Treatment of a Chronic Scedosporium apiospermum Vertebral Osteomyelitis

John W. German, M.D.; Susan M. Kellie, M.D.; Manjunath P. Pai, Pharm.Dc.; Paul T. Turner, M.D.

Disclosures

Neurosurg Focus. 2004;17(6) 

In This Article

Abstract and Introduction

Scedosporium apiospermum is a rare cause of fungal vertebral osteomyelitis that may result in chronic infection requiring multiple surgical interventions and long-term medical therapy. This case is the seventh one reported in the literature and is the first to include salvage surgery of a previous major spinal reconstruction. This report is also the first to describe the use of the new antifungal agent voriconazole. In treating this case of chronic vertebral osteomyelitis, several principles are emphasized from both the surgical and medical perspectives. From a surgical perspective, the use of salvage surgery, temporary avoidance of spinal instrumentation, and an appropriate choice of graft materials are emphasized. From a medical perspective, confirmation of the diagnosis, the need for long-term antifungal therapy, the need for long-term patient compliance, and the use of the new antifungal agent voriconazole are emphasized. Application of these principles has led to an adequate 2-year outcome.

Scedosporium apiospermum and Sc. prolificans are the two organisms responsible for scedosporiosis.[19,20] The recognition of these rare human fungal pathogens is important because both are resistant to a variety of antifungal agents. The microorganism Sc. apiospermum is the anamorphic or asexual form of the ubiquitous saprophytic fungus Pseudallescheria boydii. Previously these organisms have been referred to as Monosporium apiospermum, P. sheari, Allescheria boydii, and Petriellidium boydii.[19]

The most common clinical manifestations of Sc. apiospermum infection are chronic cutaneous mycetoma, also known as "Madura foot," and pulmonary infection.[6,19,20] The latter often occurs in the setting of previous tuberculosis.[6,8,11] This association may confound diagnosis and delay appropriate treatment. Other infections associated with this organism include sinusitis, arthritis, and extremity osteomyelitis.[20] Uncharacteristic sites of infection include the central nervous system and the spine.[4,5,6,8,11,12,20]

Six cases of Sc. apiospermum vertebral osteomyelitis have been described in the literature.[4,5,6,8,11,12] These cases are challenging in that they may evolve into a chronic, indolent infection that fails to respond to traditional antifungal agents. Management requires a multidisciplinary approach featuring surgical intervention for debridement, diagnosis, and spinal stabilization to preserve neurological function and/or spinal stability.

In this report we describe the clinical features, diagnosis, and management of the disease in a patient with a chronic, previously treated thoracolumbar osteomyelitis from an Sc. apiospermum infection.

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