Navigating the Diagnostic Challenge of Aspergillus Spinal Epidural Abscess in an Immunocompetent Patient: A Case Report and Literature Review

Abstract

Aspergillus spinal epidural abscess (ASEA) is a rare, life-threatening condition that can cause spinal cord compression with neurologic deficits. The diagnosis of ASEA can be challenging due to the atypical clinical presentation and low prevalence. We describe the successful management of a rare, immunocompetent, 85-year-old male with ASEA at the T12-L1 and L1-L2 levels and present a review of the literature. Based on most case reports and our knowledge, this is a rare presentation of ASEA in a patient without systemic symptoms, leukocytosis, or a history of immunosuppressive status due to chronic steroid use. The patient presented with multiple falls and lower extremity paraparesis with near-complete paralysis of the right lower extremity for a duration of three months. Systemic symptoms of infection were absent and standard lab evaluations were unremarkable. CT imaging identified cord signal changes at the level of T10-T11 and a contrast block at L1 suspicious for spinal stenosis and impingement. During lumbar spine exploration, purulent fluid consistent with an abscess was found in the epidural space. Cultures were forwarded to microbiology and returned with Aspergillus. Postoperatively, Infectious Disease (ID) recommended treatment with voriconazole, cefepime, and vancomycin, which yielded gradual symptom improvement. The successful management of ASEA requires a multidisciplinary approach involving neurosurgeons, infectious disease specialists, radiologists, and physical therapists. Clinicians should be aware of the possibility of ASEA regardless of systemic symptoms, and early diagnosis and prompt treatment with surgical decompression and appropriate antifungal therapy are imperative for successful management.

Keywords: aspergillus abscess; aspergillus spinal epidural abscess; infectious disease; neurosurgery; spinal abscess.

Figure 1. AP view of extensive spinal instrumentation

Figure 2. Limited lateral CT myelogram imaging study with IV contrast blockage at L1 (red arrow)