Fungal spinal epidural abscess: a case series of nine patients

Publication date: Available online 16 August 2018

Source: The Spine Journal

Author(s): Huiliang Yang, Akash A. Shah, Sandra B. Nelson, Joseph H. Schwab

Abstract

Background context

Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature.

Purpose

This study aimed to describe the clinical features, diagnosis, treatment and outcomes of FSEA.

Study design

This study is designed as a retrospective clinical case series.

Patient sample

A continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016.

Methods

We reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases were caused by fungi. We also reviewed FSEA cases in the English-language literature from 1952 to 2017 to analyse the features of FSEA.

Results

From a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of 9 cases involved the thoracic spine, and 8 were located anterior to the thecal sac. Three cases had fungemia, 6 had long symptom duration (>2 weeks) prior to presentation, 7 had concurrent immunosuppression, and 8 had vertebral osteomyelitis. Additionally, 1 case had residual motor deficit at last follow-up, 1 had S1 sensory radicular symptoms, 2 suffered recurrent FSEA, 2 died within hospitalization, and 2 died within 90 days after discharge.

Conclusions

In summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.

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