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• W2968940185 abstract "Fungal spondylodiscitis, a relatively uncommon condition when compared to pyogenic infections of the spine has a high incidence in immunocompromised individuals with a mean age of 50 years.1Caldera Gustavo Cahueque Mario Cobar Andrés Gómez Gloria Rodríguez Oscar Fungal spondylodiscitis: review.J Spine. 2016; 5: 2Crossref Google Scholar Usual causative organisms include Candida and Aspergillus. Infrequently, Blastomyces, Coccidioides, Blastoschizomyces, Scedosporium and Trichosporon also affect the spine.2Kim C.W. Perry A. Currier B. Yaszemski M. Garfin S.R. Fungal infections of the spine.Clin Orthop Relat Res. 2006; 444: 92-99Crossref PubMed Scopus (48) Google Scholar, 3Grammatico L. Baron S. Rusch E. Lepage B. Surer N. et al.Epidemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge data 2002-2003.Epidemiol Infect. 2008; 136: 653-660Crossref PubMed Scopus (216) Google Scholar, 4Tay B.K. Deckey J. Hu S.S. Spinal infections.J Am Acad Orthop Surg. 2002; 10: 188-197Crossref PubMed Scopus (77) Google Scholar We describe a rather unusual presentation of fungal spondylodiscitis caused by Sporothrix in a 35 year old immunocompetent individual. A 35 year old gentleman presented to the Orthopaedic out patient with complaints of upper back pain and numbness in the anterior aspect of right thigh for the previous 2 months. There was no history of trauma, fever or similar complaints in the past. He was not an intravenous drug abuser. Examination revealed no tenderness over the spine, no motor loss in the lower limbs but for sensory blunting over the L1 dermatome of the right side. Plain radiographs were normal. In view of persistent symptoms, an MRI of the dorso lumbar spine was requested which showed an extradural mass compressing the spinal cord at D12 - L2 level and extending over the right L1 nerve root. The lesion was hypo intense in both T1 and T2 weighted images. There was no involvement of the disc spaces at this time (Image 1, Image 2). Serology was negative for HIV. Patient was worked up for surgery. D12, L1 and L2 laminectomies were done to expose the mass. The extension on to the right L1 nerve root necessitated removal of the facet unilaterally on the right side. Intra operatively, the mass was found to be glued to the posterior dura from D12 to L2 (Image 3). The mass was greyish, friable and homogeneously firm in consistency. It was removed en bloc meticulously separating it from the dura and the right L1 nerve root (Image 4). Unilateral short segment instrumentation spanning D12 to L2 was done to stabilise the decompressed segments (Image 5). Histopathology and culture showed Sporothrix schenckii (fungal septate hyphae with conidiospores arranged in flower shape at the end of hyphae) (Image 6). Patient showed symptomatic improvement in the immediate post operative period. Antifungals - Amphotericin B was started intravenously for 2 weeks and patient was discharged on oral Itraconazole prescribed for 6 months. Regrettably, the patient defaulted treatment and came back to us 2 months later with recurrent back pain. X-rays revealed implant failure with localised kyphosis. MRI showed involvement of D12-L1 and L1-L2 disc spaces which was not seen earlier. Antifungals were restarted and the fixation revised to a long segment stabilisation from D10-L3 with debridement of D12-L1, L1-L2 disc spaces (Image 7). Patient reviewed again with the same complaints a month later. This time the MRI showed involvement of the lower L2-L3 disc space as well. A debridement of the L2-L3 disc was done and sent for culture which grew the same pathogen Sporothrix schenckii. Since then, the patient had no complaints, showed significant clinical improvement with reduced back ache and return of sensations in L1 dermatome on the right thigh. He completed 6 months of Antifungal treatment. Patient was followed up serially. At 2 years post op he was symptom free, showed fusion of D12-L1, L1-L2 and L2-L3 disc spaces with implants in position (Image 8).Image 2Sagittal cuts of MRI spine illustrating the mass compressing the spinal cord posteriorly.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 3Intraoperative image of the mass glued to the cord.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 4Image of the cord post en bloc excision of the mass and stabilisation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 5Immediate post operative radiograph of the spine after the first surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 6Photomicrograph of Sporothrix schenckii from the specimen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 7Post operative radiograph after repeat debridement and extension of posterior stabilisation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 8Radiograph at 2 years follow up showing fusion of D12-L3 levels.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The usual presentation of fungal spondylodiscitis is intermittent progressive back pain with or without fever and neurological symptoms in an immunocompromised individual.5Ganesh D. Gottlieb J. Chan S. Martinez O. Eismont F. Fungal infections of the spine.Spine. 2015; 40: E719-E728Crossref PubMed Scopus (16) Google Scholar,6Herron L.D. Kissel P. Smilovitz D. Treatment of coccidioidal spinal infection: experience in 16 cases.J Spinal Disord. 1997; 10: 215-222Crossref PubMed Google Scholar The most common causative organisms being Candida, Aspergillus and Cryptococcus. To ascertain a diagnosis of fungal etiology, the gold standard is to obtain a tissue sample for culture and histopathological examination.7Yang S.C. Fu T.S. Chen L.H. Chen W.J. Tu Y.K. Identifying pathogens of spondylodiscitis: percutaneous endoscopy or CT-guided biopsy.Clin Orthop Relat Res. 2008; 466: 3086-3092Crossref PubMed Scopus (69) Google Scholar Imaging in fungal spondylodiscitis is non specific, mimicking either tuberculous or pyogenic discitis. In any case, it involves either the endplates or the discs, though fungal infections spare the disc most often.1Caldera Gustavo Cahueque Mario Cobar Andrés Gómez Gloria Rodríguez Oscar Fungal spondylodiscitis: review.J Spine. 2016; 5: 2Crossref Google Scholar Treatment is mainly medical with antifungals; intravenous and oral for 6–12 months.8Koehler P. Cornely O.A. Contemporary strategies in the prevention and management of fungal infections.Infect Dis Clin N Am. 2016; 30: 265-275Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The indications for surgical intervention being spinal instability, neurological compression, progression of infection, resilient pain and deformity.1Caldera Gustavo Cahueque Mario Cobar Andrés Gómez Gloria Rodríguez Oscar Fungal spondylodiscitis: review.J Spine. 2016; 5: 2Crossref Google Scholar Though Minimally invasive spine surgeries were successful in pyogenic infections of spine; thoracoscopic approach in thoracic segments, percutaneous instrumentation of lumbar segments in patients who underwent double approach and for drainage of abscess; literature on their usage in treating fungal spondylodiscitis is sparse. Until recently they were done in mild cases with bony destruction. Currently, open surgery is the gold standard as aggressive debridement and stabilisation is required.1Caldera Gustavo Cahueque Mario Cobar Andrés Gómez Gloria Rodríguez Oscar Fungal spondylodiscitis: review.J Spine. 2016; 5: 2Crossref Google Scholar,9Shaikh B.S. Appelbaum P.C. Aber R.C. Vertebral disc space infection and osteomyelitis due to Candida albicans in a patient with acute myelomonocytic leukemia.Cancer. 1980; 45: 1025-1028Crossref PubMed Scopus (32) Google Scholar, 10Hummel M. Schuler S. Weber U. Schwertlick G. Hempel S. et al.Aspergillosis with Aspergillosis osteomyelitis an discitis after heart transplantation: surgical and medical management.J Heart Lung Transplant. 1993; 12: 599-603PubMed Google Scholar, 11Duarte R.M. Vaccaro A.R. Spinal infection: state of the art and management algorithm.Eur Spine J. 2013; 22: 2787-2799Crossref PubMed Scopus (185) Google Scholar The goal of surgery is to debride, obtain sample for histological diagnosis, decompress and stabilise the spine; as decompression without stabilisation leads to a certain progression to kyphosis.9Shaikh B.S. Appelbaum P.C. Aber R.C. Vertebral disc space infection and osteomyelitis due to Candida albicans in a patient with acute myelomonocytic leukemia.Cancer. 1980; 45: 1025-1028Crossref PubMed Scopus (32) Google Scholar Inter body fusions traditionally were done using autologous tricortical iliac crest graft or fibular bone graft to act as structural support and provide a biological matrix.1Caldera Gustavo Cahueque Mario Cobar Andrés Gómez Gloria Rodríguez Oscar Fungal spondylodiscitis: review.J Spine. 2016; 5: 2Crossref Google Scholar,12Cho Kyungil Lee Sun-Ho Kim Eun-Sang Eoh Whan Candida parapsilosis spondylodiscitis after lumbar discectomy.J Korean Neurosurg Soc. 2010; 47: 295-297Crossref PubMed Scopus (15) Google Scholar However, recent case reports have used inter body cages with success.13Lyons Mark K. Neal Matthew T. Patel Naresh P. Vikram Holenarasipur R. Progressive back pain due to Aspergillus nidulans vertebral osteomyelitis in an immunocompetent patient: surgical and antifungal management.Hindawi Case Rep Orthop. 2019; (Article ID 4268468): 4Google Scholar,14N. Barbosa, M.J. Gonçalves, P. Araujo, et al. Candida albicans lumbar spondylodiscitis in a non immunocompromised patient. Orthop Proc. 97-B, No. SUPP_16Google Scholar N. Barbosa et al. reported the clinical features and treatment on a rare case of Candida albicans infection of the spine in a non-immunocompromised patient who developed Candida septicaemia while in Intensive Care Unit. He subsequently developed severe low back pain with features of myelopathy in his lower limbs. MRI revealed endplate erosion at L5S1, paraspinal collection and epidural compression. End plate material confirmed Candida albicans. He underwent debridement and posterior instrumented fusion from L4-S1.14N. Barbosa, M.J. Gonçalves, P. Araujo, et al. Candida albicans lumbar spondylodiscitis in a non immunocompromised patient. Orthop Proc. 97-B, No. SUPP_16Google Scholar Mark K. Lyons published a similar case in a 61 year old who had MRI findings of abnormal intradiscal signal between L3 and L4. Open biopsy from the disc space grew Aspergillus nidulans. He showed spurious improvement with antifungals initially, but developed progressive destruction of L3 and L4. Patient underwent discectomy and partial corpectomies with expandable titanium corpectomy cage reconstruction. Good clinical recovery was noticed post surgery.13Lyons Mark K. Neal Matthew T. Patel Naresh P. Vikram Holenarasipur R. Progressive back pain due to Aspergillus nidulans vertebral osteomyelitis in an immunocompetent patient: surgical and antifungal management.Hindawi Case Rep Orthop. 2019; (Article ID 4268468): 4Google Scholar Kyungil Cho et al. reported Candida parapsilosis spondylodiscitis after lumbar discectomy of L5-S1 in a 70 year old lady. She was not on any immunosuppressive agents; presented with left lower extremity weakness and sensory disturbance. MRI showed irregular enhancing mass lesion at that level. The infected material was excised through an anterolateral approach and an iliac autograft was placed. The material excised was positive for the organism and she received fluconazole for 3 months. At 4 months she showed full recovery without residual symptoms.12Cho Kyungil Lee Sun-Ho Kim Eun-Sang Eoh Whan Candida parapsilosis spondylodiscitis after lumbar discectomy.J Korean Neurosurg Soc. 2010; 47: 295-297Crossref PubMed Scopus (15) Google Scholar Our patient had an extradural mass compressing the spinal cord. The differential diagnosis would include Epidural Angiolipoma (Non infiltrating type), Epidural Lipomatosis and Spinal epidural hematoma. Epidural Angiolipoma usually seen in the thoracic spine, is dorsal to the cord; it is hyper intense in both T1& T2 weighted MRI images.15Spinal epidural angiolipoma: a rare cause of spinal cord compression.J Neurosci Rural Pract. 2012 Sep-Dec; 3: 341-343Crossref PubMed Scopus (15) Google Scholar Epidural Lipomatosis is T1 hyperintense and T1 FS shows fat suppression. Spinal epidural hematoma (spontaneous) is T1 isointense & T2 hyper intense with hypo intense foci.16Baek Byung Suck Jin Woo Hur Kwon Ki Young Lee Hyun Koo Spontaneous spinal epidural hematoma.J Korean Neurosurg Soc. 2008 Jul; 44: 40-42Crossref PubMed Scopus (40) Google Scholar The extradural mass in our case was hypo intense in both T1 and T2 weighted images ruling out the possibility of the aforementioned conditions. Since the patient had unrelenting back pain and numbness over his right thigh with corroborative MRI findings of spinal compression, decompression with excision of the mass and stabilisation was contemplated. In the absence of predisposing factors, a clinical suspicion of fungal spondylodiscitis is difficult to establish in this case as there was no prolonged antibiotic usage and the patient was neither immunocompromised nor an iv drug abuser. Also the presentation as an extradural mass is highly uncharacteristic of fungal infection of the spine. Sporothrix schenckii, a dimorphic fungus is distributed throughout the world, especially in tropical and subtropical zones. Infection generally occurs by traumatic inoculation of soil, plants, and organic matter contaminated with it.17de Lima Barros Mônica Bastos de Almeida Paes Rodrigo Oliveira Schubach Armando Sporothrix schenckii and sporotrichosis.Clin Microbiol Rev. 2011 Oct; 24: 633-654Crossref PubMed Scopus (380) Google Scholar The extracutaneous form of sporotrichosis presents as primary pulmonary infection, chronic meningitis, osteomyelitis, tenosynovitis or bursitis.18Schwartz D.A. Sporothrix tenosynovitis--differential diagnosis of granulomatous inflammatory disease of the joints.J Rheumatol. 1989 Apr; 16: 550-553PubMed Google Scholar,19Ramirez J. Byrd Jr., R.P. Roy T.M. Chronic cavitary pulmonary sporotrichosis: efficacy of oral itraconazole.J Ky Med Assoc. 1998 Mar; 96: 103-105PubMed Google Scholar Mono arthritis is the common skeletal manifestation in osteoarticular sporotrichosis. To the best of our knowledge, this is the first case report of Sporothrix involving the spine, presenting as extradural mass and subsequent spontaneous multi level involvement of the disc spaces. The case is presented for its unique features viz. fungal discitis in an immunocompetent patient, infection presenting itself as an extradural mass with multi level involvement from D12 to L3 compressing the cord, and the causative organism being Sporothrix schenckii. It is vital that a spine surgeon has to be fully appraised of the myriad ways fungal spondylodiscitis might present clinically, which would enable him to diagnose such conditions early in the course of disease process and treat them effectively to improve patients’ clinical outcomes." @default.
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• W2968940185 title "Unprecedented clinical presentation of fungal spondylodiscitis as an extradural mass in an immunocompetent individual" @default.
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