J Korean Neurosurg Soc. 2008 January; 43(1): 45–47.
Published online 2008 January 20. doi: 10.3340/jkns.2008.43.1.45
PMCID: PMC2588164
Cervical Spondylodiscitis Caused by Candida Albicans in Non-Immunocompromised Patient
This article has been cited by other articles in PMC.
Abstract
Fungal infections of the spine are relatively uncommon. Moreover, cervical spondylodiscitis due to Candida albicans in non-immunocompromised patient is very rare. We report a case of Candida
spondylodiscitis in a 64-year-old woman who complained of neck pain.
The clinical feature and treatment option are presented with a review of
pertinent literatures.
Keywords: Candida albicans, Cervical spine, Spondylodiscitis
INTRODUCTION
Candida
species are normal flora that inhabit the skin and mucous membrane of
human host. Recently, the widespread use of antibiotics, central venous
catheters, intravenous drug and immunosuppressive chemotherapy have been
increased virulent infection by Candida species in immunocompromised individuals.
Spondylodiscitis due to Candida species have been rarely reported in the literatures to date1,7). Moreover the involvement of cervical spine is even rarer condition2,5,9,12).
We
present a case of cervical spondylodiscitis in non-immunocompromised
patient and discuss treatment option with a review of the literatures.
CASE REPORT
A
64-year-old woman presented with nuchal pain one month before
admission. She had a medical history of chronic gastritis and old
pulmonary tuberculosis. She was afebrile. The peripheral white blood
cell (WBC) count was 8,000/mm3 and the erythrocyte
sedimentation rate (ESR) was 103 mm/hr. The c-reactive protein (CRP) was
3.09 mg/dl. Cultures of the blood, urine and sputum were negative for
Candida species and tuberculosis. Initial lateral cervical radiograph
revealed diminution of the intervertebral space between C5 and C6,
associated with a destructive process involving corresponding vertebral
bodies (Fig. 1).
Magnetic resonance (MR) imaging of the cervical spine was compatible
with a diagnosis of infective spondylodiscitis at C5-6 with associated
vertebral osteomyelitis and epidural abscess characterized by low signal
intensity on T1-weighted image and high signal intensity on T2-weighted
image, with well enhancement after gadolinium administration (Fig. 2).
The surrounding epidural space, retropharyngeal space and paravertebral
space of cervical spine were similar to MR imaginges. A presumptive
diagnosis was spondylodiscitis due to tuberculosis.
Preoperative
plain lateral cervical radiograph shows marked destructive change of
C5, C6 vertebral bodies and kyphotic deformity.
Preoperative
sagittal magnetic resonance image shows low signal intensity on
T1-weighted (A), high signal intensity on T2-weighted (B), and well
enhanced (C) lesion at C5, C6 vertebral bodies, intervertebral space,
and surrounding structures.
At
surgery, the C4-5 intervertebral disc and C4 vertebral body were also
found to be destroyed. Therefore, the patient underwent corpectomy of
C4, C5, C6 vertebral bodies with radical resection of surrounding
infectious tissues and anterior interbody fusion with fibula bone and
metal plate (Fig. 3).
The pathologic findings of the removed necrotic materials were
consistent with chronic inflammation and calcification. Culture of
biopsy specimen yielded Candida albicans. Postoperatively,
antifungal treatment started with amphotericin B 25 mg daily
intravenously for 14 days and fluconazole 200 mg daily orally for 2
months and then 100 mg daily for 4 months. After 6 months of antifungal
treatment for Candida albicans, the ESR and CRP were normalized. The patient recovered and discharged uneventfully.
Postoperative
plain lateral cervical radiograph shows the fibula bone graft and plate
system and restoration of kyphotic deformity after 2 weeks (A) and 6
months (B).
DISCUSSION
Candida species are normally low virulent organisms. Despite of the increased incidence of Candida infections, spondylodiscitis due to Candida species is very rare. According to the report by Miller et al.7), a total of 59 cases of spondylodiscitis caused by Candida species were reported from 1966 to 2000 and Candida albicans
accounts for a third of these infections. Our brief review of published
literatures from 2001 to 2006 revealed additional 23 cases. We did not
find any literatures published by Journal of Korean Neurological Society
concerning Candida spondylodiscitis of the cervical spine. Only one case of Aspergillus spondylitis was reported in 20056).
Candida
spondylitis may occur by direct implantation of a contiguous infected
site or by hematogenous route. Among them, hematogenous spread is
thought to be the most important pathophysiological mechanism, owing to
abundant vascular supply in and around vertebral body and intervertebral
space11,12). In our case, we speculate that malnutrition due to chronic gastritis may cause unknown opportunistic infection.
The diagnosis of Candida
spondylodiscitis includes clinical features, laboratory results,
radiological studies and microbiological tests. The clinical features
are non-specific. The patient presented with vague nuchal or back pain.
The only 32% to 43% of patients presented with fever at admission and
about 20% of patients complained of the neurological deficits7,8). Laboratory results frequently revealed elevated ESR and CRP, but a normal WBC count, in accordance with our case5,7).
Although plain radiograph frequently reveals erosive and destructive
changes of the vertebral body, MR imaging is the diagnostic tool of
choice for Candida spondylodiscitis10,14). Williams et al.14)
reported different MR imaging features, including absence of disc high
signal intensity and preservation of the intranuclear cleft in
T2-weighted images in the case of fungal spondylitis. Unfortunately, we
could not find these findings in our case due to the collapse of
affected intervertebral space. Because various clinical, laboratory and
radiological features are non-specific, percutaneous or open biopsy and
microbiological test should be performed to confirm the diagnosis.
The treatment options of Candida
spondylodiscitis include conservative treatment with biopsy and medical
therapy, and surgical intervention. There have been many debates about
treatment regimen for Candida spondylodiscitis. Some authors reported that Candida spondylodiscitis could be successfully treated by the only antifungal therapy with amphotericin B and fluconazole1,4). To the contrary, in the their review of published literatures, Hendrickx et al.3) advocated surgical debridement soon after diagnosis of Candida
spondylodiscitis is established. Half of the patients underwent
surgical treatment in the reported cases and 33% of the patients who
initially had received only medical treatment subsequently required
surgical intervention. However, surgical intervention is recommended in a
patient with neurological compromise, spinal instability due to
extensive collapse of the vertebral bodies, and medically refractory
infection. In this report, we performed surgical treatment due to spinal
instability with kyphotic deformity Although the optimal duration of
therapy for Candida spondyloldiscitis is not established, the
current practice is to continue treatment until the resolution of
clinical symptoms, recovery of laboratory data, and amelioration of
radiological features.
CONCLUSION
Although Candida
infections of spine, especially cervical spine, are very rare, early
diagnosis and radical surgery combined with antifungal chemotherapy are
recommended to achieve good outcome in non-immunocompromised patient.
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