A 54‐year‐old African American woman with a history of hypertension and intravenous drug abuse presented to the emergency room with a 2‐month history of lower back pain and new onset right lower leg radicular pain and paresthesias. The patient had an emergent lumbosacral MRI revealing inflammatory changes at L4–L5 and L5–S1 worrisome for osteomyelitis and discitis. The patient was immediately underwent right L5 hemilaminectomy and right L5–S1 foraminotomy with microdiscectomy and disk biopsy. Despite initiation of empiric antibiotics consisting of vancomycin and ceftriaxone to cover for common bacterial causes, the patient was persistently tachycardic (130s–140s) and continued to spike intermittent fevers with a normal white blood cell count. On day five, the surgical cultures came back positive for Candida krusei. The patient was started on IV micafungin 100 mg daily and oral voriconazole 200 mg twice a day. Soon after starting these antifungals, her tachycardia and fevers resolved. In addition, her right lower leg radicular pain and paresthesias started to improve. Blood fungal cultures were negative, and ophthalmic exam was negative for evidence of Candida endophthalmitis. Echocardiogram did not show evidence of endocarditis. It is suspected that the patient contracted C. krusei through contaminated intravenous needles and the organism seeded her intervertebral space.
Candida species are an important cause of vertebral osteomyelitis in high‐risk individuals. Risk factors include being immunocompromised, having indwelling central venous catheters, recently received broad‐spectrum antibiotics, and injection drug use. It is suspected that the patient contracted C. krusei through contaminated intravenous needles and the organism seeded her intervertebral space. Since 1970, the reported cases of Candida osteomyelitis has steadily increased. It is important to note that non‐albicans Candida species are responsible for 35% of the infections. Review of the published literature revealed only 3 cases of Candida krusei vertebral osteomyelitis.
Although there are no formally published guidelines regarding empiric vertebral osteomyelitis treatment, this cases highlights the consideration for empiric antifungal coverage in high‐risk patients with osteomyelitis not responding to traditional antibacterial coverage. Since there is some non‐albicans Candida, consider adding eichinocandins as empiric antifungal therapy until final speciation is available. Surgical drainage and obtaining cultures from the disc space and the bone remain critical to guide targeted antimicrobial therapy as illustrated in this case. Based on the improvement in the pt's symptoms, we would also like to propose that 6‐month therapy of voriconazle and micafungin is a potential treatment option. IDSA guidelines currently recommend 6‐–12 months of antifungal therapy for Candida osteomyelitis due to difficulty eradicating this organism and high risk of relapse.
To cite this abstract:Shah C, Stal D, Weatherhead J, Yasukawa K, Arya M. Lumbosacral Osteomyelitis Caused by Candida Krusei: A Case Report. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 460. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/lumbosacral-osteomyelitis-caused-by-candida-krusei-a-case-report/. Accessed April 5, 2020.