Chronic Pyelonephritis may Cause Fungal Spondylodiscitis...

Case Report

31輔仁醫學期刊　第 18卷　第 1期　2020

Chronic Pyelonephritis may Cause Fungal Spondylodiscitis with Abscess: Two Rare Case Reports

Che-Wei Ku1, Bing-Juin Chiang1,2, Chun-Hou Liao1,2,*

ABSTRACT

Spondylodiscitis is an inflammatory disease characterized by primary infection of the in-tervertebral disc and/or secondary infection to the adjacent vertebrae. Fungal etiology is rare. Fungal spondylodiscitis is a rare spinal infection and usually develops in immunocompro-mised patients, especially in those with a malignant tumor, chronic urogenital tract infections, diabetes, or advanced age or in those taking immunosuppressive drugs for organ transplanta-tions. Chronic pyelonephritis is a complication of repeated bouts of acute pyelonephritis. In the present report, two patients diagnosed with chronic pyelonephritis were treated with an-tibiotics for more than six months. They presented with symptoms of sudden-onset low back pain and fever. Magnetic resonance imaging revealed fungal spondylodiscitis with abscess, which was confirmed with surgery and culture. Fungal spondylodiscitis may result from chronic pyelonephritis. The patients received intravenous antifungal agents after spinal sur-gery, followed by oral antifungal agents. Their symptoms improved with treatment, and they were discharged after surgery.

Keywords: spondylodiscitis, chronic pyelonephritis, fungal spondylodiscitis, magnetic resonance imaging

1 Division of Urology, Department of Surgery, Cardinal Tien Hospital2 School of Medicine, Fu-Jen Catholic University* Corresponding author: Chun-Hou Liao Department of Urology, Cardinal TienHospital, 362, Zhongzheng Rd., Xindian Dist., New Taipei City 23148, Taiwan R.O.C. Tel: +886-2-22193391 ext: 67240 Email: [email protected], [email protected]

DOI 10.3966/181020932020031801004

INTRODUCTION

Infections of the spine involving the verte-bral bodies, intervertebral discs, paravertebral structures, and spinal canal are known as spon-dylodiscitis, vertebral osteomyelitis, or discitis.

(8) The typical symptom is usually vague and non specific, and the most common clinical presenta-tion is back or neck pain.(6) (9) In recent years, the most frequent infection-causing bacterium is Staphylococcus aureus.(3)(9) Fungal infections are extremely rare and are primarily responsible for opportunistic infections in immunocompromised

Fu-Jen Journal of Medicine Vol.18 No.1 202032

Che-Wei Ku Bing-Juin Chiang Chun-Hou Liao　

individuals.(3) Chronic pyelonephritis is character-ized by chronic pyogenic infections of the kidney. Treatment of chronic pyelonephritis usually in-volves prolonged antimicrobial therapy. Here, we document two cases of chronic pyelonephritis treat-ed with antibiotics for more than six months prior to admission. An immunocompromised condition may have resulted in the fungal spondylodiscitis with abscess.

CASE REPORT

We document two unusual cases of lumbar spondylodiscitis infected with Candida species that may have developed due to chronic pyelonephritis.1. The first report describes the case of a

52-year-old woman who presented with severe right leg weakness, low back pain, chills, fe-ver, and bilateral flank pain for two days. She had a past medical history of cervical cancer 16 years ago that was treated with surgery, ra-diotherapy, and chemotherapy. Ten years after the radiotherapy, she suffered from radiation cystitis and bilateral ureteral stricture with hy-dronephrosis. She had a right double- J stent (DBJ) catheter and left nephrostomy tube to maintain her renal function. The patient had not been sexually active for more than a de-cade. An incident of chronic pyelonephritis treated with antibiotics more than six months ago was mentioned in her medical history. She was admitted to the urology department with a two-day history of symptoms of bilat-eral flank pain, sudden onset of low back pain, and chills with fever. Her lumbar movements were found to be restricted. The patient could not stand or walk for long periods of time.

No neurological deficit was present. She re-ceived intravenous antibacterial treatment for 6 weeks after admission. However, her back-ache did not improve with the administration of antibiotics. Magnetic resonance imaging (MRI) of the lumbar spine revealed progres-sion of L4-5 infectious spondylitis (Figure 1). Therefore, she underwent hemilaminectomy and microdiscectomy two weeks later. An ab-scess was noted in the vertebral disc during the surgical procedure. Candida rugosa was isolated from the abscess of the vertebral disc as well as from blood and urine cultures. No other organisms were found in her blood post surgery. Therefore, she received additional an-tifungal treatment with fluconazole infusion at 400mg per day for two weeks according to the decrease in C-reactive protein (CRP) level. The patient’s backache improved without any neurological deficit, and she was discharged and followed with two months of oral antifun-gal treatment.

2. The second report describes the case of a 67-year-old woman with a history of chronic pyelonephritis treated with antibiotics for more than six months. She presented with sudden onset of intermittent low back pain radiating to the left thigh. The pain was not associat-ed with nausea and vomiting. No neurological deficit was present. She had type 2 diabe-tes mellitus and hypertension that were under medical control. Her glycemic control and blood pressure were well maintained by oral drugs. There had not been sexual activity for more than a decade. She received intravenous antibiotic therapy for eight weeks post admis-sion. It was unsuccessful. Her lumbar spine

輔仁醫學期刊　第 18卷　第 1期　2020 33

　Chronic Pyelonephritis may Cause Fungal Spondylodiscitis with Abscess: Two Rare Case Reports

MRI revealed infectious spondylitis (Figure 2). She was treated with left L2 hemilaminecto-my and L2/L3 discectomy two weeks later. An abscess was noted on the vertebral disc during the surgical procedure. Candida albicans was isolated from blood, urine, and the abscess on the vertebral disc. Therefore, additional an-tifungal treatment with fluconazole infusion at 400mg per day was administered for four weeks according to the decrease in erythrocyte sedimentation rate (ESR). Her backache im-proved, and she was discharged and followed with two months of oral antifungal treatment.

DISCUSSION

Spondylodiscitis is characterized by primary infections of the intervertebral disc and/or second-ary infection of adjacent vertebrae. According to the published literature, spondylodiscitis is uncommon, with reported incidences of 4 to 24 cases per million in a year in developed countries.(2-4) (13) The ra-tio of men to women is 1.5 to 2:1.(4)(9) However, in recent years, the incidence of spondylodiscitis has been increasing due to the growth of the immuno-suppressed patient population, the aging population, presence of nosocomial infections, and improved diagnostic equipment.(3) Spondylodiscitis is the pri-mary manifestation of hematogenous osteomyelitis that was seeding by bacteremia and has a bimod-al age distribution with peaks at ages less than 20 years and in ages between 50 and 70 years.(3) (12) Additional routes of spinal infection are direct ex-ternal inoculation during spinal surgery or spread of infection from contiguous tissues such as from a uro-genital tract infection.(3) (12) More than 90% of the typical symptoms are back pain; less common symp-

toms are paresis and fever (less than 20%).(3) The diagnosis of fungal spondylodiscitis is made via the presence of clinical symptoms, laboratory results, radiological images, and microbiological cultures.(7) Thus, early symptoms of spondylodiscitis are non-specific and remain challenging. Adequate treatment is complex.(8) Neurological deficits, including leg weakness, paralysis, sensory deficits, radiculopa-thy, or loss of anal sphincter control, exist in 30% of spondylodiscitis cases. The reasons for these defects are considered to be delayed diagnosis, epidural ab-scess, or primary tuberculosis infection.(1) ESR and CRP are non-specific laboratory indicators of fun-gal spondylodiscitis; however, they can be used to follow-up the response to treatment.(7) CRP is a protein whose blood concentration reflects the pres-ence and intensity of inflammation and infection. There is no evidence to demonstrate which mark-er is a better predictor of the response to treatment. The microbiological culture of specimens such as blood, urine, and infective spine tissue can result in a definitive diagnosis and drug susceptibility test.(7) Fungal spondylodiscitis is a rare infection that should be considered while treating immunocompro-mised individuals. A study in 2010 documented that the majority of spinal infections were pyogenic in origin.(3) In this context, the most common patho-gen worldwide is Mycobacterium tuberculosis, and Staphylococcus aureus is the predominant pathogen in non-tuberculous cases.(3) (11) It can occur due to hematogenous or local spread of chronic infections to the urogenital tract.(1) (5) (8) (10) In our patients who had chronic pyelonephritis, the use of antibi-otics for more than six months and the presence of type 2 diabetes mellitus or a malignant tumor were the risk factors for acquiring Candida species infec-tions. A previous literature review illustrated that for



immunocompromised patients with lumbar pain and progressive onset with atypical changes in spine im-aging, negative cultures, and persistent symptoms despite antibiotic treatment, fungal infection should be considered.(14) Prophylactic antifungal treat-ment may be recommended in immunosuppressed patients with chronic pyelonephritis accompanied by sudden onset of low back pain. In immunosup-pressed patient, specimens for fungal culture should be collected as they may benefit from further treat-ment. Conservative treatment should be the first choice prior to any surgical intervention. The pri-mary regimen is amphotericin B for 2-3 weeks followed by fluconazole for 6-12 months in fungal spondylodiscitis. If monotherapy with fluconazole is chosen, the recommendation is to begin 4-6 weeks of fluconazole infusion at 400mg per day, followed by 2-6 months of oral treatment. The treatment period is shortened if surgical debridement is per-formed.(14) Spinal MRI appears to be the method of choice for evaluating and confirming the diagnosis of fungal spondylodiscitis. Most fungal spinal infec-tions are presented as non-specific findings on MRI, whereas vertebral body destruction in this type of disease may mimic tuberculosis or pyogenic infec-tion. Spondylodiscitis caused by fungi is uncommon and often associated with sepsis, urinary tract infec-tion, and respiratory system infection (especially of the lung with pulmonary aspergillosis). Direct inva-sion or local spread from the genitourinary system to the spine is thought to be the process of infection transmission. In conclusion, fungal spondylodisci-tis caused by chronic pyelonephritis with antibiotic treatment for more than six months is relatively rare that particularly occurs in immunosuppressed pa-tients. Predisposing risk factors include older age, male sex, malignant tumor, chronic urogenital tract

infections, diabetes, or administration of immuno-suppressive drugs. No significant clinical features that are strongly suggestive of fungal spondylodis-citis have been reported to date. This is the reason physicians should be aware of small but impor-tant symptoms possibly indicating this condition, such as neck or back pain, fever, and neurological deficit in an immunocompromised individual. Al-though fungal spondylodiscitis is not potentially life-threatening, early medical intervention, includ-ing antifungal therapy, chronic infection treatment, and glycemic control, can contribute toward achiev-ing a favorable prognosis without the requirement of surgical intervention. We recommended at least six weeks of antibiotics or antifungal treatment; how-ever, this depends on the culture results prior to any operation. Surgical interventions are necessary if long-term medical treatment fails, progressive neu-rological deficits arise, and/or progressive spinal deformity occurs.(5)

REFERENCES

[1]. Del PozoFJF, Alonso JV, Ruiz MÁC, et al. Community Acquired Spondylodiscitis caused by Escherichia Coli; Case Report and Literature Review. Bulletin of emergency and trauma. 2016;4(3):174-9.

[2]. Digby JM, Kersley JB. Pyogenic non-tuber-culous spinal infection: an analysis of thirty cases. The Journal of bone and joint surgery British volume. 1979;61(1):47-55.

[3]. Gouliouris T, Aliyu SH, Brown NM. Spon-dylodiscit is: update on diagnosis and management. J AntimicrobChemother. 2010;65(suppl_3):iii11-iii24.

[4]. Grammatico L, Baron S, Rusch E, et al. Ep-



idemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge da-ta 2002-2003. Epidemiology & Infection. 2008;136(5):653-60.

[5]. Herren C, Jung N, Pishnamaz M, et al. Spondylodiscitis: Diagnosis and Treatment Options. DeutschesArzteblatt international. 2017;114(51-52):875-82.

[6]. Jensen AG, Espersen F, Skinhøj P, et al. Bacteremic Staphylococcus aureus Spon-dylitis. Archives of Internal Medicine. 1998;158(5):509-17.

[7]. Jorge VC, Cardoso C, Noronha C, et al. ‘Fungal spondylodiscitis in a non-immuno-compromised patient’. BMJ case reports. 2012;2012:bcr1220115337.

[8]. Lener S, Hartmann S, BarbagalloGMV, et al. Management of spinal infection: a re-view of the literature. Actaneurochirurgica. 2018;160(3):487-96.

[9]. Mavrogenis AF, Megaloikonomos PD, Igou-

menou VG, et al. Spondylodiscitis revisited. EFORT open reviews. 2017;2(11):447-61.

[10]. Muller A. [Bacterial spondylodiscitis af-ter Escherichia coli urinary tract infection]. Deutsche medizinischeWochenschrift (1946). 2001 Nov 16;126(46):1299-300.

[11]. Turunc T, DemirogluYZ, Uncu H, et al. A comparative analysis of tuberculous, brucellar and pyogenic spontaneous spondylodiscitis pa-tients.Journal of infection. 2007;55(2):158-63.

[12]. Widdrington JD, Emmerson I, Cullinan M, et al. Pyogenic Spondylodiscitis: Risk Fac-tors for Adverse Clinical Outcome in Routine Clinical Practice. Medical sciences (Basel, Switzerland). 2018;6(4):96.

[13]. Zarghooni K, Röllinghoff M, Sobottke R, et al. Treatment of spondylodiscitis. Internation-al orthopaedics. 2012;36(2):405-11.

[14]. Caldera G, Cahueque M, Cobar A, et al. Fungal Spondylodiscitis. Review.J Spine. 2016;5:302.



Figure 1. Magnetic resonance image of the L4 and L5 vertebral body of the spine reveals infectious spondylitis (white cir-cle). T2 hyperintensity and enhancement within the lower L4 and L5 vertebral body (white circle).

Sagittal Axial

Figure 2. Magnetic resonance image of the L2 and L3 vertebral body of the spine shows infectious spondylitis (white cir-cle). T2 hyperintensity and enhancement within the lower L2 and L3 vertebral body (white circle)

Sagittal Axial



慢性腎盂腎炎可能導致真菌性脊椎間盤炎合併膿瘍：

兩個罕見病例報告

古哲維 1，姜秉均 1,2，廖俊厚 1,2,*

中文摘要

脊椎間盤炎是一種椎間盤感染合併或不合併周邊及椎骨感染的發炎疾病。由真菌

造成的感染是罕見的。真菌性脊椎間盤炎是罕見的，尤其通常出現在惡性腫瘤、慢性

生殖泌尿道感染、糖尿病、年長者或使用免疫抑制劑的器官移植等免疫抑制的病人。

而慢性腎盂腎炎是一種反覆急性腎盂腎炎的併發症。我們提出兩個慢性腎盂腎炎合併

出現下背痛及發燒的病人，經由脊椎核磁共振檢查及尿液和手術檢體的真菌培養確診

為真菌性脊椎間盤炎合併膿瘍。治療包括靜脈注射抗真菌劑和脊椎手術。病人在治療

後順利出院。

關鍵詞：脊椎間盤炎，慢性腎盂腎炎，真菌性脊椎間盤炎，核磁共振

1 天主教耕莘醫院外科部泌尿外科2 輔仁大學醫學系* 通訊作者：廖俊厚　電子信箱：[email protected] 收稿日期：2019年 08月 07日接受日期：2020年 01月 03日

Chronic Pyelonephritis may Cause Fungal Spondylodiscitis...

Documents

Transcript of Chronic Pyelonephritis may Cause Fungal Spondylodiscitis...