Isolated lumbar-4 vertebral cryptococcosis in an immunocompetent patient—A case report and literature review

doi:10.4236/crcm.2013.26094

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Vol.2, No.6, 348-350 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.26094

Isolated lumbar-4 vertebral cryptococcosis in an

immunocompetent patient—A case report and

literature review

Tanya Minasian1,2,3,4,5, Omid R. Hariri1,2,3,4,5*, Casey Corsino2, Dan E. Miulli1,2,

Saman Farr2, Javed Siddiqi1,2,3,4

1Department of Neurosurgery, Arrowhead Regional Medical Center, C o lton, USA; *Corresponding Author: [email protected]

2Division of Neurosurgery, Department of Surgery, College of Osteopathic Medicine, Western University of Health Sciences,

Pomona, USA

3Department of Neurosurgery, Riverside County Regional Medical Center, Moreno Valley, USA

4Department of Neurosurgery, Institute of Clinical Orthopaedics & Neurosciences, Desert Regional Medical Center, Palm Springs,

USA

5Department of Neurosurgery, Kaiser Permenante Medical Center, Fontana, USA

Received 11 July 2013; revised 2 August 2013; accepted 8 August 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The purpose of this case report is

to present an unusual and unique case of ver-

tebral osteomyelitis due to the organism Cryp-

tococcus neoformans, which was found to be

isolated to the fourth lumbar vertebra in an im-

munocompetent patient. Cryptotoccus neofor-

mans is an encapsulated yeast which typically

presents in severely immunocompromised pa-

tients. Vertebral osteomyelitis is most common-

ly associated with bacterial infections. Case

Description: A 51-year-old male presented with

severe pain localized to the lumbar region, and a

high grade fever for 15 days, chills, urinary hesi-

tancy, dysuria, and fatigue. The patient’s only

past medical history included Type II Diabetes

Mellitus. Neoplasms and HIV were ruled out. No

source of entry was located upon examination

and the lungs were negative for the presence of

Cryptococcal pathogen. The CT scan revealed a

lytic lesion located in the fourth lumb ar vertebral

body. A bone biopsy confirmed the presence of

Cryptococcus neoformans as the source of in-

fection. A follow up visit was also conducted to

examine the patient’s status of infection, and for

the presence of complications. Conclusion: At

this time, it is important to note Cryptococcus

neoformans can be isolated to a single vertebral

level. This case study is pivotal in demonstrat-

ing the import ance of the comprehension of rare,

and non-traumatic Cryptococcal infections in

Central Nervous System, showing also that im-

munocompetent patients are well at risk for this

infectious process.

Keywords: Vertebral Osteomyelitis; Cryptococcus;

Immunocompetent; Lytic Lesion; Isolated Infection

1. INTRODUCTION

Vertebral osteomyelitis is an infection of the vertebral

body, which can progress to abscess formation and

spread to adjacent structures hematologically. This can

ultimately lead to destruction of intervertebral discs and

vertebral bodies, possibly leading to eventual spinal ins-

tability, vertebral body collapse, and neural compression.

Because the spread of the infection is typically via the

blood, multiple loci of infection are common. The most

common site of infection is the lumbar spine, with a rate

of 45% - 55%, followed by thoracic, cervical, and sacral

regions [1]. The most common organisms found in ver-

tebral osteomyelitis are Staphylococcus aureus and co-

agulase negative staphylococci, and occurrences are rare-

ly caused by fungal and parasitic infections [1,2].

Cryptococcus neoformans is a budding yeast sur-

rounded by a polysaccharide capsule that contains anti-

genic determinants permitting identification. It is distri-

buted worldwide, existing in nature as a soil saprophyte,

and is most commonly found in roosting sites of birds,

particularly pigeons [3]. Infection results from inhalation

of spores, which germinate in pulmonary tissue and may

T. Minasian et al. / Case Reports in Clinical Medicine 2 (2013) 348-3 50 349

disseminate via the bloodstream to the brain, meninges,

bone marrow, and skin. Bone involvement, usually os-

teolytic, is documented in 5% - 10% of patients with

cryptococcal infection. Differential diagnosis must be

determined to rule out neoplastic lesions or osseous tu-

berculosis [4-6]. Moreover, diabetes mellitus can in-

crease incidence rates of infection with Cryptococcus

neoformans. This infection is common in adults with an

average age of 60 to 62 years old, affecting males more

so than females, with a predominance of 55% - 75% [1].

The yeast is known for its opportunistic infection, es-

pecially in those who are immunosuppressed and immu-

nocompromised. Infection in the United States prior to

1980 with Cryptococcus neoformans was less than one

case per million persons per year. In the 1980’s during

the AIDS epidemic, the incidence in creased to 5% - 10%

of AIDS patients. With advances in antiretroviral therapy,

the annual incidence rate has decreased to seven cases

per 1000 people in the year 2000 [7]. It is very rare for

immunocompetent patients to be afflicted with this

disease, with amounts estimated to be 0.2 per million per

year [2]. There have been few documented cases re-

porting thoracic vertebral cryptococcus with cord com-

pression [8]. However, to our knowledge and extensive

research, there have been no previously documented

presentations of an isolated lumbar vertebral crypto-

coccosis [9].

We are reporting a case of an unusual presentation of a

pathologically proven case of isolated cryptococcosis

infection to a single level lumbar vertebral body in an

immunocompetent patient.

2. CASE REPORT

A 51-year-old Pakistani male presented with low back

pain and fever for 15 days associated with chills and

night sweats. Other symptoms reported include urinary

hesitancy, dysuria, and fatigue. He described the severity

of his pain as 10/10, sharp, increasing with movement,

and located in the mid-lumbar region. However, he

denied any weight loss, headaches, dizziness, blurred

vision, cough, or nasal discharge. He also denied sore

throat, neck stiffness, chest pain, hematuria, or loss of

balance. The patient denied pain, paresthesias, or weak-

ness radiating into the bilateral lower extremities, saddle

anesthesia, or bladder or bowel incontinence.

The patient’s past medical history was significant for

Type II Diabetes Mellitus for ten years and he had been

on Metformin. The patient reported chewing tobacco for

16 years with no use in the previous 10 years. The patient

lived in Virginia and was employed as a truck driver.

Patient denied illicit drug us e.

Upon physical examination, the patient was awake,

alert, and oriented to person, place, time, and event. Vital

signs were stable except sinus tachycardia. No lympha-

denopathy was noted. His exam was significant for

tenderness to palpation along Lumbar 2, 3, 4 spinous

processes with no tenderness to percussion. Normal

muscle tone was present, and no atrophy noted. No evi-

dence of trauma to the lumbar region. He had 5/5 muscle

strength bilaterally in his upper and lower extremities.

Normal deep tendon reflexes were noted, without any

long tract signs. Rectal exam was intact.

Differential diagnosis for a 51-year-old immunocom-

petent male presenting with an isolated lumbar vertebral

body lytic lesion must include an infectious etiology, but

given the location of the lesion in addition to the pa-

tient’s complaint of urinary hesitancy/urgency, a meta-

static lesion from the prostate to the vertebral body must

be excluded.

Laboratory workup revealed a WBC count of 8.2, HgB

of 14.1, Hct of 42.1, and Platelet count of 240. ESR and

CRP values were elevated, 77 and 4.26, respectively. His

tumor markers (AFP, CEA, CA 19-9, CA 125, B-HCG,

and PSA) were all neg ative. His HIV and Hepatitis p anel

were also negative. Blood cultures were negative on

three separate occasions. His urinalysis was positive for

2+ glucose but urine culture was ne gat i ve.

CSF was clear with WBC 61, RBC 3, Lymphocytes

100, Glucose 92 and Protein 81. His Cryptococcus anti-

gen, Histoplasmosis, and India Ink all came back nega-

tive. Microbiology culture was po sitive for Cryptococcus

neoformans. The patient was found to have a negative

protein electrophoresis for multiple myelo ma.

A CT chest/abdomen/pelvis was performed and no

masses or other sources of primary neoplasm were iden-

tified. Other studies including dedicated spine CT were

performed and a lytic lesion was identified in the L4

vertebral body. There was no evidence of canal compro-

mise on MR imaging. An Interventional Radiology CT

guided L4 vertebral lytic lesion biopsy was performed.

Microsections demonstrated diffuse acute and chronic in-

flammatory exudate with non-caseating granulomas. No

normal hematopoiesis tissue was present. There were nu-

merous small to intermediate size encapsulated yeast

forms occurring singly and occasionally as narrow-based

budding yeasts. The microorganisms were morphologi-

cally suggestive of Cryptococcus by fungal stain (GMS

with adequate controls) (Figure 1).

3. DISCUSSION

Certain predisposing factors make the vertebral co-

lumn a suitable site for infection, including the lack of

epiphyseal growth, voluminous, yet slow blood supply,

and the presence of bone marrow within the vertebral

body. Approximately 40% of the cases of vertebral os-

teomyelitis lack an obvious port of entry [1].

Cryptococcus can infect any organ in the body, but has

a predilection for the lung and central nervous system

T. Minasian et al. / Case Reports in Clinical Medicine 2 (2013) 348-3 50

350

Figure 1. The above photograph is the result of the patient’s

biopsy from the IR guided L4 vertebral body lytic lesion. Mic-

rosections demonstrate diffuse acute and chronic inflammatory

exudate with non-caseating granulomas. No normal hemato-

poiesis tissue is present. There are numerous small to inter-

mediate size encapsulated yeast forms occurring singly and oc-

casionally as narrow-based budding yeasts. The microorganisms

are morphologically suggestive of cryptococcus by fungal stain

(GMS with adequate controls).

and travels via the bloodstream [7] . S ympt oms c an ran ge

from asymptomatic colonization to severe pneumonia.

Cryptococcal vertebral infection can be treated medi-

cally with anti-fungal agen ts including a six week course

of amphotericin B, fluconazole, and flucytosine [10].

Biopsy with demonstration of the infectious organism is

the gold standard for diagnosis. Approximately only

30.4% of patients who have radiographic evidence of

infection will have positive blood cultures [11]. Surgical

intervention is only warranted if there are neurological

symptoms indicating cord compression [1]. In immuno-

competent patients, relapse of infection has not been

documented to our knowledge. However, in immuno-

compromised and immunosuppressed persons, relapse is

common. Long-term maintenance treatment with fluco-

nazole has prevented relaps e in patients with AIDS [8].

4. CONCLUSION

The patient presented in this case study returned for a

follow up visit post treatment of a six week course of

intravenous amphotericin B, fluconazole, and flucytosine

and was found to have no signs of recurrent infection or

complications. Upright X-rays were not suggestive of

any vertebral column instability. The pain had improved

and the patient was doing well. There have been no other

documented cases of isolated cryptococcal infection in-

volving only a single vertebral bod y in the lumbar verte-

bral region.

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