Cervical spondylodiscitis caused by Candida albicans in a non-immunocompromised patient: A case report and review of literature

History and physical examination

A 32-year-old male with a history of intravenous drug use and hepatitis B and C presented with a 2-month history of progressive limited cervical range of motion, neck pain, bilateral upper extremity weakness, and paresthesias. His examination revealed mild 4/5 bilateral upper extremity weakness, right greater than left, with mild bilateral hyperreflexia, and significant kyphosis.

Diagnostic workup

Computed tomography and magnetic resonance studies

The computed tomography (CT) scan demonstrated severe bony erosion of the C6-C7 vertebral bodies with kyphosis and retropulsion of bone into the central canal, resulting in marked cord/root compression [Figure 1a]. The magnetic resonance imaging (MRI) demonstrated extensive prevertebral swelling, while contrast enhancement showed erosive lesions involving the C6 and C7 vertebral bodies with epidural phlegmon extending from C4 to C7-T1 [Figure 1b-d].

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Figure 1:: Sagittal (a) computed tomography without contrast, axial T1 magnetic resonance imaging w/contrast (b) and sagittal T1 magnetic resonance imaging without (c) and with (d) contrast demonstrate an enhancing erosive lesion involving the C6 and C7 vertebral bodies with peripherally enhancing fluid collection within the intervertebral disc space and a large fluid collection along the posterior aspect of the vertebral bodies with compression of the ventral spinal cord at C6-C7. There is also extensive prevertebral swelling with anterior and posterior epidural enhancement extending from C4 to T1.

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Hospital course

The patient underwent a C6 and C7 anterior corpectomy with instrumented fusion (e.g., placement of an expandable cervical cage and C5 to thoracic [T] 1 anteriorly). Intraoperatively, frank pus was noted within the C6-C7 disc space and was accompanied by thick prevertebral and epidural phlegmon extending from C5 to T1. Three days later, a C6-C7 laminectomy with C4-T2 posterior instrumented fusion was performed [Figure 2]. Intraoperative cultures again grew only Candida albicans. He was treated with intravenous micafungin followed by 6–12 months of 400 mg fluconazole. Three months postoperatively, the patient is doing well without complication but is continuing his oral antifungal therapy along with physical therapy.

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Figure 2:: Postoperative cervical X-rays anterior-posterior (a) and lateral (b) show placement of C6-C7 expandable cervical cage and C5 to T1 anterior discectomy with instrumentation and fusion, as well as posterior C4 to T2 instrumentation and fusion with C6 and C7 laminectomy. There is restoration of normal anatomic height with interval improvement in alignment of the cervical spine and reduction of the preoperative kyphotic deformity.

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Risk factors

Risk factors for C. albicans spondylodiscitis include long courses of broad-spectrum antibiotics, central venous catheter use, intravenous drug use, poorly controlled diabetes, immunosuppressive therapies, and spinal surgeries.[1-3] Here, the patient presented with a history of intravenous drug use, but no immunosuppression.

Laboratory studies for Candida spondylodiscitis

Candida spondylodiscitis can occur either as a result of a contiguous infection, direct inoculation (through lumbar puncture, spinal anesthesia, or spinal surgery), or hematogenous spread after prolonged candidemia. The classical time interval between the initial candidemia and onset of spondylodiscitis is several months.[3,4,6] The laboratory markers for inflammation such as white blood cell count, ESR, and CRP are often equivocal.

XR, magnetic resonance, and computed tomography of Candida spondylodiscitis

MRI is the best imaging modality for spondylodiscitis; it delineates early erosive bony changes consisting of hypointensities in the vertebral bodies on T1-weighted images, the absence of disc hyperintensity, and preservation of the intranuclear cleft in the disc on T2-weighted images.[3,5,6] Plain radiographs and CT spinal images may later detect vertebral abnormalities in conjunction with Candida spondylodiscitis. The definitive diagnosis typically requires image-guided biopsy, surgery, and/or direct documentation with fungal studies.[4,5]

Treatment of Candida spondylodiscitis

Candida osteomyelitis can be treated nonoperatively with a prolonged course of fluconazole or a lipid formulation of amphotericin B. Where applicable, optimizing risk factors such as tight glycemic control (e.g., in diabetics) or prompt removal of central venous catheters are often advocated. Surgical intervention may be necessary, particularly where nonsurgical measures fail. Critically, any evidence of new/progressive neurological deficits or radiological findings of significant spinal cord compression/instability may warrant surgical decompression with/without fusion.[1,4]