The Spine Journal 11 (2011) e1–e6

Case Report

Candida lusitaniae discitis after discogramin an immunocompetent patient

Brian C. Werner, MD, MaCalus V. Hogan, MD, Francis H. Shen, MD*Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt, Charlottesville, VA 22908, USA

Received 29 December 2010; revised 8 July 2011; accepted 7 September 2011

Abstract BACKGROUND CONTEXT: Discitis or epi

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dural abscess after discogram is a rare but knowncomplication. It is more commonly bacterial; however, fungal discitis has been previously reportedin immunocompromised patients. The management of fungal discitis in immunocompetent patientsis rarely presented or addressed in the literature.PURPOSE: To present a rare atypical fungal discitis after routine discogram with a typical presen-tation in an immunocompetent host, review diagnostic and management guidelines for discitis, andprovide recommendations for management of atypical discitis in immunocompetent patients.STUDY DESIGN: Case report and review of the literature.METHODS: A 40-year-old woman presented with a 3-week history of progressively worsening lowback pain after a lumbar discogram. Magnetic resonance imaging revealed L3–L4 discitis without anepidural abscess. Left L3 and L4 hemilaminectomies with L3–L4 discectomy were performed. Aninflammatory mass was seen in the L3–L4 disc space region extending to the left L3 foramen.RESULTS: Culture specimens obtained during surgery from both the disc and epidural spacespeciated to Candida lusitaniae. The patient completed a 6-month course of fluconazole therapy.At 2-year follow-up, she continued to be asymptomatic, without any recurrence of infection or neu-rologic sequelae.CONCLUSIONS: We report a case of C. lusitaniae spondylodiscitis after discography in an immu-nocompetent patient with long-term follow-up. Clinicians must maintain a high index of suspicionfor discitis in patients who undergo this procedure. If discitis is suspected, culture specimens must beevaluated for fungal andmycobacterial organisms, even in the immunocompetent host.With proper sur-veillance, surgical intervention, and appropriate postoperative follow-up, this complication can be ef-fectively managed with excellent long-term outcome. � 2011 Elsevier Inc. All rights reserved.

Keywords: Candida lusitaniae; Discitis; Discogram; Immunocompetent

Introduction

Discitis or epidural abscess after discogram is a rare butknown complication. The incidence of discitis after

status: Not applicable.

: BCW: Nothing to disclose. MVH: Nothing to dis-

: Elsevier Publishing (B); Consulting: Synthes Spine

); Speaking/Teaching Arrangements: DePuy Spine

s: Musculoskeletal Transplant Foundation (B, Paid di-

ployer); Scientific Advisory Board: Kuros (Nonfinan-

ort: AO (D).

can be found on the Table of Contents and at www.

e.com.

uthor. Department of Orthopaedic Surgery, University

em, POBox 800159,Charlottesville, VA22908,USA.

fax: (434) 243-0242.

hs2g@virginia.edu (F.H. Shen)

nt matter � 2011 Elsevier Inc. All rights reserved.

011.09.004

discography has been reported to be 1% to 4%, which ledto the use of the double-needle technique and prophylacticantibiotics during discography [1–8]. Spondylodiscitis afterlow back procedures is more commonly bacterial; however,fungal discitis because of Candida and Aspergillus has alsobeen reported. Most previously reported cases of fungal dis-citis are in immunocompromised patients [9–14]. We reporta case of C. lusitaniae spondylodiscitis after discography inan immunocompetent patient with long-term follow-up. Toour knowledge, there are no previous reports in the literatureof fungal discitis after discogram in an immunocompetentpatient nor has C. lusitaniae previously been implicated asa causative organism of discitis.

Clinicians should maintain a high index of suspicion forpostprocedural fungal discitis. The purpose of this casereport was to present an atypical (fungal) discitis with

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a typical presentation in an immunocompetent host, reviewdiagnostic and management guidelines for discitis, and pro-vide recommendations for management of atypical discitisin immunocompetent patients.

Case report

A 40-year-old woman with a history of chronic low backpain presented to the emergency room complaining of pro-gressively worsening severe low back pain 3 weeks statusafter lumbar discogram. She denied any constitutionalsymptoms, including fevers, bowel, or bladder changes.She had a history of an L5–S1 discectomy done at an out-side facility 2 years earlier, a lumbar epidural steroid injec-tion 1 year prior and left lumbar facet injection 6 monthsbefore presentation. Magnetic resonance imaging (MRI)obtained 6 months before the discogram did not revealany significant abnormalities; specifically, there was no ev-idence of indolent infection or erosive process that could beimplicated as the cause of her back pain (Fig. 1). She hadno medical comorbidities that would raise concern for im-mune compromise, and her social history was negative fortobacco and intravenous drug use. Her only medicationswere antidepressants and antihypertensives.

At the time of presentation to the emergency department,her clinical examination was unremarkable. She was afe-brile, with normal motor and neurologic function. Her white

Fig. 1. (Left) Parasagittal and (Right) axial T1-weighted postcontrast magnetic

normalities; specifically, there is no evidence of indolent infection or erosive pro

blood cell count was 3.96 (4–11 k/uL) with 49% neutrophils(47–82%), hematocrit was 35% (35–47%), and plateletswere 306 (150–450 k/uL). Her erythrocyte sedimentationrate was elevated to 64 mm/h (0–20 mm/h) and C-reactiveprotein to 11.9 mg/dL (!0.8 mg/dL). Basic metabolic paneland coagulation profile were each within normal limits.Peripheral blood cultures showed no growth.

Magnetic resonance imaging of the lumbar spine withand without gadolinium contrast revealed abnormally en-hancing soft tissue in the L3–L4 left anterior epidural spaceextending into the left L3 foramen, with a conspicuous cen-tral nonenhancing component, causing moderate to severecentral canal stenosis (Figs. 2 and 3). No discrete epiduralabscess was present; however, there was increased edemawithin the L3 and L4 vertebral bodies. These findings werefelt to be most consistent with discitis, associated epiduralabscess, and possible early vertebral body osteomyelitis.

The decision was made to proceed with operative inter-vention. A left L3 and L4 hemilaminectomy with L3–L4discectomy was performed. An inflammatory mass wasseen in the L3–L4 disc space region extending to the L3 fo-ramen. No frank pus was noted. Aerobic, anaerobic, andfungal cultures were obtained from this region. All anti-biotics were held until tissue samples and cultures wereobtained. After consultation with our colleagues in Infec-tious Diseases, the patient was empirically treated postop-eratively with intravenous nafcillin and cefazolin to coverthe most likely bacterial pathogens, pending her final tissue

resonance imaging obtained before discogram. There are no significant ab-

cess that could be implicated as the cause of the patient’s back pain.

Fig. 2. (Left) Parasagittal and (Right) axial T1-weighted precontrast magnetic resonance imaging reveals an abnormal enhancing soft tissue in the L3–L4

left anterior epidural space, which extends into the left L3 foramen. Together with a disc herniation (broad bulge with focal protrusion/extrusion and large

annular tear), this causes moderate to severe central canal stenosis. There is a minute poorly enhancing center to this abnormality.

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culture report. Her final aerobic and anaerobic cultureswere negative. All specimens obtained during surgery fromboth the disc and epidural space grew yeast on preliminaryresults, which speciated to C. lusitaniae, susceptibile to Di-flucan and Amphotericin B (Mayo Medical Laboratories,Rochester, MN, USA).

She was discharged home on postoperative Day 9 in sta-ble condition. She was seen in follow-up 2 weeks postoper-atively and was stable with no systemic signs of infection orneurologic symptoms. She completed a 6-month course offluconazole, over which time her C-reactive protein anderythrocyte sedimentation rate normalized. At 2-yearfollow-up, she continued to be asymptomatic, without anyrecurrence of infection or neurologic sequelae. Computedtomography and MRI obtained at her 2-year follow-up visitdemonstrated resolution of her infectious process.

Discussion

Fungal infection is a rare cause for discitis and is evenmore uncommon in an immunocompetent patient. To ourknowledge, this is the first case of fungal discitis after dis-cogram in an immunocompetent patient reported in the lit-erature. Both Candida and Aspergillus discitis, althoughrare, more commonly affect intravenous drug abusers orimmunocompromised individuals [9–19]. Fungal discitishas previously been reported in immunocompetent patients,

but these cases were following lumbar discectomy or epidu-ral steroid injections [9,20,21].

Discography has been in use since 1948 when it was in-troduced by Lindblom [22] as a diagnostic modality for theconfirmation of intervertebral disc prolapse. Newer tech-niques such as computed tomography and MRI have madediscography less popular; however, it is still used to assessfor internal disc disruption in patients with nonspecific clin-ical findings [23–31].

The most frequent and severe complication reportedfrom discography is discitis, with a reported incidence of1% to 4%. Discitis after discography is believed to be be-cause of the introduction of bacteria into the disc by a con-taminated needle [1,4]. Osti et al. in a prospective studyused angiografin as the contrast agent, which was mixedimmediately before injection with cephazolin at a concen-tration of 1 mg of antibiotic per 1 mL of contrast. Of 337lumbar discs injected, no infection was reported. This ledto the recommendation of the addition of a broad-spectrum antibiotic to radiographic contrast material atthe time of discography, which has been affirmed in otherstudies and is now commonly used [2,7,8,32]. Improved ra-diographic equipment, improved technique, and smallerneedles have also decreased the incidence of infection asso-ciated with this procedure.

The discogram for our patient was ordered and per-formed by an experienced pain management team to assessthe culpability of the disc as the source of the patient’s

Fig. 3. (Left) Parasagittal and (Right) axial T1-weighted fat saturation postcontrast magnetic resonance imaging supports the same diagnosis, with further

demonstration of contrast enhancement of the soft tissue.

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persistent pain. During the discogram, standard pro-cedures were followed. A 5-inch 22-gauge needle wasused to enter the L3–L4 disc from the left under fluoro-scopic guidance. Omnipaque-300 and Ancef 2 mcg/mLfor a total of 2 mL of injection were used during the proce-dure. Discs at L4–L5 and L5–S1 levels were also accessedin a similar fashion. No complications were noted duringthe procedure.

Despite taking these precautions, the initial presentationand imaging studies for this patient were concerning fordiscitis or epidural abscess, but there were no identifiableindicators to differentiate this case from the more commonbacterial discitis. Gadolinium-enhanced MRI is the imagingmodality of choice in patients with suspected discitis or epi-dural abscess. The addition of intravenous contrast allowsfor better detection of epidural abscesses; however, noradiographic finding distinguishes a fungal from bacterialetiology for discitis.

The management of fungal discitis in an immunocompe-tent patient is not standardized, as it is a relatively rare en-tity, and no randomized trials have demonstrated whethernonoperative or surgical management yields better results.In our patient’s case, progressively worsening pain andMRI findings of a forming epidural abscess with progres-sive involvement of the adjacent vertebral bodies led usto early surgical management with biopsy, irrigation, anddebridement.

The lack of standardized treatment protocols for fungaldiscitis and associated anterior epidural abscess leaves the

treating surgeon with numerous possibilities for manage-ment of such a lesion. The first goal of surgical interventionfor this patient was to decompress the epidural componentof her infection, and the second was to obtain an open bi-opsy of both the epidural abscess and the disc materialfor tailoring antimicrobial treatment. Complete eradicationof the osteodiscitis was not a primary goal of surgical inter-vention; rather, surgical debridement and debulking of in-fected disc material was completed as an adjunct tomedical therapy.

The choice of surgical approach and technique formanagement of such a lesion is also not standardizedand incorporates many factors, including age of the pa-tient and medical comorbidities, location of the abscessin the epidural space, extent of osteodiscitis, or vertebralosteomyelitis, and other factors such as reliability forfollow-up. There is ample literature to support the useof posterior, anterior, and circumferential approaches fordecompression of epidural abscesses and debridement ofosteodiscitis [33–35]. A posterior decompression of theepidural abscess with debulking of accessible disc mate-rial and bone-only fusion was chosen for this patient.Her clinical course was then closely followed. Had shenot adequately responded to medical therapy, an anteriorprocedure would have been used as a staged procedurefor complete debridement of her osteodiscitis. Certainly,an initial anterior discectomy with anterior lumbar inter-body fusion or initial circumferential surgery would alsohave been literature-supported approaches to manage

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her condition. Broad-spectrum antibiotic coverage againstcommon bacterial pathogens was started immediately fol-lowing the procedure, and this was changed to antifungaltherapy once intraoperative tissue cultures were positivefor yeast.

The final tissue cultures speciated to C. lusitaniae. Can-dida lusitaniae is an uncommon pathogen that is infre-quently found as a human commensal, or a fungal speciesthat exists in a symbiotic relationship on human skin, andnoteworthy because of some isolates being resistant to am-photericin B [36,37]. Possible sources of contamination forthis patient include the skin, needle, contrast dye, or ancef.Given that C. lusitaniae can exist as a human commensal, itis most likely that her skin is the source of the fungalinfection.

In a single-center study, less than 1% of yeasts recoveredfrom hospitalized patients speciated to C. lusitaniae [38].Candida lusitaniae is different from most medically impor-tant Candida species because it can readily develop in vivoresistance to amphotericin B during therapy, with resistancerates reported in literature from 22% to 60% [39–41]. Re-sistance to amphotericin B has been an important clinicalfinding in C. lusitaniae isolates [42]. Current publishedpractice guidelines recommend fluconazole as first linetherapy for C. lusitaniae because of potential amphotericinB resistance [43].

Our patient had an excellent outcome with early surgicaldebridement and fluconazole therapy. To our knowledge,there are no previous reports in the literature of fungal dis-citis after discogram in an immunocompetent patient norhas C. lusitaniae previously been implicated as a causativeorganism of discitis in either an immunocompetent or im-munocompromised host.

Conclusions

Clinicians must maintain a high index of suspicion forinfection in patients who undergo this procedure. No histor-ical physical examination or radiographic finding can reli-ably differentiate bacterial from fungal discitis; thus,atypical organisms should remain in the differential diagno-sis, especially for indolent infection. When a case of discitisdoes not follow the expected course or is not responding tobroad-spectrum antibiotics, we recommend biopsy. If theculture is positive, or if there is progression of the infectionwith epidural extension, surgery with debridement andwound cultures is recommended. Culture specimens mustbe evaluated for fungal and mycobacterial organisms, evenin the immunocompetent host. Initial antimicrobial therapyshould be broad spectrum and then tailored to cultures forlong-term treatment. With proper surveillance, surgical in-tervention, and appropriate postoperative follow-up, thiscomplication can be effectively managed with an excellentlong-term outcome.

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