Vertebral osteomyelitis secondary to Pseudallescheria boydii

Because Pseudallescheria boydii vertebral osteomyelitis is rare and frequently resistant to available antifungal agents, the proper treatment of this lesion has not been defined. To better determine the best treatment of this lesion, the authors evaluated a case P. boydii vertebral osteomyelitis and reviewed the literature. A 48-year-old man had isolated thoracic vertebral osteomyelitis resulting from P. boydii and associated severe thoracic back pain and proximal lower extremity pain and weakness. Magnetic resonance imaging studies revealed continued collapse of the T6--T7 vertebrae despite previous posterior debridement and appropriate antifungal chemotherapy. On admission to the authors' institution, the patient underwent a right thoracotomy, anterior debridement with transthoracic T6--T7 corpectomies and strut grafting, followed by posterior fusion and stabilization with pedicle screws. After operation, the patient's pain, hyperalgesia, and lower extremity symptoms resolved. He was treated with a 12-month course of itraconazole. Imaging and laboratory studies show no evidence of recurrence. P. boydii vertebral osteomyelitis can have devastating neurologic sequelae if not treated properly. The frequent lack of response of this unusual fungal infection to systemic therapy requires frequent serial follow-up examinations. Patients with evidence of progression on imaging studies or neurologic findings should undergo early and aggressive surgical debridement.     

Mucormycosis spondylodiscitis after lumbar disc puncture

Vertebral osteomyelitis due to mucormycosis is a rare but fulminant and fatal disease. Only one case has been reported in literature, with postmortem diagnosis. The present paper reports a female case of mucormycosis spondylodiscitis and vertebral osteomyelitis after lumbar disc puncture and radio frequency nucleoplasty. She subsequently underwent two surgical debridements, continuous local irrigation and drainage, together with local and systemic Amphotericin B treatments. The infection was controlled 4 months after the second debridement; however, there was no improvement in the neurological function at the most recent follow-up, 16 months after the surgery. The experience of this patient, though a single case, supports early recognition, surgical debridement, systemic and local antifungal treatment, closed irrigation and drainage as the keys to successful treatment.     

Thoracoscopic debridement and stabilization of pyogenic vertebral osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.     

Candida albicans osteomyelitis of the spine: progressive clinical and radiological features and surgical management in three cases

Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3–6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5–6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.     

Chronic suppurative cryptococcal extensor tenosynovitis in a patient with Castleman's disease: a case report

Cryptococcus neoformans is an ubiquitously occurring encapsulated fungus that is commonly found in the environment. It is also an opportunistic pathogen that has potential to cause systemic fungal infection, predominantly in the immunocompromised host with cell-mediated immunological defects. Cryptococcal tenosynovitis is an extremely rare condition, with only a few cases previously documented in the literature. We report a case of chronic suppurative cryptococcal extensor tenosynovitis in a patient with Castleman's disease who was successfully managed with surgical debridement and antifungal therapy.     

Chronical rhino-orbital mucormycosis in an immunocompetent host: A case report

Mucormycosis is an opportunistic fungal infection caused by molds within the order Mucorales. The rhino-orbital-cerebral localization is the most frequent. It is a destructive, necrotizing and potentially fatal disease. The treatment involves aggressive surgical debridement combined with antifungal drugs. The course is quickly fatal in the event of delayed diagnosis and / or treatment. This infection usually affects immunocompromised and diabetic patients, but cases of mucormycosis in immunocompetents are increasingly reported. Chronic mucormycosis is extremely rare and affects both immunocompromised and immunocompetent patients, its clinical evolution is nonspecific and its treatment is not standardized.We report the case of a destructive rhino-orbital and pulmonary involvement in a 59 years old immunocompetent patient who presented a right periorbital edema associated and a vision loss and a notion of nasal obstruction and progressive onset headache four months before admission. Her condition progressed with rapidly extensive necrosis. She underwent extensive surgical resection but soon succumbed to multiple organ failure. The diagnosis of mucormycosis was confirmed post mortem on the excisional piece.The purpose of this article is to draw attention to chronic mucormycosis in the immunocompetent and to emphasize the importance of early diagnosis and adequate management of this fatal infection.     

Zenker's diverticulum associated with multilevel cervical osteomyelitis

STUDY DESIGN: A case report of cervical osteomyelitis possibly associated with a Zenker's diverticulum perforation. OBJECTIVES: To present clinical, radiologic, and surgical findings of a cervical osteomyelitis due to a Zenker's diverticulum perforation. SUMMARY OF BACKGROUND DATA: A 56-year-old patient was in an intensive care unit for a severe head injury. He was fed via a nasogastric tube. Four months later he developed a pyogenic cervical vertebral infection. METHODS: Plain films and magnetic resonance imaging showed a diffuse cervical osteomyelitis. Investigation of his dysphagia revealed a Zenker's diverticulum. RESULTS: After administration of antibiotics and surgical treatment of the diverticulum, the cervical infection resolved. Plain films and magnetic resonance imaging showed healing with vertebral fusion. CONCLUSIONS: Cervical osteomyelitis is uncommon. Only one case of direct contamination leading to cervical vertebral osteomyelitis after esophageal perforation has been previously described. Direct contamination of the prevertebral soft tissues by bacteria traveling through the fistula may have occurred. The development of vertebral osteomyelitis in this case is consistent with the hypothesis of direct contamination. Management relies on appropriate antimicrobial therapy and surgical management of the diverticulum. The association of Zenker's diverticulum with vertebral osteomyelitis and discitis is a unique, previously undescribed situation.     

Sternectomy for Candida albicans sternal osteomyelitis after left ventricular assist device implantation

Fungal osteomyelitis is an uncommon complication after cardiac surgery and associated with high mortality. A case of Candida albicans and Staphylococcus epidermidis osteomyelitis with device infection after implantation of a left ventricular assist device in a 60-year-old male patient is presented here. After clinical identification and confirmation with microbiological examinations and fluorodeoxyglucose positron emission tomography (FDG-PET) scan, debridement was performed. Surgical specimens grew C. albicans and S. epidermidis. Fluconazole, daptomycin, and negative pressure wound therapy were initiated, but failed to achieve healing. Total sternectomy and pectoralis flap reconstruction were performed. There was no recurrent infection for C. albicans on a prolonged antifungal regime. The combination of antifungal therapy and aggressive surgical debridement may be useful to control fungal osteomyelitis.     

Aspergillus vertebral osteomyelitis in immunocompetent patients

Fungal infections are one of the important cause of morbidity and mortality in immunocompromised patients. Aspergillus vertebral osteomyelitis is extremely rare. We report two cases of aspergillus vertebral osteomyelitis in immunocompetent men in the absence of an underlying disorder. The clinical and radiological findings were suggestive of Pott''s spine. The absolute CD4, CD8 counts and their ratio were normal. The HIV status was negative in both patients. Both patients underwent surgical decompression. The histopathology of tissue obtained were suggestive of aspergillus osteomyelitis. One patient had antifungal treatment for 3 months and was doing well at 1 year followup, whereas other patient did not turnup after 2 months.     

Aspergillosis of the cranial base

Aspergillus is an ubiquitous organism seldom pathogenic in normal hosts. Aspergillus osteomyelitis of the spine occurs rarely in immunocompromised patients as a result of hematogenous spread from distant foci. We present a case of Aspergillus osteomyelitis in the region of the jugular foramen in a previously healthy male with no antecedent event. He presented with dysphagia, hypophonia, and weight loss of several months duration. Diagnosis was delayed due to nonspecific results of various imaging tests. We review the clinical course of fungal osteomyelitis, including appearance on magnetic resonance imaging and computed tomography, culture characteristics, and gross appearance. Current treatment consists of surgical debridement and antifungal medications such as amphotericin B and itraconazole, and the efficacy of these are discussed.     

Primary subacute osteomyelitis of the talus in children: a case series and review

Subacute haematogenous osteomyelitis of the talus in children is a rare condition. All previously reported cases have been managed by hospital admission with surgical debridement and antibiotics or by intravenous antibiotic therapy followed by oral antibiotics. This case series documents the management of the condition at our institution and reviews the current published literature. We conclude that with appropriate patient selection, primary subacute haematogenous osteomyelitis of the paediatric talus can be managed on an out-patient basis with oral antibiotic therapy.     

Pyogenic osteomyelitis of the spine in the elderly

The authors report 10 cases of spontaneous pyogenic spinal osteomyelitis encountered within a 3-year period. There were six women and four men, ranging in age from 60 to 84 years. Six cases occurred at the thoracic level, three at the lumbar level, and one in the cervical spine. No patient was diabetic, immunocompromised, or receiving steroid therapy, and none had a history of endocarditis or intravenous drug abuse. No patient had undergone previous spinal surgery. There were no instances of coexisting tuberculosis or malignancy. Contemporaneous cases with known predisposing factors have been excluded from this report; however, three patients did have a recent history of somatic infection, one with known sepsis. All 10 patients had been previously misdiagnosed, frequently by neurosurgeons and orthopedists as well as by internists and family practitioners. Three had undergone inappropriate or unnecessary surgical procedures, and two had received inappropriate radiation therapy. Seven cases were caused by Staphylococcus species. Gram-negative bacteria, or anaerobic infections. In the other three, no bacteriological diagnosis was made, secondary to prolonged antibiotic therapy before surgery. Each patient had developed symptomatic neural element compression, spinal instability, or both by the time of their referral. The patients with subcervical pyogenic spinal osteomyelitis underwent transthoracic or retroperitoneal decompression and corpectomy with simultaneous autologous bone grafting, followed by 6 weeks of bed rest and 6 weeks of intravenous broad-spectrum or organism-specific antibiotic therapy. They were then mobilized in orthoses for an additional 6 weeks. In no case were foreign implants employed or further stabilization procedures necessitated. One patient required an additional 6 weeks of antibiotics for recalcitrant Pseudomonas colonization. Despite the patients' advanced age and the extensive surgical procedures, there was no mortality and no neurological morbidity. All patients were asymptomatic or demonstrated objective improvement upon discharge from the hospital. In this subset of patients with spontaneous pyogenic vertebral osteomyelitis, the only predisposing factor was advanced age.     

Nosocomial post-traumatic <Emphasis Type="Italic">Rhizomucor</Emphasis> soft tissue and bone infection treated with liposomial amphotericin B: case report

Mucornycosis is a rare fungal infection most commonly occuring in patients with severe immunocompromise, diabetes, uremia or trauma. Only a few cases of non axial skeletal bone osteomyelitis have been reported. We report a case of nosocomial cellulitis and osteomyelitis complicating a posttraumatic bacterial infection, successfully treated with liposomial amphotericin B and surgical debridement. Traumatized patients with extensive tissue loss, receiving broad-spectrum antibiotics, can develop impaired immune responses and are at risk for fungal infections.     

A case report on a rare cause of bowel ischaemia in penetrating trauma

Introduction and importanceGastric mucormycosis is a rare condition that usually manifests in immunocompromised patients. It's a lethal disease with a poor prognosis requiring prompt diagnosis and aggressive management. Although found more commonly in immunocompromised patients, it can also affect the immunocompetent patient, highlighting the importance of clinical suspicion when dealing with a critically ill patient.Case presentationThis is a case report on a patient who presented with penetrating trauma to the abdomen requiring surgical intervention. Damage control surgery was performed in the form of a right hemicolectomy (‘clip and drop’) for extensive colonic injuries (AAST Grade V) with contamination of the abdominal cavity [1]. In the days subsequent to the injury, he developed sepsis and progressive bowel ischaemia and necrosis, requiring surgical debridement. Histological findings revealed mucormycosis of the gastrointestinal tract.Clinical discussionThe diagnosis of mucormycosis depends on high clinical suspicion as well as histopathological evidence. The management comprises of surgical debridement and appropriate antifungal therapy. Timeous diagnosis and adequate treatment may improve the prognosis.ConclusionThis was a challenging case for the clinicians involved, highlighting that the clinician should consider this infection as a rare cause of bowel ischaemia in the back of their minds when dealing with such patients.     

Surgical treatment of hematogenous vertebral Aspergillus osteomyelitis

Three cases of Aspergillus fumigatas vertebral osteomyelitis failed courses of medical treatment. Each was subsequently treated with anterior vertebral debridement and posterior segmental spinal instrumentation. Despite poor nutritional and immune systems, resolution of the infection and subsequent anterior ankylosis occurred in each patient, with follow-up ranging from 1 to 3 years. If patients with aspergillus vertebral osteomyelitis do not respond to medical treatment, early surgical debridement and stabilization in combination with intravenous amphotericin B can lead to resolution and bony ankylosis.     

Extent of surgical intervention in primary soft-tissue aspergillosis.

Primary invasive Aspergillus Infection of the soft tissue is rare and typically affects immunocompromised patients in several distinct patterns of clinical presentation. In general, the role of surgery in the treatment of this disease is the removal of infected or necrotic tissue to prevent dissemination and mortality. However, the specific surgical recommendations have varied widely among reports due to the varied clinical circumstances in each series. The authors present the case of a patient with a primary invasive Aspergillus infection. They review the reported surgical experience with this disease, and discuss outcomes and surgical approaches in the context of several variations in clinical presentation. In all situations, antifungal therapy and prompt surgical intervention are critical in treating these initially localized but potentially lethal infections. The extent of intervention can range from minor debridement to amputation, and is based on the presence of persistent immunocompromise, the presence and extent of tissue necrosis, and the rate of progression during antifungal therapy.     

Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis.

BACKGROUND CONTEXT: Vertebral osteomyelitis can be successfully treated with spinal immobilization and parenteral antibiotics. Failure of medical therapy may necessitate surgical treatment consisting of anterior debridement and structural anterior column reconstruction. Autologous structural bone graft has traditionally been the gold standard in anterior column reconstruction. Because of the morbidity related to graft harvest, vertebral body replacement cages have emerged as a viable option for reconstructing a deficient anterior column. PURPOSE: To evaluate the efficacy of titanium mesh cages in the reconstruction of anterior column defects in the presence of active pyogenic infection. STUDY DESIGN: Prospective case series. METHODS: Eleven patients underwent operative treatment for osteomyelitis of the thoracolumbar spine using staged anterior debridement and reconstruction with cylindrical titanium mesh cages followed by delayed posterior spinal fusion with pedicle screw instrumentation during a 2-year period. Patients were postoperatively evaluated clinically and radiographically. RESULTS: Follow-up averaged 17+/-9 months. Average increase in kyphosis of 10+/-6 degrees corresponding to 4+/-4 mm loss in the height (subsidence) of the anterior construct. One patient died during revision surgery for hardware failure. Seven of the remaining 10 patients have not required antibiotics after the initial postoperative course of treatment. Three patients are maintained on chronic suppressive therapy as a precaution. There has been no evidence of recurrence or residual infection in any patient. Seven of the 10 patients were pain free at latest follow-up. There has been one case of pseudarthrosis. CONCLUSION: Cylindrical titanium mesh can be used with consistently good results for large anterior column defect reconstructions even in the face of active pyogenic infection. In our cohort of patients with pyogenic vertebral osteomyelitis, the use of titanium mesh cages has not been associated with early recurrence of infection.     

Acute wound closure and reconstruction following head zygomycosis: presentation of two cases and review of literature

Zygomycosis is a rare but very aggressive fungal infection mainly seen in immunocompromised patients. Immediate diagnosis and treatment with antifungal therapy, control of underlying disease, and early surgical debridement is essential. We present two cases of head zygomycosis treated with systemic liposomal amphotericin B, surgical debridement, and immediate free flap reconstruction. A retrospective chart review of two cases of zygomycosis was performed; one with rhino-sino-orbital-cerebral and the other with scalp/cranial zygomycosis. Both patients were treated with systemic liposomal amphotericin B, aggressive debridement, and immediate reconstruction following local control. The multidisciplinary team approach and the surgical technique are discussed. Patient 1 (with rhino-sino-orbital-cerebral zygomycosis) died 2 weeks after diagnosis, and patient 2 (with scalp/cranial zygomycosis) was disease free at 1-year follow-up. Both patients' flaps survived, although patient 2 needed to undergo an arterial revision with an interpositional vein graft within 24 hours of surgery. We concluded that to treat zygomycosis effectively, a multidisciplinary team approach is needed, focusing on immediate diagnosis, empirical antifungal therapy, reversal of underlying predisposing factors, and early surgical debridement. When definitive debridement results in critical structures being exposed, then early wound closure with healthy vascularized tissue is indicated. In these two patients with exposed dura after definitive debridement, immediate closure was performed to minimize the risk of meningeal and cerebral infections.     

Candida albicans Infection of Sternum and Costal Cartilages: Combined Operative Treatment and Drug Therapy with 5-Fluorocytosine

Two patients with candidal sternal osteomyelitis have been successfully treated by operative debridement and adjuvant drug therapy with 5-fluorocytosine. One patient had developed postoperative candidal wound infection after sternotomy, and the other acquired candidal sternal osteomyelitis following Candida fungemia. The diagnosis, suggested by culture, was confirmed by identification of Candida pseudohyphae in debrided tissue. Histological confirmation of candidal sternal osteomyelitis indicates the need for operative debridement and specific systemic antifungal therapy. The drug 5-fluorocytosine appears to provide effective oral therapy in this situation.