Aspergillus terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent host: case report and literature review

Abstract

Aspergillus terreus is a fungus responsible for various infections in human beings; however, spine involvement is uncommon. Herein, we report a case of A. terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent Chinese patient. Admission lumbar magnetic resonance imaging (MRI) revealed infection at the L4/5 level without significant vertebral destruction. After unsuccessful symptomatic and anti-tuberculosis treatments, A. terreus was identified through culture, microscopy of isolate, histological examination and VITEK system. Intravenous voriconazole was then given; however, the patient's spinal condition deteriorated rapidly, resulting in evident destruction of the L4/5 vertebral bodies. Surgeries including L4/5 intervertebral disc debridement, spinal canal decompression, posterior lumbar interbody fusion (PLIF) with allogeneic fibula ring fusion cages, and posterior pedicle screw fixation were then performed. Imaging findings at one-month and six-month follow-up suggested that the patient was successfully treated. This case highlighted two important points: firstly, although acupuncture and acupotomy are generally regarded as safe conservative treatments for pain management, they can still lead to complications such as fungal spinal infection. Therefore, vigilance is necessary when considering these treatments; secondly, PLIF with allogeneic fibula ring fusion cages may be beneficial for A. terreus spondylodiscitis patients with spinal instability.

Keywords: Aspergillus terreus; acupotomy; acupuncture; allogeneic fibula ring; spondylodiscitis.

Figure 1

(A) The clinical timeline of the patient; (B) Lumbar sagittal T1-weighted MRI image at admission showed hypointensity of L4/5 vertebral bodies and intervertebral disc; (C) Lumbar sagittal T2-weighted image and (D) T2-weighted fat-suppression image at admission showed hyperintensity of L4/5 vertebral bodies and intervertebral disc; (E) Axial T2-weighted image at the level of L4/5 showed paravertebral soft tissue swelling and slight paraspinous abscess; (F) H&E staining showed massive inflammatory cells infiltration with some degree of purulent inflammation and necrosis (scale bar=20μm; magnification=10×); (G) Periodic acid–Schiff staining revealed septate fungal hyphae in the cartilage area; arrow indicates fungal hyphae (scale bar=20μm; magnification=40×); (H) Morphology features observed on the Sabouraud dextrose agar at 28°C after 5 days of incubation; and (I) Microscopic image of the subculture of the isolate following lactophenol cotton blue staining (magnification, 400×).

Figure 2

MRI and CT findings at approximately 24 days after antifungal therapy. (A) Sagittal T1-weighted image; (B) Sagittal T2-weighted image; (C) Sagittal T2-weighted fat-suppression image; (D) Axial T2-weighted image at the level of L4/5; (E) Sagittal CT image; (F) Coronal CT image; (G) Axial CT image; (H) Preoperative CT three-dimensional reconstruction image.

Figure 3

MRI, CT and X ray findings at six month follow-up. (A) Sagittal T1-weighted image; (B) Sagittal T2-weighted image; (C) Axial T2-weighted image at the level of L4/5; (D) Sagittal CT image; (E) Coronal CT image; (F) Axial CT image; (G) Lateral X ray image; (H) Anteroposterior X ray image; (I) CT three-dimensional reconstruction image. Imaging findings revealed that: the pedicle screws and cages were inserted in the right place, without cracked or displacement; there was no evidence of spinal infection; a certain level of L4/5 interbody fusion was observed.