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The Journal of Bone and Joint Surgery 83:560 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.

Fungal Infections of the Spine

Report of Eleven Patients with Long-Term Follow-up

Daveed D. Frazier, MD, David R. Campbell, MD, Timothy A. Garvey, MD, Sam Wiesel, MD, Henry H. Bohlman, MD and Frank J. Eismont, MD

Investigation performed at University of Miami School of Medicine, Case Western Reserve University School of Medicine, and George Washington University School of Medicine
Daveed D. Frazier, MD Orthopaedic Associates of New York, 343 West 58th Street, New York, NY 10019
David R. Campbell, MD 3401 PGA Boulevard, Suite 500, Palm Beach Gardens, FL 33410
Timothy A. Garvey, MD Department of Orthopaedics, University of Minneapolis, 420 Delaware Street S.E., P.O. Box 492, Minneapolis, MN 55455
Sam Wiesel, MD Department of Orthopaedics, Georgetown University, 3800 Reservoir Road N.W., Washington, DC 20007
Henry H. Bohlman, MD Department of Orthopaedics, University Hospitals Spine Institute, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106
Frank J. Eismont, MD Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, P.O. Box 016960 (D-27), Miami, FL 33101
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this article.

Background:

Fungal infections of the spine are noncaseating, acid-fast-negative infections that occur primarily as opportunistic infections in immunocompromised patients. We analyzed eleven patients with spinal osteomyelitis caused by a fungus, and we developed suggestions for treatment.

Methods:

All patients with a fungal infection of the spine treated by the authors over a sixteen-year period at three teaching institutions were evaluated. There was a total of eleven patients. Medical records and roentgenograms were available for every patient. Long-term follow-up of the nine surviving patients was performed by direct examination by the authors or by the patient’s primary physician.

Results:

For ten of the eleven patients, the average delay in the diagnosis was ninety-nine days. Nine patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local extension (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spine infection developed in eight patients. Ten patients were treated with surgical débridement. All eleven patients were treated with systemic antifungal medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal hemorrhage at five months. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.

Conclusions:

Treatment of fungal spondylitis is often delayed because of difficulty with the diagnosis. Delay in the diagnosis led to poorer results in terms of neurologic recovery in our study. Performing fungal cultures whenever a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible complications of the disease.


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