amphotericin-b and Spondylitis

In this paper, we present a case of cervical spondylitis due to Phaeoacremonium venezuelense, in a fifty-two-year-old male who complained about neck pain and tingles in his right arm. Fungal cervical spondylitis is extremely rare in immunocompetent patients. This case is the first case of spondylitis due to P. venezuelense.

Topics: Amphotericin B; Antifungal Agents; Ascomycota; Cervical Vertebrae; Epidural Abscess; Humans; Immunocompetence; Kidney Diseases; Magnetic Resonance Imaging; Male; Middle Aged; Mycoses; Pyrimidines; Species Specificity; Spondylitis; Tomography, X-Ray Computed; Triazoles; Voriconazole

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillus; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Resistance, Fungal; Follow-Up Studies; Humans; Immunocompetence; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Pyrimidines; Risk Assessment; Severity of Illness Index; Spondylitis; Treatment Failure; Treatment Outcome; Triazoles; Voriconazole

Sixteen patients with spinal infection from Coccidioides immitis were treated. Lesion location was cervical in two, thoracic in four, lumbar in six, sacroiliac joint in one, and disseminated spinal in three. The neurological status was intact in 11 patients. One patient had incomplete quadriplegia, three patients had incomplete paraplegia, and a fifth patient had a lumbar root lesion. Treatment was medical only in 4 patients (one of whom required surgery 2 years later) and combined medical and surgical in 13 patients. All patients received amphotericin B intravenously. Follow-up averaged 24 months in 15 patients (range, 12-42 months). The outcome in four patients treated medically alone was one death, one remission, one relapse with disease progression, and one without follow-up. The outcome in the combined medical and surgical group was nine fusions, one pseudarthrosis, and three lesional excisions, all with remission. Successful treatment outcome is disease arrest, as opposed to "cure."

Topics: Adult; Aged; Amphotericin B; Antifungal Agents; California; Cervical Vertebrae; Coccidioidomycosis; Combined Modality Therapy; Debridement; Discitis; Disease Outbreaks; Female; Follow-Up Studies; Humans; Internal Fixators; Lumbar Vertebrae; Lung Diseases, Fungal; Male; Middle Aged; Nerve Compression Syndromes; Paraplegia; Postoperative Complications; Prisoners; Quadriplegia; Remission Induction; Ribs; Sacroiliac Joint; Spinal Fusion; Spinal Nerve Roots; Spondylitis; Thoracic Vertebrae; Treatment Outcome

We have recently treated three patients with Candida vertebral osteomyelitis. In each patient there was at least one characteristic prodromal condition, including trauma, multiple antibiotics following bowel surgery, and acute nonlymphocytic leukemia. All patients were treated successfully with amphotericin B. Based on our findings and a review of the literature, we would recommend a 1.0-1.2 gm total dosage of amphotericin B. Alternative therapeutic choices such as 5FC and/or ketoconazole, under specific clinical conditions, have been successfully employed. However, cure can best be confirmed by post-treatment biopsy.

Topics: Adult; Aged; Amphotericin B; Candidiasis; Humans; Lumbar Vertebrae; Male; Osteomyelitis; Spondylitis; Thoracic Vertebrae

Invasive spinal aspergillosis in an immunocompetent child is rare and often there is a considerable delay in diagnosis. A 13-year-old male child treated medically as tuberculosis of spine elsewhere for 1 year, came with complete paraplegia, dorsolumbar kyphosis and intermittently discharging sinus in the back. The child was taken up for surgical decompression and stabilization. Intraoperatively black granulomatous material was noted inside the canal extending anteriorly towards the vertebral body. There was complete cord transection with severe vertebral destruction and osteoporosis. The pathology and microbiology confirmed aspergillosis and the child was started on antifungal treatment. At further follow up, the infection was found to spread to the lung and caused further vertebral destruction. A change in the antifungal medication controlled further spread but failed to eradicate the infection at 2-year follow-up. In this patient, the delay led to extensive vertebral destruction with spine deformity and spontaneous cord transection. Retrospective review of the clinical and radiological findings suggests that this complication could have been prevented if these findings were carefully interpreted. In this era of transplantation and increase in use of immunosuppressive drugs the authors suggests having fungal infection as a differential diagnosis for infections of the spine.

Topics: Adolescent; Amphotericin B; Antifungal Agents; Aspergillus fumigatus; Decompression, Surgical; Diagnosis, Differential; Humans; Magnetic Resonance Imaging; Male; Neuroaspergillosis; Spine; Spondylitis; Treatment Outcome; Tuberculosis, Spinal

Topics: Amphotericin B; Antifungal Agents; Back Pain; Biopsy; Braces; Coccidioidomycosis; Combined Modality Therapy; Diagnosis, Differential; Disease Progression; Fluconazole; Humans; Magnetic Resonance Imaging; Male; Patient Isolation; Spinal Fusion; Spondylitis; Thoracic Vertebrae; Treatment Outcome

This study was conducted to review the presentation and management of patients with coccidioidomycosis involving the spine.. The authors reviewed 23 cases of spinal coccidioidomycosis treated at their institutions. There were 20 males and three females who ranged in age from 9 to 62 years. Non-Caucasian individuals were disproportionately represented. Spinal disease was the first manifestation of disseminated coccidioidomycosis in 10 cases. Thirteen patients with meningitis, soft-tissue involvement, or pulmonary involvement developed new spinal lesions despite undergoing continued systemic therapy with amphotericin and/or fluconazole. In all patients computerized tomography and magnetic resonance imaging studies demonstrated preferential involvement of the disc spaces, vertebral bodies, and pedicles with extensive paravertebral phlegmons and retropharyngeal, mediastinal, or psoas abscesses. Despite the significant imaging findings, only four patients presented with a significant neurological deficit. Local pain or radiculopathy was the most common complaint. Twenty patients underwent invasive therapy. In five patients with prominent psoas abscesses and disc space disease, drainage was performed after inserting a percutaneous catheter. Progressive bone destruction necessitated debridement and fusion in one of these patients, and two others had poor outcomes after receiving antifungal therapy alone. Initially 15 patients underwent debridement and fusion in which instrumentation (10 cases) or bone graft alone was used (five cases). One patient worsened neurologically after surgery, and another patient required reoperation for a failed fusion and to correct progressive kyphosis. Four of the 23 patients died of complications related to fungemia. Most of the 15 surviving patients have required long-term antifungal therapy for spinal and extraspinal foci.. Spinal coccidioidomycosis can be an aggressive disease process. Systemic antifungal therapy fails to prevent de novo spinal involvement and is usually insufficient treatment for established spinal disease.

Topics: Adolescent; Adult; Amphotericin B; Child; Coccidioidomycosis; Debridement; Drainage; Drug Therapy, Combination; Female; Fluconazole; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Postoperative Complications; Psoas Abscess; Reoperation; Spinal Fusion; Spondylitis; Tomography, X-Ray Computed; Treatment Failure

We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.

Topics: Administration, Oral; Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Antifungal Agents; Bone Transplantation; Child; Combined Modality Therapy; Cryptococcosis; Decompression, Surgical; Diagnosis, Differential; Female; Flucytosine; Humans; Ketoconazole; Male; Spondylitis

A 5-year-old male patient presented with flank pain, limping, weight loss, and cachexia. Magnetic resonance imaging revealed destructive vertebral changes, an epidural mass, psoas abscesses, and lack of involvement of the disc spaces. Blastomyces dermatitidis was isolated from a needle aspiration specimen. Sparing of the disc spaces, an unusual finding, suggested that the spread of infection was by way of paravertebral structures and surrounding potential spaces. Management was simplified by using gadolinium contrast-enhanced magnetic resonance imaging, which indicated that the epidural mass was mainly solid, thereby obviating abscess drainage.

Topics: Amphotericin B; Antifungal Agents; Blastomycosis; Child, Preschool; Diagnosis, Differential; Humans; Itraconazole; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Psoas Abscess; Sacrum; Spondylitis

Topics: Amphotericin B; Arthritis, Infectious; Combined Modality Therapy; Debridement; Diabetes Mellitus, Type 1; Diagnosis, Differential; Disease Susceptibility; Humans; Knee Joint; Lumbar Vertebrae; Male; Middle Aged; Mycetoma; Occupational Exposure; Osteomyelitis; Pseudallescheria; Rheumatic Diseases; Soil Microbiology; Spondylitis

To assess the effectiveness of medical treatment by clinical, radiological, and biological analysis of outcome in 9 patients with aspergillus spondylodiscitis.. Retrospective study including 9 patients with aspergillus discitis, in which 7 were immunosuppressed; 3 were heart transplant patients, 2 had acute lymphoblastic leukemia, 1 hairy cell leukemia and one was receiving prednisone for bronchial asthma. Four patients had isolated spinal aspergillosis infection. In 4 cases, disc space infection occurred after pulmonary aspergillosis. In the last case the spondylodiscitis occurred after aspergillus endocarditis and mycotic limb embolism. In all cases a percutaneous needle biopsy of the intervertebral disc was performed; the subsequent culture produced Aspergillus fumigatus in 8 cases and Aspergillus flavus in 1. Itraconazole was given to all patients (mean dose: 350 mg/day); it was given alone in 2 cases, in addition to 5 flucytosine and amphotericin B in 6 cases, and in addition to amphotericin B in the last case.. Improvement was obtained in the 9 cases, with full recovery in the absence of any surgical debridement after a mean treatment duration of 5.5 months and a mean followup delay of 16 months.. Early recognition of aspergillus spondylodiscitis in immunocompromised hosts is important. Itraconazole alone or in combination is an effective therapy. There may be an increased incidence of aspergillus discitis due to the increasing frequency of immunosuppression associated conditions including organ transplantation, chemotherapy, or acquired immune deficiency syndrome.

Topics: Adult; Aged; Amphotericin B; Aspergillosis; Discitis; Drug Therapy, Combination; Female; Flucytosine; Humans; Immunosuppression Therapy; Itraconazole; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Myelography; Retrospective Studies; Spondylitis; Thoracic Vertebrae

We report two patients with chronic granulomatous disease (CGD) and life-threatening infections: a 10 10/12-year-old boy had Aspergillus fumigatus spondylitis with destruction of the 11th vertebral body and paravertebral abscess formation, and an 8 5/12-year-old boy had multiple Staphylococcus aureus hepatic abscesses with subphrenic abscess formation. Both patients failed to respond to intense antimicrobial therapy but showed a remarkable recovery following surgical drainage combined with granulocyte transfusions. These results suggest that antimicrobial therapy and surgical drainage followed by granulocyte transfusions may be the ideal mode of treatment for severe infections in patients with CGD.

Topics: Amphotericin B; Blood Transfusion; Child; Drug Combinations; Flucytosine; Granulocytes; Granulomatous Disease, Chronic; Humans; Liver Abscess; Male; Spondylitis; Staphylococcal Infections; Subphrenic Abscess; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination

Aspergillus infection of the spine is rare; for it to lead to paraplegia is still more rare. When this does occur it is usually treated by decompression and antifungal agents, but the results have usually been poor. We report two cases of successful conservative treatment of Aspergillus paraplegia in patients with chronic granulomatous disease.

Topics: Amphotericin B; Aspergillosis; Aspergillus fumigatus; Aspergillus niger; Child; Drug Therapy, Combination; Flucytosine; Humans; Male; Paraplegia; Radiography; Spondylitis; Thoracic Vertebrae

A 58-year-old patient with neutropenia due to SLE developed spondylitis of the lumbar region caused by Candida albicans. The spondylitis was probably superinfected with Staphylococcus aureus. The initial one month's intravenous combination therapy with amphotericin B and flucytosine was discontinued because of fever reactions to amphotericin B, suspected myelosuppressive effect of flucytosine and insufficient clinical response. This therapy was followed by four months of oral ketoconazole and clindamycin with good results and without any side-effects.

Topics: Amphotericin B; Candidiasis; Clindamycin; Drug Therapy, Combination; Female; Flucytosine; Humans; Ketoconazole; Lumbar Vertebrae; Middle Aged; Osteomyelitis; Spondylitis

In a patient with spondylodiscitis secondary to cardiac valve prosthesis infection with endocarditis the fungus Drechslera longirostrata, which had not yet been known to cause mycoses, was isolated from cultures of prosthetic material and an intervertebral disc. The cardiac prosthesis had to be replaced and the vertebral lesion, which extended along 3 lumbar segments and was destructive enough to produce neurological disorders, required surgical immobilization of the spine. The disc infection was cured after combined administration of amphotericin B and ketoconazole, both drugs having proved unsuccessful when given alone. Infections caused by rare opportunistic fungi are becoming increasingly common and are difficult to diagnose since immunological methods are inapplicable. In some resistant or extremely severe fungal infections antifungal agents can be used in combinations for their synergistic effects, with subsequent reduction of dosage and potential side-effects. Combinations must be based on in vitro sensitivity tests.

Topics: Adult; Amphotericin B; Antifungal Agents; Endocarditis; Female; Heart Valve Prosthesis; Humans; Imidazoles; Ketoconazole; Mitosporic Fungi; Mycoses; Piperazines; Postoperative Complications; Spondylitis

In spite of the development in cases of deep mycoses, cases of osteoarthritis with Candida remain rare (only thirty seven cases reported). Among these, ten observations of spondylodiscitis have been collected and the authors report a new case where Candida albicans was isolated in the discovertebral focus through bone puncture. This spondylodiscitis occurring in a leukemic patient receiving antibiotics, corticosteroids, cytostatics drugs and radiotherapy, was treated successfully by an association of Amphotericin B-5-Fluorocytosine. The authors take this opportunity to report the main characteristics of the ten previously described cases specifying the rules for the uses of fungicidal drugs in the treatment of deep mycoses and for the first time, they study simultaneously seric concentration, penetration into healthy bone and into discovertebral focus of the 5-Fluorocytosine. They also justify their preference for the association of Amphotericin B-5-Fluorocytosine as a "first line" treatment after confirming the sensitivity of the strain to 5-Fluorcytosine.

Topics: Amphotericin B; Candidiasis; Cytosine; Drug Therapy, Combination; Flucytosine; Humans; Intervertebral Disc; Male; Middle Aged; Spondylitis

A review of twelve cases in which disseminated coccidioidomycosis caused localized infection of the spine showed that eight of the twelve patients were alive and well with no evidence of active infection an average of eleven years after onset (range, two to thirty-five years). One patient who was followed for more than twenty-three years had a slowly developing neurological impairment in the lower extremities as a result of lumbosarcral destruction instability. One patient died early in the course of the disease from fulminating cervical spondylitis and quadriplegia. A second patient had a paraplegia from thoracic spondylitis. On patient had no evidence of active spondylitis five years after the onset of the disease, but then died of coccidioidal meningitis. All patients were treated with intravenous amphotericin at some time in the course of their illness, although its effect was not always dramatic. The three patients with neurological impairment did not undergo spine fusion, but most of the others had that operation. Surgical evacuation of abscesses and debridement of infected bone was also performed in many cases.

Topics: Adult; Amphotericin B; Arthrodesis; Black People; California; Child; Coccidioidomycosis; Complement Fixation Tests; Debridement; Female; Follow-Up Studies; Humans; Male; Middle Aged; Racial Groups; Spinal Fusion; Spondylitis; Therapeutic Irrigation