria. The patient was prescribed combination antibiotic therapy with vancomycin, a third-generation cephalosporin, and rifampicin. Clinical status improved after 8 weeks of therapy. Lumbar MRI revealed remission of the discitis and osteomyelitis after 10 months of follow-up.

CONCLUSION

Chronic renal failure patients with low-back pain should be investigated for spinal infection. These individuals are prone to low-grade infection in the form of discitis or osteomyelitis. Corynebacterium subspecies rarely cause spontaneous discitis. This case is interesting because of the unusual causal organism and the occurrence of discitis in the setting of chronic renal failure.

New clinical presentations of invasive aspergillosis in non-conventional hosts

Infections by Aspergillus spp. are most typically associated with invasive pulmonary aspergillosis. However, an increasing number of reports deal with unusual manifestations of invasive aspergillosis. In the lung this may take the form of chronic invasive pulmonary aspergillosis, bronchocentric granulomatosis or tracehobronchitis. A number of extrapulmonary infections have been noted, sometimes in immunocompetent individuals. Examples include vertebral osteomyelitis, primary cutaneous aspergillosis (such as in premature neonates), prosthetic vascular graft infection and infective endocarditis. Early recognition of these entities, prompt initiation of new, highly active antifungal therapies and adjunctive surgical management may improve the prognosis of these conditions.

Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

Aspergillus spondylodiskitis in a patient with chronic obstructive pulmonary disease

Invasive aspergillosis is a well-known complication in immunocompromised patients. There are only a few reports of invasive aspergillosis in non-immunocompromised patients. We describe a 72-year-old female patient with clinical signs of spondylodiskitis occurring 4 months after what had appeared to be successful treatment of pulmonary aspergillosis. The patient used inhalation corticosteroids on a daily basis because of chronic obstructive pulmonary disease (COPD). Spondylodiskitis of the intervertebral disc Th11 and Th12 with involvement of both adjacent vertebral bodies was confirmed by magnetic resonance imaging. Histopathological examination revealed the presence of septate hyphae, indicative of Aspergillus species. Subsequently, evidence of Aspergillus spondylodiskitis was obtained by amplification of Aspergillus-DNA with a specific polymerase chain reaction method. Aspergillus spondylodiskitis after pulmonary aspergillosis is only very rarely encountered. Patients with COPD, managed with short-term courses of systemic corticosteroids or with high-dose corticosteroid inhalation therapies, are considered non-immunocompromised but might be at risk of developing invasive aspergillosis.

Aspergillosis in lung transplantation: incidence, risk factors, and prophylactic strategies

Invasive aspergillosis remains a significant cause of morbidity and mortality in transplantation, especially lung and allogeneic bone marrow transplant recipients. The epidemiology, classic and newly recognized risk factors, and incidence of aspergillosis are reviewed. Risk factors include environmental exposures, airway colonization, profound immunosuppression, neutropenia, prior cytomegalovirus infection, and renal dysfunction. Clinical and radiographic presentations of invasive aspergillosis are discussed, including some unusual manifestations in lung transplant recipients. Early and accurate diagnosis of aspergillosis remains a challenge, and diagnostic strategies are reviewed, with an emphasis on the chest computerized tomography scan and on transbronchial or open lung biopsy. Recent advances include prophylactic and pre-emptive antifungal strategies, newer therapeutic agents, and improved risk stratification.

Imaging of spinal infection

MR imaging is the modality of choice for the detection, staging, and differential diagnosis of inflammatory disorders of the spine. Infectious spondylitis is characterized by the involvement of two adjacent vertebrae and the intervening disk with severe BME and early destruction of the end plates. The disk space is narrowed and typically exhibits water-equivalent signal intensity on T2-weighted or STIR images. Prevertebral and epidural extensions, abscess formation, enhancement of the BME, the disk space, and the surrounding granulation tissue are well demonstrated by gadolinium-enhanced images. Cervical spondylitis frequently involves more than one level. Bone marrow abnormalities may be subtle at this level and increased signal intensity of the disk space on T2-weighted or STIR images is an important finding. The risk for neurologic complications is increased. Granulomatous infections caused by tuberculosis, brucellosis, fungi, and parasites, including hydatid disease (Echinococcus), are frequently associated with imaging findings different from those seen with nonspecific bacterial infection. In patients with chronic infectious spondylitis, diffuse reactive bone marrow changes with decreased signal intensity on T1-weighted images, increased signal intensity on T2-weighted and STIR images, and increased uptake after gadolinium administration may occur. This phenomenon is probably caused by reactive bone marrow stimulation, simulating diffuse hematologic neoplastic disease. Erosive intervertebral osteochondrosis with bandlike disk gadolinium enhancement and BME, which is commonly associated with local pain, is the most important differential diagnosis of bacterial spondylitis.