Rev. bras. ortop. vol.50 número6

rev bras ortop.2015;50(6):739–742

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Case

report

Fungal

spondylodiscitis

due

to

Candida

albicans

_:

_an

atypical

case

and

review

of

the

literature

夽

Álynson

Larocca

Kulcheski

,

Xavier

Soler

Graells

,

Marcel

Luiz

Benato

,

Pedro

Grein

Del

Santoro

,

André

Luis

Sebben

a_{OrthopedicsandTraumatologyService,HospitaldeClínicas,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil}

b_{HospitaldoTrabalhador,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil}

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Articlehistory:

Received18August2014 Accepted14November2014 Availableonline18October2015

Keywords: Candidaalbicans Discitis Spinaldiseases

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SpondylodiscitisduetoCandidaisararecomplicationfromhematogenicdissemination ofinfectioncausedbythisfungus.Wepresentanatypicalcaseofspondylodiscitiscaused bythisgermthatoccurredafterchestcontusionandprogressedwithnecrotizingfasciitis oftheanteriorregionofthechestandosteomyelitisofthesternum.Throughcontiguity, italsoaffectedtheupperthoracicspine.Thepatientevolvedwithneurologicalalterations andrecoveredsatisfactorilyafterappropriatetreatmentwithsurgicaldecompressionofthe spinalcordandspecificantibiotictherapy.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Espondilodiscite

fúngica

por

Candida

albicans

_:

_um

_caso

_atípico

_e

_revisão

da

literatura

Palavras-chave: Candidaalbicans Discite

Doenc¸asdacolunavertebral

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e

s

u

m

o

A espondilodiscite por Candida albicans é uma rara complicac¸ão da disseminac¸ão hematogênica da infecc¸ão por esse fungo. Apresentamos um caso atípico de espondilodiscite por esse germe ocorrido após trauma contuso torácico que cursou com fasceíte necrotizante da região anterior do tórax, osteomielite de esterno e, por contiguidade,afetouacolunavertebraltorácicaalta.Opacienteevoluiucomalterac¸ão neu-rológicaerecuperou-sesatisfatoriamenteapóstratamentoadequadocomdescompressão medularcirúrgicaeantibioticoterapiaespecífica.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

StudycarriedoutattheOrthopedicsandTraumatologyService,HospitaldeClínicas,UniversidadeFederaldoParaná(UFPR)and HospitaldoTrabalhador,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil.

∗ _{Correspondingauthor.}

E-mails:alylarocca@gmail.com,alynsonlarocca@hotmail.com(Á.L.Kulcheski). http://dx.doi.org/10.1016/j.rboe.2015.10.005

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Fig.1–Initialaspectofthesternumlesion.

Introduction

Spinalcordinfectionsare rareandcompriseapproximately 1% of bone infectious involvement.1 _{Most of these}

infec-tionsareofpyogenicortuberculousorigin.Fungalinfections are increasing, but are still extremely rare and occur more as opportunistic infections in immunocompromised individuals.2 _{Despite the increased frequency, infection by}

Candidaalbicansisnotcommon.3_{Wereportanunusualcaseof}

thoracicspondylodiscitiscausedbyC.albicans.Theliterature wasreviewed,aimingtobetterunderstandingthesubject.

Case

report

Thepatient was a39-year-old homeless, chronic alcoholic maleindividual.HefelltwometerstothegroundinOctober 2012.Hewastreatedinatraumahospital,whereheshowed signs of septicshock, hyperemia and crackles in the ster-nalregion, with 10cm indiameter. Chest radiography and computedtomography(CT)showedpre-sternalsubcutaneous emphysemaandsignsofsternumfracture,andculminated withadiagnosis ofanterior chest wallnecrotizingfasciitis (Fig.1).Surgicaldebridementwasperformedinthisregion. Theresultoftheofsternumsofttissueculturewaspositivefor

Fig.3–CobbangleinthepreoperativeperiodbetweenT2 andT7.

multisensitiveEscherichiacoliandtheresultofthesternalbone fragmentcultureforC.albicanswaspositive.Treatmentwith fluconazole(6mg/kg/day)andCiprofloxacin(400mg12/12h) wasstartedanddrugusewasscheduledforsixmonths, ini-tially intravenouslyand,afterclinicalimprovement,byoral route. Thepatient developed vertebral osteomyelitis signs, with decreasedheight ofthe vertebral bodiesand discs at thethoracicspinelevelsofT4–T5–T6(Fig.2).Thepatientwas paralyzed,withalteredsensitivityattheT4level,compatible withFrankelB.InitialCobbangleof68◦_{(Fig.3)wasobserved.}

Thepatientunderwentthoracotomy,whichdisclosedaspinal abscessandalargeamountofpurulentsecretion.A corpec-tomywasperformedfromT4toT6withautologousiliacgraft replacementandcomprehensivespinaldecompressioninT4. There wasimprovementofpaincomplaintsinthethoracic spine,withfeverdisappearanceandimprovementtoFrankel

rev bras ortop.2015;50(6):739–742

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Fig.4–postoperativeAPandprofileradiographies.

C.Atasecondprocedure,hewassubmittedtoposterior fix-ationandarthrodesiswithpediclescrewsatthelevelofthe thoracicspinefromT3toT7(Fig.4).

Postoperatively,heshowedimprovementof13◦_of

kypho-sisintheCobbangleandremainedat55◦_{(Figs.4and5).After}

eightmonthsofthediagnosis,thepatientshowed improve-mentoftheneurologicalleveltoFrankelDattheT4level. Uponassessmentat12monthsafterthefirstdiagnosis,the woundswerehealedandheshowedsignificantimprovement inthethoracickyphosis(Fig.5).Thepatientwaswell, com-municative,independentinrelationtoself-care,andmanaged toperformhisactivitieswithoutassistanceordifficulty. Dur-ing hospitalization the Oswestry Disability Index 2.0 was appliedpreoperatively andafterthe definitivesurgical pro-cedure.Preoperatively,hescored 70%and wasclassified as disabled.Postoperatively,theindexwas25%,whichshowed goodresultsinthepain/disabilityitem.

Discussion

Despitetheincreaseinthefrequencyoffungemia,infectionby C.albicansisalsoararecauseofspinalinfection.3_Themain

riskfactorsare:priorantibiotictherapy,ICUstay,long-term catheteruse,corticosteroids,intravenousdrugs,transplants andchemotherapy.1,2,4,5_{Inourcase,thepatientwasalcoholic,}

homelessandimmunocompromised.

ThemostcommonlocationofspondylodiscitisbyCandida isinthelumbarspine,andthepresenceofneurologicaldeficit isinfrequent.2

In2001,Miller6 _{described59casesofspinalinfectionby}

Candida,33affectingthelumbarspine,17thechest,threethe cervicalandsixboththethoracicandlumbarspine.

In ourcase,the upperthoracicregionwas affected and therewasneurologicaldeficit,incontrasttotheliterature.This

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conditionisusuallyinsidious.Themostusefulclinical find-ingispainintheaffectedarea,bothboneandparavertebral types.7_{Theparaplegiawasnoteworthyinourcase.An}

asso-ciationwasobservedbetweenchest traumaandthe spinal injury,afactvalidatedbyliterature.8

WhenC.albicansaffectsthespine,itusuallycausesdisk narrowing,destructionoftheendplatesandthesubjacent ver-tebralbone.4_{Theseimagingfindingsareconsistentwithwhat}

wefoundinourcase.

Theoptimized managementofspinalinfectionsby Can-didaremainsunclear.Casereportssuchasthisonehelpto increasetheexperienceinthemanagementandtreatmentof thisdisease.

Surgicaltreatmentisnotrequiredinspondylodiscitisby Candida. However, it should be performed in cases where thereisneurologicaldeficitandvertebralinstability.4,5_Inthe

presentreport,the patienthadneurologicaldeficit(Frankel B)andvertebralinstability,characterizedbykyphosingofthe thoracicspine.

Clinical treatment is carried out with antifungal drugs, usingamphotericinBorfluconazole.Oneproposedtreatment consistsof 6–10 weeks ofAmphotericin BIV at a dose of 0.5–0.6mg/kg/day.9_{StudieshaveshownthatFluconazoleisas}

effectiveasamphotericin,showinghighersafetyand tolera-bility.Inourinstitution,wechosetocarryoutthetreatment withfluconazole.

Studies have documented that diagnostic delay is common.10 _{That is attributed to the rare occurrence and}

difficulty in cultivating the microorganisms. It has been suggestedthatadelay inthestart ofantifungaltherapy is associated with a worse outcome, particularly the neuro-logical one.10 _{Webelieve that our success was due to the}

earlydiagnosisandconfirmationbybiopsyandthesternum bone culture, as well as the identification of spinal cord compression.Thetreatmentwaspromptlycarriedout with spinaldecompression,rapidmicrobiologicalresultsandstart ofspecificantifungaltreatment.

Spondylodiscitis by Candida should be considered in immunocompromised patients. The definitive diagnosis is

achievedthroughisolationofC.albicansinbloodorcultures. Theantifungaltreatmentoftenresultsinthe cure,evenin casesofdelayeddiagnosis.Whenthereisneurological insta-bilityordeficit,surgicaltreatmentshouldbeconsidered.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.GhanayemAJ,ZdeblickTA.Cervicalspineinfections.Orthop ClinNorthAm.1996;27(1):53–67.

2.BronerFA,GarlandDE,ZiglerJE.Spinalinfectionsinthe immunocompromisedhost.OrthopClinNorthAm. 1996;27(1):37–46.

3.JohnsonMD,PerfectJR.Fungalinfectionsofthebonesand joints.CurrInfectDisRep.2001;3(5):450–60.

4.GatheJCJr,HarrisRL,GarlandB,BradshawMW,WilliamsTW Jr.Candidaosteomyelitis.Reportoffivecasesandreviewof theliterature.AmJMed.1987;82(5):927–37.

5.AlmekindersLC,GreeneWB.VertebralCandidainfections.A casereportandreviewoftheliterature.ClinOrthopRelatRes. 1991;267:174–8.

6.MillerDJ,MejicanoGC.Vertebralosteomyelitisdueto Candidaspecies:casereportandliteraturereview.ClinInfect Dis.2001;33(4):523–30.

7.SmithAS,BlaserSI.Infectiousandinflammatoryprocessesof thespine.RadiolClinNorthAm.1991;29(4):809–27.

8.GraellsXS,ZaninelliEM,Collac¸oIA,NasrA,CecílioWAC, BorgesGA.Thoracicinjuriesandspinaltrauma:acomplex association.Coluna/Columna.2008;7(1):8–13.

9.RexJH,WalshTJ,SobelJD,FillerSG,PappasPG,DismukesWE, etal.Practiceguidelinesforthetreatmentofcandidiasis. InfectiousDiseasesSocietyofAmerica.ClinInfectDis. 2000;30(4):662–78.