INTRODUCTION

Candida infections are increasing due to the growth of predisposing factors such as neutropenia, prior receipt of broad-spectrum antibiotics, prolonged corticosteroids or intravascular catheters[1]. Also, repeated Candida infection is increasing[1],[2],[3]. Infections such as Candida endocarditis or oropharyngeal candidiasis are well recognized to recur despite antifungal therapy[4],[5]. But, few data exist on candida spondylodiscitis following bloodstream Candida infection. We report on a rare case of Candida spondylodiscitis after candidemia.

CASE

A 66-year-old woman to have been underwent chemotherapy (Carboplatin-Paclitaxel) for ovarian cancer was diagnosed with candidemia associated with the central venous catheter. Ocular candidiasis also diagnosed but, there was no evidence of endocarditis. Ocular involvement was confirmed only in the vitreous body. The catheter was removed, and antifungal agent (fluconazole) was administrated until two weeks after no detection of fungus in the blood culture. The doe of fluconazole was 400 mg/day and total duration of fluconazole use was 5 weeks. Then, after the Chemoport® insertion, the 4th chemotherapy for ovarian cancer was performed. Neutropenic fever occurred after the 4th chemotherapy. Blood cultures were negative and piperacillin-tazobactam was administrated. The number of neutrophil was recovered and no more fever was identified. There was no complication during the 5th and 6th chemotherapy. But, she was hospitalized after the 6th chemotherapy because of abdominal pain and diarrhea. Computed tomography (CT) scans of abdomen demonstrated non- specific colitis. Abnormal finding was not identified in the spine (Fig. 1). Pseudomembranous colitis (PMC) was diagnosed through sigmoidoscopy. After metronidazole administration, she was improved and discharged. But, she revisited after 2 weeks due to severe back pain and fever. Magnetic resonance image (MRI) demonstrated spondylodiscitis on the 10th~11th thoracic spine with epidural abscess (Fig. 2). But, it was negative study in culture from vertebral bone biopsy and blood, so second generation cephalosporin (cefoxitin) was administrated. However, the infection was worsen on follow-up MRI study after a month (Fig. 2). Open curettage and spinal stabilization was performed (Fig. 3). C. albicans was identified. The isolate was sensitive to amphotericin B, caspofungin, fluconazole, flucytosine and voriconazole. Eye examination was per- formed, but ocular candidiasis was much improved. Fluconazole was administrated intravenously for two months and the patient was discharged. Additional oral fluconazole was administrated. The dose was 400 mg/day. Total duration of fluconazole was 4 months. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were normalized at 6 weeks after using oral fluconazole. The back pain was improved and there was no neurologic deficit. The follow-up x-ray image showed no significant difference from the initial postoperative image, and there was no evidence of spondylodiscitis aggravation.

DISCUSSION

The contamination routes of infective spondylitis were generally known to hematogenous spread, spread from contiguous infected tissue, direct inoculation or post-operative infection[6]. In our case, we suspected that the spondylodiscitis happened through the hematogenous route. There were several reasons. At first, there was no infection focus to be contiguous to thoracic spines on abdomen CT scans before two weeks. Second, there was no history of penetrating wound to enable direct inoculation. Finally, there was no medical history of the invasive procedure or the surgery at the thoracic spine. So, this spondylodiscitis might result from bloodstream infection of C. albicans.

Candida spondylodiscitis after candidemia has been rarely reported[7]. Early detection and treatment of spondylodiscitis was important because that caused severe disability such as paraplegia. Early symptom of spondylodiscitis was simple back pain. However, because simple back pain was relatively a common symptom, so it was easy to overlook. Thus, clinicians should be aware of this entity, if the patient who completely treated candidemia complained of back pain.

The ideal treatment of Candida spondylodiscitis has been not established. Amphotericin B has been considered as the treatment of choice, but the azoles, if susceptible, have also been used with good results[8],[9]. Miller et al recommend 4~6 weeks of intravenous amphotericin B therapy followed by oral fluconazole for 2~6 months[8]. The Infectious Diseases Society of America (IDSA) recommendations for vertebral Candida osteomyelitis include surgical debridement and an initial course of amphotericin B for 2~3 weeks, followed by fluconazole for a total duration of 6~12 months[10]. The European Society for Clinical Microbiology and Infectious Disease (ESCMID) guidelines for treating Candida spondylodiscitis recommended strongly to use fluconazole for 6~12 months if the species is susceptible, and fluconazole may be preceded by induction phase with lipid-based amphotericin B[11]. In this case, we initially administrated fluconazole intravenous for two months. Then, oral fluconazole was administrated for two months. ESR and CRP was normalized after using fluconazole for 3.5 months.

For candidemia management, many authors have emphasized the importance of intravascular catheter removal[1],[12],[13]. In the first cadidemia, we followed this principle. However, this patient's the central venous line (Chemoport®) was not removed when treating spondylodiscitis. Because other venous lines for the intravenous antifungal agent could not find due to repetitive chemotherapy and there was no evidence of the central venous line infection. There was no tenderness or redness near the central venous line and blood culture from the central venous line was negative.

CONCLUSION

We report a rare case of late onset Candida spondylodiscitis following candidemia. And, although back pain is an ambiguous symptom, clinicians should be aware of this entity if they have sustained back pain in a recently treated candidemia patient.