Delayed Treatment of Pulmonary Blastomycosis Causing Vertebral Osteomyelitis, Paraspinal Abscess, and Spinal Cord Compression

Abstract

A 36-year-old woman with gallbladder disease had an incidental finding of asymptomatic cavitary lung infection with Blastomyces dermatitidis. No treatment was given initially, and 2 months later she presented with vertebral osteomyelitis, paraspinal abscess, and spinal cord compression due to dissemination of the fungus. The patient recovered following surgical debridement and treatment with 1 g of amphotericin B, followed by itraconazole 400 mg QD for 6 months. In spite of previous reports of the self limiting nature of primary pulmonary blastomycosis in the normal host, antifungal therapy may be needed in cases that do not resolve spontaneously within a short period of time, or if transient immunosuppression may be anticipated as may occur following surgery or after acquisition of other infections.

Blastomycosis of the lumbar spine: case report and review of the literature, with emphasis on diagnostic laboratory tools and management

“…Some are of the opinion that in immunocompetent patients with uncomplicated pulmonary forms of the disease, therapy may not be necessary [6,27,32]. Considering the complication of blastomycosis and the relative safety of oral antifungal medication, we tend to agree with others [3,10,18], that when blastomycosis is suspected, even in its mildest form (as in the case of our healthy patient), antifungal therapy should be instituted.…”

“…Itraconazole is an oral triazole which has excellent in vitro and in vivo activity against Blastomyces dermatitides. It has an efficacy rate of 90% at doses of 200-400 mg daily and the patient needs to be treated for 6 months [18]. Itraconazole has superior efficacy and lower side effects, so it should be used as the drug of choice in immunocompetent patients with blastomycosis.…”

“…Amphotericin B remains the drug of choice in patients who are severely immunocompromised, and have a disseminated form of the disease in a life-threatening situation. The recommended total dose of Amphotericin B is 1.5-2.5 g [9,18]. The cure rate of Amphotericin B was reported to be 87% when a 1-g course therapy was used, and 97% when a 2-g course treatment was used.…”

“…The disease may remain asymptomatic or become fulminant with life-threatening forms. Reported surgical treatments deal with drainage of spinal abscesses and spinal fusion [1,18]. However, spinal deformity may be crippling, and surgical options tailored specifically to reconstructing blastomycotic spinal deformities have not been established.…”

Vertebral infection

“…Подчеркивается важность ранней дифференциальной диагностики, так как принципы лече-ния при этом другие, что может влиять на конечный исход [57,61,81,82,90,95,96,116,134,157,159,179,194].…”