Volume VI, Number 1 | March 2022

Bilateral Foot Drop in the Setting of a Rare Disseminated Aspergillus Spinal Epidural Abscess

1. Anthony Kamson DO – University of Pittsburgh Medical Center – Pinnacle
2. David Phillips DO – University of Pittsburgh Medical Center – Pinnacle
3. Curtis Goltz DO – Orthopedic Institute of Pennsylvania

KEYWORDS: Disseminated, Aspergillus, Epidural Abscess, Foot Drop, Back Pain, Decompression, Osteodiscitis, Fungus

INTRODUCTION: The diagnosis of a spinal epidural abscess (SEA) as the cause of low back pain and lower extremity weakness is rare. However, in recent years, the occurrence of SEAs has increased secondary to higher IV drug use, increased spinal instrumentation, an aging population, and advances in chemotherapeutics (1,2,4). The majority of SEAs are due to bacteria such as Staphylococcus Aureus, although fungal organisms such as Candida and Aspergillus may be responsible in the immunocompromised host (7).

We present a case of an immunocompetent patient who developed a lumbar epidural abscess secondary to Aspergillus. In the current literature there appears to be less than 50 cases reported, with the majority of these occurring outside of the United States (8).

CASE REPORT: 64-year-old male presented to the general medical floor with bilateral foot drop for 1 month duration. He was recently discharged from an outside facility after being diagnosed with L3-4 osteodiscitis and undergoing treatment with IV antibiotics and PO voriconazole. Bone biopsies were negative. Over the following month, he rapidly lost his ability to ambulate independently. He denied any bowel or bladder changes, fever, and chills. Past medical history was significant for immune thrombocytopenic purpura treated with IVIG and long-term prednisone which was discontinued 3 months prior and a lung aspergilloma treated with VATS and IV antibiotics/antifungal 1 year prior. Labs on presentation were WBC 17.4, CRP 11.8 (0-1 mg/dL), ESR 105 (0-20 mm/hr). An MRI Brain demonstrated a focal 1 cm density in the left frontal lobe. CT Chest/Abdomen/Pelvis was significant for an aspergilloma in the right upper lobe. MRI of the lumbar spine demonstrated L3-4 discitis with an epidural abscess measuring 7 cm x 2.4 cm x 0.9 cm with severe thecal sac effacement with the abscess extending into bilateral neural foramen, diffuse nerve root enhancement, possible intrathecal spread of infection. He subsequently underwent an urgent L3-S1 decompression, intraoperatively a hypertrophic ligamentum flavum was engorged with pus, and hour-glassing of the spinal canal was noted. Postoperatively, he progressed with physical therapy and there was noted improvement of neurologic status. He was successfully discharge to a rehab facility. He later underwent a posterior L3-S1 decompression with instrumented fusion performed at an outside hospital 5 months later. No operative notes are available. He as well completed courses of IV Voriconazole, PO Voriconazole, IV Micafungin and started on chronic Isavuconazole

DISCUSSION: Given the high morbidity and mortality associated with fungal spinal infections, it remains paramount to effectively treat these patients. Surgical intervention may ultimately be necessary in the setting of new or progressive neurologic deficits. Early identification of a spinal abscess pathogen is essential to provide appropriate treatment. There needs to be a high index of suspicion of Aspergillus in order to start the necessary empiric medications while awaiting culture results (4,6-8). Studies have shown that even in rare cases, an Aspergillus spinal epidural abscess can appear in immunocompetent patients

Aspergillus remains a rare cause of infection, most commonly presenting itself in the immunocompromised patient. These patients can include those with malignancy, diabetes, organ transplants, or acquired immunodeficiencies. Invasive aspergillosis classically affects the pulmonary system, possibly appearing as an aspergilloma. It has been estimated that invasive aspergillosis affects bone in only 3% of cases (6).

CONCLUSION: Fungal discitis associated with a spinal epidural abscess is a rare condition, complicated by high morbidity and mortality if not treated promptly. Early definitive diagnosis remains challenging given the non-specific radiologic features of a fungal abscess. Therefore, early anti-fungal coverage should be considered in all patients, whether immunocompromised or immunocompetent. Surgical biopsy can help establish the diagnosis and ensure proper treatment.

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5


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The Journal of the American Osteopathic Academy of Orthopedics

Steven J. Heithoff, DO, FAOAO

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Authors in This Edition

J. Michael Anderson BS, OMS IV
Rigel Bacani BA, BS, OMS II
David Beckett OMS I
Bhakti Chavan MBBS, MPH
Jake Checketts DO
Grant Chudik OMS II
Adam Dann
Marc Davidson MD
Clinton J. Devin MD
Jeffrey Dulik DO
Bryan Dunford BS, OMS II
Diego Galindo DO
Gregory Galvin DO
Curtis Goltz DO

Jordan Grilliot DO
Brian Handal
Safet Hatic
Scott Dean Hodges DO
David Houserman DO
Jenna Jarrell MS IV
Michael Jones DO
Anthony Kamson DO
Tyler Metcalf MS IV
Anna Elisa Muzio DO
Cesar Cornejo Ochoa OMS I
Brandi Palmer MS
Joseph Patrick
David Phillips DO

Jonathan Phillips MD
Kornelis Poelstra MD
Jesse Raszewski DO, MS
Katherine Sage DO
Steven Santanello DO, FAOAO
Jared Scott DO
Julieanne Sees
James Seymour DO
Jonathan Schneider DO
John Alex Sielatycki MD
Benjamin Taylor MD, FAAOS
Trevor Torgerson BS, OMS IV
Phong Truong DO
Matt Vassar PhD