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Case Report Vertebral Osteomyelitis Caused by Scedosporium Apiospermum in an Immunocompetent Male: a Case Report

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Case Report Vertebral Osteomyelitis Caused by Scedosporium Apiospermum in an Immunocompetent Male: a Case Report Int J Clin Exp Med 2018;11(8):8672-8676 www.ijcem.com /ISSN:1940-5901/IJCEM0066200 Case Report Vertebral osteomyelitis caused by Scedosporium apiospermum in an immunocompetent male: a case report Dan Cao1,2*, Dajiang Li1,2*, Le Yu1,2, Hongxia Bi1,2, Rong Deng1,2, Lichun Wang1,2 1Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, P.R. China; 2Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, P.R. China. *Equal contribu- tors. Received September 25, 2017; Accepted April 25, 2018; Epub August 15, 2018; Published August 30, 2018 Abstract: We describe an extremely rare case in which Scedosporium apiospermum caused vertebral osteomy- elitis in an immunocompetent 47-year-old man after he nearly drowned in a pond. The patient was admitted to West China Hospital complaining of lower back pain. Computed tomography (CT) of the chest revealed a chest-wall abscess, and CT of the lumbar spine revealed destruction in the L-3, L-4, and L-5 vertebrae. S. apiospermum was cultured from a paravertabral necrotic secretion, and antifungal therapy with voriconazole was initiated. The lower back pain disappeared after antifungal treatment, and the previously elevated white blood cell count, pro-calcitonin level, and erythrocyte sedimentation rate returned to normal. Moreover, CT showed improvement in the condition of the chest wall and lumbar spine. We report this case to advise physicians that lower back pain in near-drowning victims should raise suspicion of vertebral osteomyelitis due to the ubiquitous fungus S. apiospermum. Keywords: Vertebral osteomyelitis, Scedosporium apiospermum, near-drowning, antifungal therapy Introduction Case description Scedosporium apiospermum, is the asexual A motorcycle was submerged in a pond owing form of the filamentous fungus Pseudallesche- to a traffic accident. The driver, a 47-year-old ria boydii [1]. It is highly invasive and opportu- healthy man, was trapped head-down under nistic pathogen and can withstand high tem- the sewage. After being rescued, he was admit- peratures, high salinity, and hypoxia. It is found ted to the Affiliated Hospital of Southwest Me- most commonly in soil, sewage, and stagnant dical University (first hospital), at which time he water [2]. In recent years, the incidence of S. was diagnosed with aspiration pneumonia and apiospermum infections has tended to increase respiratory failure. Antibiotics including moxi- in immunocompromised individuals, HIV/AIDS floxacin and biapenem were administered for patients, leukemia sufferers, organ transplant the pneumonia. Acinetobacter Baumanii was recipients, and patients who received immuno- detected in endotracheal sputum cultures. Cli- suppressants for long periods of time. S. apio- nical symptoms improved after administration spermum infection can also occur in immuno- of naproxen, vancomycin, and moxifloxacin to competent individuals in situations such as control the infection in the lungs. One week trauma and near-drowning [3-6]. S. apiosper- after treatment, the patient experienced right mum causes soft tissue infections, pneumonia, eye blindness and lower-back pain. Radiography arthritis (most often in knee joints), and brain revealed bone destruction, disc bulging, and abscesses [7-10]. In near-drowning victims, endplate osteochondritis at the L-4 and L-5 ver- pneumonia and brain abscesses are its most tebral levels. He was diagnosed with vertebral common effects, whereas osteomyelitis is rare osteomyelitis, and extensive debridement, par- [11]. Here, we describe a rare case of verteb- tial corpectomy, and internal fixation were per- ral osteomyelitis in an immunocompetent man formed at the L-4 and L-5 levels. Surgical find- who contracted S. apiospermum infection after ings included the presence of a necrotic secre- nearly-drowning. tion. Although the Mucor was detected in cul- S. apiospermum-induced vertebral osteomyelitis notransferase: 23 U/L, albumin: 33.2 g/L. CT of the lumbar spine showed destruction of the L-3, L-4, and L-5 vertebrae (Figures 1 and 6), and CT of the chest showed the lungs scatter- ing in the infected focus, inflammatory nodules, and an abscess in the chest-wall (Figure 2). An orbital CT scan of the anterior and posterior diameters of the right eye revealed that the density of the vitreous body was slightly above normal and that the lens was invisible. In etio- logical examinations, the following were nega- tive: blood and chest-wall pus cultures; Asper- Figure 1. CT of the lumbar spine demonstrating bone gillus galactomannan, fungal (1,3)-beta-D dex- destruction of the L5 vertebral body in April 21, 2016. tran tests, and interferon gamma release tests; acid-fast staining; and gram staining of the pa- ravertebral necrotic secretion. A biopsy of the chest-wall abscess was negative. Percutaneous needle aspiration biopsy of the L-4 and L-5 ver- tebrae revealed a large number of neutrophils, monocytes, lymphocytes, and plasma cells, but no septate hyphae. After admission to West China Hospital, the patient’s temperature fluctuated from 38°C to 38.5°C between April 20th and April 25th. Levofloxacin and carbenin were administered to control the infection. S. apiospermum was present in cultures of the paravertebral necrot- ic secretion, and antifungal therapy (200 mg voriconazole intravenously for 12 hours) was initiated. The patient’s temperature and inflam- Figure 2. CT revealing the lungs scattering with nodu- matory indexes (white blood cell count, neutro- lar, hyper-dense shadows and local abscess of the phil ratio, pro-calcitonin level, and erythrocyte right anterior inferior wall in April 19, 2016. sedimentation rate) decreased gradually. His lower back pain subsided, and less pus was secreted in the sinuses. These findings indi- tures, the patient refused antifungal treatment cated that the infection had been controlled. and the fever recurred, as did infection of the During treatment, liver enzyme levels increased L-3 and L-4 vertebrae as shown via CT. For fur- to 102 U/L, but then returned to normal after ther care, the patient was admitted to West liver protective therapy. Eight weeks after re- China Hospital (Secondary Hospital), with a ceiving antifungal therapy, the patient was dis- description of “a traffic injury 3 months ago and charged home. He required oral administration lower back pain for 2 months”. Physical exami- of voriconazole (200 mg bid for 12 months) out- nation revealed right eye blindness and tender- side the hospital. In a telephone follow-up 6 ness on the right side of the chest without local months after discharge, the patient stated that swelling. Sinuses were 1×1 cm in size at the L-4 he no longer had a fever or lower back pain. CT and L-5 levels, with tiny amounts of pus, mild showed that his condition had improved. tenderness, and knocking pain. Heart and abdominal physical examinations showed no All procedures performed in these studies abnormal findings. involving human participants were in accor- dance with the ethical standards of the institu- Laboratory examination revealed the following tional and/or national research committee and white blood cell count: 6.11×109/L, neutrophil with the 1964 Declaration of Helsinki and its ratio: 73.6%, pro-calcitonin level: 1.52 ng/mL, later amendments or comparable ethical stan- erythrocyte sedimentation rate: 70 mm/h, ala- dards. Informed consent was obtained from the nine aminotransferase: 24 U/L, aspartate ami- patient included in the study. 8673 Int J Clin Exp Med 2018;11(8):8672-8676 S. apiospermum-induced vertebral osteomyelitis Figure 3. Sabouraud dextrose agar showing growth Figure 5. S. apiospermum conidiophores bearing of S. apiospermum (multiple fungal colonies). one celled obovoid conidia produced singly under electron microscope. Figure 4. Photomicrograph of S. apiospermum (wet mount, lactophenol aniline blue stain) demonstrat- Figure 6. ing multiple obovoid conidia with truncate bases, Reconstructed CT of the lumbar spine dem- arising from short conidiophores or directly from hy- onstrating bone destruction of the L-3, L-4 and L-5 phae. vertebral bodies. Discussion are rare. S. apiospermum is a rare fungal patho- gen hat can invade multiple organs, sometimes Suppurative spondylitis, which includes verte- fatally. S. apiospermum infections typically oc- bral osteomyelitis and epidural abscesses, cur in immunocompromised patients and com- mainly occurs in young adults [12]. Because it mon infection sites include the skin, lungs, has no specific symptoms, its early-stage diag- joints, and nervous system. In our case, the pa- nosis is difficult, and its consequences include tient had nearly drowned and was predisposed spinal deformities, neurological damage, paral- to infection. Our case is of interest for two rea- ysis, and even death [13]. It is primarily caused sons: the patient was a young immunocompe- by a hematogenous infection, followed by trau- tent man, and the S. apiospermum infection ma and local spread of the infection [13]. The occurred in the lumbar vertebrae. Because he pathogens responsible for infection are usual- had no previous history of lumbar trauma or ly bacterial (Staphylococcus aureus [14] and chronic lumbar spine disease, this case sug- Escherichia coli [15]), whereas fungal sources gests that S. apiospermum can cause a dis- 8674 Int J Clin Exp Med 2018;11(8):8672-8676 S. apiospermum-induced vertebral osteomyelitis seminated infection in immunocompetent indi- spermum infection. In support, S. apiosper- viduals. mum was detected in cultures of the paraver- tebral necrotic secretion. Direct contact of the At present, diagnosis of an S. apiospermum in- eyes with S. apiospermum-infested sewage fection is difficult because its clinical features can cause ocular and corneal infections, which and histopathology resemble those of infect- can be painful and vision impairing. Indeed, the ions caused by other filamentous fungi such as patient in our study became blind in the right Aspergillus and Fusarium spp. Microorganism- eye after crashing his motorcycle into a sew- detecting cultures are a reliable diagnostic age-containing pond.
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