Journal of Craniovertebral Junction and Spine

CASE REPORT
Year
: 2022  |  Volume : 13  |  Issue : 2  |  Page : 204--211

Aspergillus spinal epidural abscess: A case report and review of the literature


Mohammad Humayun Rashid1, Mohammad Nazrul Hossain1, Nazmin Ahmed1, Raad Kazi1, Gianluca Ferini2, Paolo Palmisciano3, Gianluca Scalia4, Giuseppe Emmanuele Umana3, Samer S Hoz5, Bipin Chaurasia6,  
1 Department of Neurosurgery, H Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh
2 Department of Radiation Oncology, REM Radioterapia Srl, Viagrande, Italy
3 Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
4 Department of Neurosurgery, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
5 Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
6 Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Correspondence Address:
Giuseppe Emmanuele Umana
Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Via Messina, 829, 95126 Catania
Italy

Abstract

Aspergillus spinal epidural abscess (ASEA) is a rare entity that may mimic Pott's paraplegia as it commonly affects immunocompromised patients. We present one institutional case of ASEA with concomitant review of the literature. A 58-year-old female presented with intermittent low back pain for 10 years recently aggravated and with concurrent spastic paraparesis, fever, and weight loss. Emergent magnetic resonance imaging (MRI) showed T11–T12 epidural abscess with discitis and osteomyelitis. After empirical treatment with antibiotics, computed tomography-guided, percutaneous biopsy with drainage was performed, showing granulomatous tubercular-like collection. Antitubercular therapy was initiated, but after 1 month, the patient's condition deteriorated. Repeat MRI showed growth of the spinal epidural abscess with significant cord compression and vertebral osteomyelitis. T11–T12 laminectomy and tissue removal were performed with a posterior midline approach. Tissue histopathology showed necrotic debris colonies of Aspergillus spp. Antifungal therapy was started, and the patient rapidly improved. ASEA may mimic Pott's disease at imaging, leading to immediate start of antitubercular treatment without prior biopsy, leading to severe worsening of patients' clinical status. Cases of ASEA should be considered at pretreatment planning, opting for biopsy confirmation before treatment initiation so to prevent the occurrence of fatal infection-related complications.



How to cite this article:
Rashid MH, Hossain MN, Ahmed N, Kazi R, Ferini G, Palmisciano P, Scalia G, Umana GE, Hoz SS, Chaurasia B. Aspergillus spinal epidural abscess: A case report and review of the literature.J Craniovert Jun Spine 2022;13:204-211


How to cite this URL:
Rashid MH, Hossain MN, Ahmed N, Kazi R, Ferini G, Palmisciano P, Scalia G, Umana GE, Hoz SS, Chaurasia B. Aspergillus spinal epidural abscess: A case report and review of the literature. J Craniovert Jun Spine [serial online] 2022 [cited 2022 Aug 9 ];13:204-211
Available from: https://www.jcvjs.com/text.asp?2022/13/2/204/347324


Full Text



 Introduction



Aspergillus species inhabit the soil and plants worldwide and may become pathogenic only in immunocompromised hosts.[1],[2] Inhaled by humans, Aspergillus infections may result in severe pulmonary diseases with human-to-human spread via blood contact. Invasive aspergillosis rarely affects bone structures, with the spine being the most common site.[3] In immunocompromised patients, Aspergillus spinal epidural abscesses (ASEAs) may occur via hematogenous route or contiguous spread following any surgery or procedure in the respiratory system, gastrointestinal tract. ASEAs are typically found in the thoracic or lumbar spine but have been reported also in the cervical spine.[4] In 1.9% of patients, they may also involve the skeletal muscle system.[5] Due to their delayed onset and nonspecific clinical manifestations, ASEAs are often misdiagnosed at initial presentation as tuberculous spondylitis, especially due to the imaging similarities between the two entities. However, accurate differential diagnosis is mandatory as their management strategy differs, and severe risks of fatal complications may follow the initiation of inappropriate therapeutic plans.[6] Owing to the rarity of this condition, only a few patients with ASEA have been reported. We present one institutional case of ASEA successfully treated with a combination of antifungal and surgical management and further review the current literature.

 Case Illustration



Clinical history

A 58-year-old female normotensive, nonasthmatic, and diabetic presented intermittent low back pain for 10 years recently aggravated. The pain gradually increased in the last 4 months, radiating down to the anterior left leg and associated with decrease in walking distance. Intermittent fever and prolonged weight loss were also referred. Physical examination revealed spastic paraparesis with normal sensation and reflexes. She had normal rectal tone. Complete blood count was negative for leukocytosis or anemia, and erythrocyte sedimentation rate was elevated at 75.

First hospitalization

Emergent magnetic resonance imaging (MRI) showed a T11–T12 epidural abscess with discitis and osteomyelitis [Figure 1]. The patient was admitted and started an empirical antibiotic treatment with meropenem, linezolid, and metronidazole for a presumed bacterial spinal epidural abscess. Percutaneous computed tomography (CT)-guided abscess aspiration and fluid cytopathology were positive for granulomatous tubercular-like infection [Figure 2]. Smear showed adequate cellular material containing plenty of degenerative polymorphs, lymphocytes, and histiocytes, and few epithelioid cell granulomas of tubercular origin. Decompressive surgery was not indicated because the patient lacked any neurological deficits or signs of cauda equina syndrome. Antitubercular therapy was initiated with rifampicin, pyrazinamide, ethambutol, isoniazid, and pyridoxine.{Figure 1}{Figure 2}

Second hospitalization

After 1 month of antitubercular therapy, the patient's condition worsened, with aggravating pain and increased weakness in the left lower limb. A new MRI study showed T11–T12 paravertebral soft-tissue intensity with central liquefaction consistent with spinal epidural abscess, and concurrent significant cord compression with vertebral osteomyelitis. The patient underwent partial T11–T12 laminectomy and subtotal removal of the granulation tissue via a posterior midline approach [Figure 3]. Tissue was sent for histopathology, showing negative bacteriological findings but revealing necrotic debris of Aspergillus spp. [Figure 4]. Long-term oral voriconazole was administered together with the antitubercular therapy. The patient was discharged to a skilled nursing facility to complete the planned 3-month course of antifungal therapy. Physical and occupational therapy noted the patient to progress well.{Figure 3}{Figure 4}

Literature review

A literature search was performed on PubMed and returned 21 articles reporting patients with ASEA [Table 1]. Most patients were males in their third to sixth decade of life. The most common comorbidities were diabetes mellitus, tuberculosis, immunodeficiency, cancer, and kidney failure. The thoracic spine and the lumbar spine were the most affected. Common presenting symptoms were lower back pain, neurological deficits, low-grade fever, and weight loss. Diagnostic management mostly consisted of MRI imaging and/or CT-guided fine-needle aspiration. The most common pathogen was the Aspergillus fumigatus (60%) [Table 2]. Treatment commonly comprised a combination of antibiotics and surgical intervention. Only a few cases were treated with antibiotics alone.[15] Most patients recovered completely or partially at a mean follow-up of 14.4 months. Some patients developed drug-related complications and died at a mean of 1.8 months.[15]{Table 1}{Table 2}

 Discussion



ASEA is a rare entity with a recent increase in incidence owing to raising prevalence of systemic diseases responsible for immunosuppressive states (e.g., diabetes, kidney failure, and cancer). Corticosteroid therapy and intravenous drug abuse also play a major role in the development of these opportunistic infections.[25] In immunocompromised patients, Aspergillus may spread to the spine from continuous lung foci, exposure to contaminated blood, or direct inoculation from the surrounding air during trauma or surgery and involve vertebral bodies with intervertebral discs causing osteomyelitis.[26] Clinical features are nonspecific, mostly characterized by lower back pain with or without fever. Symptoms of spinal cord compression may occur after time. Men are most frequently affected, with involvement of their thoracic and lumbar spine regions.

For diagnostic confirmation, routine fungal culture, microbiological testing, imaging examinations, and histopathology need to be combined to exclude differential diagnoses. White blood cell counts have poor sensitivity and specificity. Specific genetic Aspergillus examinations often fail to rule out Aspergillus infection because immunocompromised patients cannot produce a significant inflammatory response, but inflammatory markers monitoring may help to assess response to treatment.[5],[7],[8],[27] The differential diagnosis between spinal aspergillosis and tuberculosis is challenging only based on clinico-radiological examinations, but delay in diagnosis and treatment may be responsible for the development of invasive aspergillosis with high morbidity and mortality burden. From a radiological perspective, spinal tuberculosis frequently begins in the anteroinferior portion of the vertebral body and then spreads beneath the anterior longitudinal ligament to involve the adjacent vertebral body with secondary narrowing of the disc space.[1],[9] In invasive aspergillosis, the lesions often expand circumferentially destroying the surrounding spinal structures (vertebral bodies and discs) and the contiguous structures (ribs, thoracic wall, and lungs), as seen in our case. This imaging feature may support in the correct differential diagnosis. If the diagnosis is missed or delayed until there is extensive paravertebral, para-aortic, chest wall, or skull base invasion, complete eradication of disease by antifungal agents or surgery is not possible.[1],[4],[10] For this reason, expedite diagnosis and distinction from the more common tubercular spondylitis are mandatory. The most reliable diagnostic methods for ASEA are histopathological examination and bacterial culture. When hematological and imaging examinations are doubtful, CT-guided fine-needle biopsy should be promptly performed to confirm the suspicion and start the appropriate therapy. Methods of molecular biology including enzyme-based and polymerase chain reaction-based assays can aid in the earlier diagnosis, but these are limited by lower sensitivity and higher false positives. In our case, the granulomatous inflammation detected at CT-guided biopsy posed some challenges in the differential diagnosis. Indeed, CT-guided biopsy is less invasive than intraoperative biopsy, but provides an insufficient number of specimens to make a proper diagnosis.

A review of the available literature shows that combined operative and medical treatment in early cases offers the best chance for the patient.[1],[4],[10] Surgery is usually indicated for spinal cord compression, microbiological diagnosis, and stabilization of the spine. Biopsy and decompression by posterior approach followed by antifungal therapy may be successful in most cases. In our case, this strategy was pursed as the disease was limited in only two spine segments with no spine instability. However, extension of the pulmonary aspergillosis infection to the chest wall and mediastinum carries higher risks of morbidity and mortality burden.[11],[12]

As regards antifungal therapy, amphotericin B was used in earlier cases of ASEA but later disregarded because of its high nephrotoxicity and its ineffectiveness in invasive aspergillosis, owing to the lack of entry into bones. As shown in more recent cases, second-generation broad-spectrum triazoles are often tolerated well and favor survival improvement in ASEA patients.[8],[13],[15] The aspergillosis treatment guidelines[28] proposed by the Infectious Diseases Society of America recommend voriconazole as primary therapy for extrapulmonary central nervous system aspergillosis including Aspergillus osteomyelitis, while itraconazole can be used in patients who cannot tolerate voriconazole. Voriconazole is associated with higher survival rate and higher remission rate than amphotericin B. In our patient, we started voriconazole obtaining optimal clinical improvement with no neurological deficit in postoperative period.

 Conclusion



ASEA represents a rare cause of compressive myelopathy, which shows clinico-radiological similarities with tubercular spine disease. Early definitive diagnosis is challenging, but surgery with antifungal drugs is often indicated to establish the definite diagnosis and decompression of the spine in severe cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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