Thoracic cryptococcal osteomyelitis mimicking tuberculosis: A case report

Abstract

Background: Isolated cryptococcal osteomyelitis of the spine is extremely uncommon; there have been only seven cases identified in literature. The majority were originally misdiagnosed as tuberculosis. Here, we present a patient with cryptococcal osteomyelitis of the thoracic spine with associated fungal retinal deposits. Case Description: A 45-year-old, type II diabetic female presented with a 5-month history of severe back pain. Her magnetic resonance imaging (MRI) revealed osteomyelitis involving the T4 vertebral body with epidural and prevertebral extension; notably, the intervertebral disc spaces were not involved. Although the fine-needle aspiration cytologic examination was inconclusive, the patient was empirically placed on antitubercular drug therapy. One month later, she became fully paraplegic. The MRI now demonstrated osteolytic lesions involving the T4 vertebral body with cord compression. She underwent biopsy of the T4 vertebral body and a transfacet T4 decompression with T2-T6 pedicle screw fixation. Culture and histopathological examinations both documented a cryptococcal infection, and she was placed on appropriate antifungal therapy. Notably, 3 weeks after surgery, she developed a sudden loss of vision loss due to retinal fungal endophthalmitis. She recovered vision in one eye after the administration of intravitreal voriconazole but lost vision in the other eye despite a vitrectomy. Over the next 8 months, she gradually recovered with motor function of 4/5 in both lower extremities without evidence of recurrent disease. Conclusion: Cryptococcal infection should be among the differential diagnostic considerations for patients with vertebral osteomyelitis. Notably, diagnostic delay can lead to devastating neurological deficits and involvement of other organ systems.

Cryptococcal meningitis presenting as anterior spinal cord syndrome with accessory nerve palsy in immunocompetent patient: A case report

“…First-line of treatment is medical with antifungal drugs, with in consensus with international guidelines, amphotericin followed by treatment with azoles for 12 months or more, presents a partial or total recovery of lost functions. [ 1 , 2 , 7 , 9 , 10 ] In our case, in addition to the previously mentioned treatment, surgery was needed to solve the compression produced by meningeal thickening and cystic formations at the bulbomedullary level, causing significant deterioration of both the ascending and descending pathways, as well as the cranial nerves. The diagnosis was definitively established by histopathological study.…”

“…It is caused by Cryptococcus neoformans and Cryptococcus Gattii , the first is associated with immunocompromised patients due to organ transplantation, especially in patients with advanced HIV disease and low CD4 cell count, and the second is more commonly associated with immunocompetent patients. [ 2 , 5 , 7 , 9 , 11 ] This fungal disease occurs in 10–20% patients without detectable immunocompromising factors[ 1 , 10 ] and has a mortality of 35–50% due to delay in diagnosis and treatment. [ 8 ]…”

Pulmonary and Extrapulmonary Manifestations of Fungal Infections Misdiagnosed as Tuberculosis: The Need for Prompt Diagnosis and Management

“…The clinical features of pulmonary cryptococcosis may mimic pulmonary TB resulting in misdiagnosis of cases especially in areas highly endemic for TB including Asia and Africa [ 39 , 42 , 43 ]. In addition, abnormal radiologic findings in cryptococcal disease including nodules, pulmonary infiltrates, pleural effusions, hilar lymphadenopathy, lung cavitation and osteolytic lesions are also found in TB [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Furthermore, in the absence of India ink, the large encapsulated yeast may be mistaken for lymphocytes in CSF microscopy.…”

Isolated cryptococcosis of a lumbar vertebra in an immunocompetent patient: A case report and literature review

“…Unfortunately, the full text of three of the articles could not be found. Upon reviewing the 14 published studies, we found 14 cases (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). The clinical features of cryptococcal spine lesions were atypical.…”

“…Fever, cough, pain at the infected site, and radiating pain were the most common symptoms. Incontinence of urine and faeces and full paraplegia occurred in some severe cases (10,13,14). The above symptoms are similar to those of spinal tumours and spinal tuberculosis.…”