We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy.

Retrospective data analysis.

A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor.

During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac.

The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery.

Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment.

Osteomyelitis is usually related to trauma, surgery, immunocompromised patients, IV drug abuse, poor vascular supply, diabetes, sickle cell disease or peripheral neuropathy. We report an unusual case of femur osteomyelitis without any of these risk factors.

A 31 years old male, light smoker, presented at the Emergency Room for pain in the left thigh for about a month, without any previous event. He had 2 previous visits to the hospital with similar diffuse complaints interpreted as irradiated low back pain. He was pale, feverish but no signs of local inflamation. His left knee ROM was 30°-15°-0°. He had no neurologic deficits. Blood tests showed high WBC count and PCR (400mg/L). After contrasted CT showing an 1,2×6×2,5cm abcess the patient was taken to the OR for irrigation and debridment.

The day after the patient did a MRI that showed extended femur osteomyelitis and adjacent myositis (images). He underwent new surgery for a more extensive irrigation and debridment, femur medular canal included, from where a large pus quantity erupted.

The hemocultures and bone biopsys, revealed a Multissensible Strep. Alfa-hemolitic (S. anginosus) and appropriate antibiotherapy was implemented (Amoxicillin/Clavulanate). He slowed improve till 11th day when he showed rise of PCR and a new MRI showed the same inflammatory process. He underwent new surgery but no pus was visible. He gradually improved, started hyperbaric oxygen therapy and was discharged on the 28th day after the first surgery, continuing antibiotherapy at home for a total of 8 weeks.

Transthoracic Ecography was normal, as well Brucella, HIV, and other serologies.

Three weeks later, the patient again presented to the ER with fever and rise of inflammatory markers in blood, consistent with recurrence of the infection. The patient was taken to the OR for surgical debdridment and irrigation, but this time the cultures showed a multissensible Gemella haemolysans, possible contamination during the hyperbaric oxygen therapy sessions.

This is the case of a healthy young adult with an idiopathic femur osteomyelitis, initially misinterpreted for irradiated low back pain, that recurred after the first medical and surgical successful treatment, with an unusual agent.