Fungal infections of the spine - Report of eleven patients with long-term follow-up

Background: Fungal infections of the spine are noncaseating, acid-fast-nega tive infections that occur primarily as opportunistic infections in immunoc ompromised 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 a uthors over a sixteen-year period at three teaching institutions were evalu ated. There was a total of eleven patients. Medical records and roentgenogr ams were available for every patient. Long-term follow-up of the nine survi ving 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 di abetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrit ion. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local exten sion (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spi ne infection developed in eight patients. Ten patients were treated with su rgical debridement. All eleven patients were treated with systemic antifung al medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal h emorrhage at five months. After an average of 6.3 years of follow-up, the i nfection had resolved in all nine surviving patients. Conclusions: Treatment of fungal spondylitis is often delayed because of di fficulty with the diagnosis. Delay in the diagnosis led to poorer results i n terms of neurologic recovery in our study. Performing fungal cultures whe never a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible compl ications of the disease.