Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 5, 2010, pp. 806-808

Neurology India, Vol. 58, No. 5, September-October, 2010, pp. 806-808

Letter to Editor

Aspergillus vertebral osteomyelitis in an immunocompetent person

Rakesh Ranjan¹, Sachin Mishra², Shweta Ranjan³

¹ Department of Neurosurgery, Aditya Birla Memorial Hospital, Pune - 411 033, India
² Department of Neurology, Aditya Birla Memorial Hospital, Pune - 411 033, India
³ Department of Neurosurgery, Patna Medical College, Patna, India

Correspondence Address:
Rakesh Ranjan
Department of Neurosurgery, Aditya Birla Memorial Hospital, Pune - 411 033
India
rakeshr1@hotmail.com

Date of Acceptance: 23-Jul-2010

Code Number: ni10230

PMID: 21045528

DOI: 10.4103/0028-3886.72196

Sir,

A 53-year-old lady presented with the complaints of low back ache with radiation to both the thighs and legs of one month duration. She used to feel uncomfortable while standing or walking. There was history of low-grade fever, but no loss of weight or appetite. She was not a diabetic and did not have any malignancy or chronic illness. General physical and neurological examinations were essentially normal. However, straight leg-raising test on both the sides revealed restricted movement. Magnetic resonance imaging (MRI) of the lumbosacral spine revealed osteolysis at the antero-inferior portion of the end plates of L2 and L3 vertebrae with abnormal signal intensity of the L2/3 intervertebral disc. It was noted as hypointense lesion on T1-weighted image [Figure - 1] and as hyperintense signal on T2 weighted [Figure - 2] and STIR sequences. There was paraspinal and epidural collection at the involved segment with mild thecal compression. Aspiration of the collection yielded a thin purulent fluid [Figure - 3]. The aspirate was negative on Gram and Zeihl-Neelsen stains. However, fungal examination revealed hyphae and dichotomous branching [Figure - 4], which was confirmed as Aspergillus fumigatus on the culture studies. The patient was advised surgical treatment, which she refused. She was treated with complete bed rest and antifungals, including fluconazole and amphotericin B. The patient succumbed to the disease within two months of diagnosis.

Vertebral osteomyelitis due to Aspergillus infection in an immunocompetent patient is rare ^[1],[2] and more often described in immunocompromised patients. ^[3] Aspergillus spine infection closely mimics tubercular spine disease and presents with similar clinical features. ^[1],[2],[4] In the absence of predisposing factors, or infection in some other organ, clinical diagnosis can be difficult.

MRI study in a tubercular infection shows paradiscal involvement with the collapse of the vertebral body. Tubercular infection is commonly associated with pre and paravertebral pus collection with occasional epidural involvement. However, the disc itself is spared till late in the illness. Whereas MRI features in fungal infection show hypodense lesion on T1-weighted sequence at the involved vertebral level and hyperintense signal intensity on T2 images. There is significant enhancement following gadolinium contrast injection. However, the disc destruction is rapid and early in fungal osteomyelitis. ^[3] A tissue examination remains the final and definitive method to establish the diagnosis. Needle aspiration from the infected focus may be done using computerized tomography (CT) or fluoroscopic guidance. Erythrocyte sedimentation rate, blood and bone aspirate culture studies may aid in diagnosis. The appearance of hyphae with dichotomous branching is diagnostic of Aspergillus infection. ^[1]

Treatment involves systemic therapy, with antifungal agents and surgery is reserved for specific indications. ^{[1],[2],[3],[4]} Amphotericin B remains the first-line drug. The indications for surgery have been cases with abscess formation, significant vertebral destruction or those with neurological deficit. ^[1],[2] Spinal instrumentation is usually necessary to restore spinal stability and maintain alignment. ^[5] The outcome of Aspergillus vertebral osteomyelitis remains poor. ^[1],[2],[5]

References

Copyright 2010 - Neurology India

The following images related to this document are available:

Photo images