Treatment outcomes of fungal vertebral osteomyelitis: A case series study and literature review

Abstract

Introduction: Fungal vertebral osteomyelitis (FVO) is rare and difficult to treat. It is usually an opportunistic infection in immunocompromised patients or is related to a prior surgery. Difficulty diagnosing the infection often leads to delayed treatment. Medical treatment and surgical outcomes are not always predictable. Purpose: To report the outcomes of FVO in our hospital and to review cases reported in the literature. Methods: In this retrospective series, 15 cases between January 2000 through June 2014 in Chang Gung Memorial Hospital’s Spinal Surgery Registry were reviewed. Demographic data, surgical records, culture results, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, and image studies (X-ray and magnetic resonance imaging) were reviewed. A PubMed and Medline literature review was also done. Results: The causative pathogens were primarily Candida species (86.6%, Candida albicans in 11 patients; others were Candida glabrata, Candida parapsilosis, and Candida tropicalis) and Cephalosporium. All 15 patients had severe back pain, 5 had radiculopathy, and 1 had paralysis. Ten patients (66.7%) had an epidural abscess and spinal cord compression. The time to diagnosis ranged from 8 to 237 days from the onset of symptoms. Thirteen patients were managed with surgical debridement and antifungal treatment, 1 with antifungal treatment without surgery, and 1 with neither surgery nor antifungal treatment. Although the infections resolved in 12 patients, 4 recurred before complete resolution. One patient died of fungal sepsis and 2 of systemic disease. Antifungal treatment usually required more than 3 months; and off treatment CRP and ESR levels were usually higher than the normal range. Conclusions: The post-treatment FVO recovery rate was 80%. Surgical treatment was usually necessary. When vertebral collapse and spinal cord compression occur, surgical debridement, fusion, and stabilization combined with antifungal medications eradicated the infection and resolved the neurological deficits.