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CC BY-NC-ND 4.0 · Asian J Neurosurg 2025; 20(02): 383-386
DOI: 10.1055/s-0045-1802624
Case Report

Aspergillus terreus Fungal Spondylodiscitis in a Healthy Patient Post-Lumbar Spine Surgery: A Rare Case Report

Raghava D. Mulukutla
1   Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India
,
Phani Krishna Karthik Yelamarthy
1   Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India
,
Thiruvoipati Venkata Krishna Narayan
1   Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India
,
Ambadas Kathare
1   Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India
,
Vijay V. Yeldandi 
2   Division of Infectious Diseases, University of Illinois, Chicago, Illinois, United States
› Author Affiliations

Funding None.
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Abstract

We present a case of hospital-acquired Aspergillus terreus spondylodiscitis following lumbar spine surgery. The objective is to highlight the need for a high index of suspicion for rare fungal pathogens as causative organisms in postoperative spinal infections. A 39-year-old female underwent posterior decompression, stabilization, and interbody fusion at L4–5. Six weeks post-surgery she developed fever, back pain, and right leg pain. A diagnosis of postoperative spinal infection was made. On exploration and debridement of the wound, the fungal cultures grew positive for A. terreus. She was treated with voriconazole for 6 months. Following debridement and antifungal therapy, symptoms and inflammatory markers subsided over a period of time. There was no recurrence of infection till the last follow-up at three and half years. To the best of our knowledge, this is the only case report of an A. terreus spondylodiscitis following lumbar spine surgery. The possibility of fungal infection should be considered in elderly and immune-compromised patients. In our institution, all postoperative spinal infections, irrespective of age and comorbidities, are subjected to microbiological cultures including fungal cultures and sensitivities. Thorough debridement, involvement of infection control specialists, and use of long-term antifungal therapy help resolve these infections.


 

Keywords

Aspergillus terreus - fungal infection - spondylodiscitis - surgical site infection - osteomyelitis

Introduction

Spondylodiscitis refers to an infection of the spine and accounts for 2 to 7% of pyogenic osteomyelitis cases.[1] Fungal spondylodiscitis is rare[2] with an incidence of 0.6 to 1.6% in various studies among all spondylodiscitis cases.[3] [4] Postoperative fungal spondylodiscitis is even rarer but is increasing worldwide due to prolonged spine surgeries, particularly in elderly and immunocompromised patients.[5]

Candida and Aspergillus are the commonest fungi infecting the spine.[6] Aspergillus terreus is an extremely rare cause of discitis.[7] We present a case of A. terreus spondylodiscitis following lumbar spine surgery in a healthy female patient. To the best of our knowledge, this is the only case reported in the literature of an A. terreus spondylodiscitis in an otherwise healthy patient.


 

Case Report

A 39-year-old female with mild diabetes presented to us with back pain and bilateral leg pain with numbness of 3-year duration. She was thoroughly investigated and after a trial of conservative treatment failed to relieve her symptoms, she was advised surgery. X-rays ([Fig. 1]) and magnetic resonance imaging (MRI) lumber spine (LS) ([Fig. 2]) showed left postero-lateral disc extrusion with inferior migration and canal stenosis L4–5. The patient underwent posterior decompression, stabilization, and interbody fusion L4–5. The postoperative period was uneventful and patient was mobilized and discharged.

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Fig. 1 Plain radiographs of lumbosacral spine—AP and lateral views showing decreased lordosis, calcified posterior annulus L4–5. AP, anteroposterior.
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Fig. 2 MRI LS spine T2 weighted images showing extruded and inferior migrated disc fragment, facet effusion and stenosis. LS, lumber spine; MRI, magnetic resonance imaging.

Six weeks later she presented with fever, back pain, and left leg pain with raised erythrocyte sedimentation rate and C-reactive protein. There was serous discharge from the wound. Contrast MRI ([Fig. 3]) showed hyperintensity at L4–5 disc with an abscess dorsal to the dura.

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Fig. 3 Six weeks post-surgery contrast MRI LS spine T2-weighted images showing epidural collection with peripheral enhancement dorsal to the dura with disc hyperintensity at L4–5. LS, lumber spine; MRI, magnetic resonance imaging.

In view of surgical site infection, thorough debridement was done. Samples sent for microbiological and fungal cultures grew A. terreus, sensitive for voriconazole. Microbiologist and infection control specialist's opinions taken. Antifungal drug sensitivity with minimum inhibitory concentration (MIC) values is available in very few centers in the world and is not available in our region, 3 years ago. According to Berkow EL and Lockhart SR et al[8], identifying the pathogen accurately can sometimes allow for the empirical selection of an antifungal drug without requiring susceptibility testing. For instance, in the United States, Aspergillus is typically treated with voriconazole empirically, as resistance to this antifungal has not been widely observed. Furthermore, for fungal pathogens lacking established interpretive criteria, such as breakpoints or epidemiological cutoff values, obtaining an MIC value might not provide a definitive clinical interpretation. Moreover, voriconazole is a first-line treatment according to Infectious Diseases Society of America (IDSA) guidelines for Aspergillus species.[9] Hence, the patient was started on intravenous voriconazole for 2 weeks followed by oral therapy.

Six weeks after starting antifungal therapy, the patient was significantly relieved of her leg pain but moderate back pain persisted. A contrast MRI ([Fig. 4]) revealed a 10 mm intradural granuloma at L3 level and hyperintensity of L4–5 disc. Blood parameters gradually returned to normal with no constitutional symptoms. The patient was closely monitored and oral antifungal therapy was continued for a total duration of 6 months as advised by infectious disease specialists. At the end of 6 months of antifungal therapy, the patient had no fever or any back pain, with normal blood parameters and hence was decided to stop the therapy.

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Fig. 4 Follow-up contrast MRI LS spine sagittal images showing intradural granuloma behind L3 body with reduced bony and disc edema.

At three and half years post-surgery, there was no relapse and ([Fig. 5]) the patient was asymptomatic and was back to her activities of daily living.

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Fig. 5 Three and half year follow-up X-ray showing no evidence of any bony destruction or implant loosening.

 

Discussion

Aspergillosis is primarily a respiratory pathogen but can rarely involve the musculoskeletal system, with 50% of cases affecting the spine.[2] [10]

Sources of infection include contagious lung spread, hematogenous spread, and direct inoculation (trauma/surgery), with hospital-acquired infections linked to immune-compromised hosts and construction/renovation sites.[11] Immune dysfunction predisposes individuals with risk factors.[2] [7] [11] Around one-third of patients affected have no predisposing factors.[12]

Clinical presentation is nonspecific[7] with an overall mortality rate of 25%, hence the need for high index of suspicion and accurate diagnosis.[2] [7] [13] Laboratory tests are often not useful.[13] Recently, biomarkers such as galactomannan and serum β D-glucan have been used to confirm the diagnosis.[14] Definitive identification of A. terreus is through culture in sabouraud dextrose agar (SDA) medium, showing cinnamon-brown colonies, smooth-walled conidiophores, and biseriate conidial heads.[7] Radiological findings depend on patient's immunity and disease severity. Differentials are other fungal infections, tuberculosis, and pyogenic discitis.[15]

Till now, only eight human cases of A. terreus spondylodiscitis have been reported but none of them occurred after lumbar spine surgery in a healthy patient. One resulted from direct inoculation (stab injury),[10] two from hematogenous spread,[16] [17] two from contiguous lung spread,[18] [19] one from a vascular surgery complication,[20] one with multifocal bone involvement,[21] and one from traumatic inoculation.[7]

In our patient, we hypothesize that the source of infection could be from an adjacent operation theater where renovation work was going on. Although this area was isolated, we suspect that the fungus could have infected via the air-conditioning ducts which may not have been sufficiently packed. This is our suspicion in retrospect and we cannot be sure of this hypothesis.

Management involves surgical debridement and long-term antifungal therapy for 6 to 12 months, with voriconazole as first-line treatment according to IDSA guidelines. For refractory patients, itraconazole is recommended.[5] [7] [9] Precautions to reduce fungal infections include patient optimization, strict aseptic protocols, and avoiding surgeries during renovations in high-risk patients.


 

Conclusion

Aspergillus terreus is an extremely rare postoperative spinal pathogen. This is the first reported case in the literature of A. terreus spondylodiscitis following lumbar spine surgery in a healthy patient. Our patient underscores the need for high index of suspicion, fungal cultures in all suspected postoperative spinal infections, early and thorough debridement, and appropriate antifungal therapy.


 

 

Conflict of Interest

None declared.

Patients' Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Address for correspondence

T. V. Krishna Narayan, D Ortho, MS Ortho, FNB
Department of Spine Surgery, Udai Omni Hospital
Hyderabad 500001, Telangana
India   

Publication History

Article published online:
10 February 2025

© 2025. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Zoom
Fig. 1 Plain radiographs of lumbosacral spine—AP and lateral views showing decreased lordosis, calcified posterior annulus L4–5. AP, anteroposterior.
Zoom
Fig. 2 MRI LS spine T2 weighted images showing extruded and inferior migrated disc fragment, facet effusion and stenosis. LS, lumber spine; MRI, magnetic resonance imaging.
Zoom
Fig. 3 Six weeks post-surgery contrast MRI LS spine T2-weighted images showing epidural collection with peripheral enhancement dorsal to the dura with disc hyperintensity at L4–5. LS, lumber spine; MRI, magnetic resonance imaging.
Zoom
Fig. 4 Follow-up contrast MRI LS spine sagittal images showing intradural granuloma behind L3 body with reduced bony and disc edema.
Zoom
Fig. 5 Three and half year follow-up X-ray showing no evidence of any bony destruction or implant loosening.