Candida Spondylitis Considered as Microbial Substitution After Multiple Surgeries for Postoperative Lumbar Spine Infection

Abstract

Candida spondylitis is a relatively rare disease. The primary risk factor is an immunocompromised status. Here, we report an immunocompetent patient who developed Candida spondylitis. The patient was a 70-year-old male. After multiple surgeries, he developed a fever and was diagnosed with chronic pyogenic spondylitis of the lumbar spine, which was treated by long-term antimicrobial therapy. However, his back pain persisted and the inflammatory response was prolonged. We performed posterior thoracolumbar pelvic fixation with a percutaneous pedicle screw system to stabilize the infected vertebral bodies and simultaneously performed a full-endoscopic intervertebral disc biopsy to identify the causative organisms. Candida parapsilosis was identified from a fungal culture of the biopsy specimen. The patient was diagnosed with Candida spondylitis and started on antifungal treatment with fluconazole. His back pain disappeared quickly after surgery, and up to the time of this writing, the patient has continued to receive fluconazole. We attributed the development of Candida spondylitis to the patient's long-term antibiotic treatment of a postoperative infection of the lumbar spine, which was associated with multiple back surgeries. Fungal spondylitis, including spondylitis caused by Candida spp., should be suspected in patients, even immunocompetent patients, with intractable postoperative spinal infections and pyogenic spondylitis due to microbial substitution. Long-term antimicrobial therapy without definitive identification of the causative organism of a postoperative infection of the lumbar spine that is associated with multiple surgeries can be a cause of Candida spondylitis. A biopsy is strongly recommended for the definitive diagnosis.

Keywords: candida; fluconazole; fungal disease; spondylitis.

Figure 1. Images on admission.

(a) Lumbar anterior-posterior plain radiograph of the lumbar spine showing the damaged L3/4 plate and L4 screw. (b) Computed tomography scan (sagittal slice) showing bone destruction of the vertebral endplates and osteosclerosis of the L2-4 vertebral bodies. (c) Sagittal T2-weighed magnetic resonance image showing the low-intensity signal of the L2-4 vertebral bodies.

Figure 2. Post-operative images.

(a, b, c) Posterior thoracolumbar pelvic fixation with percutaneous pedicle screw system to stabilize the infected unstable vertebral bodies, anterior plate removal, lesion curettage, and fibula graft via retroperitoneal approach.