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Osteomyelitis of the spine in a burn patient due to Candida albicans
174
Bums (1993) 19,(2), 174-176 Printed in Great Britain
Osteomyelitis of the spine in a burn patient due to Candida albicans R. F. Mullins, J. M. Still Jr, J. Savage, J. B. Davis and E. J. Law Humana Hospital Center, Augusta,
Georgia, USA
A 38-year-old white-skinned male was burned in an ulfralighf plane crash and sustained a 59 per cent body surface area burn, mostly full thickness skin loss. A fracfure of the first lumbar vertebra was noted at admission which was treated without surgery. Candida sepficaemia was diagnosed and freated dun’ng the acufe phase of injury. Extensive grafting was required. Following discharge, the pafienf began expwiencing low-grade back pain which was aggravated on postbum day 2 77 by a fall down a fhght of stairs. Spinal radiographs obtained following this fall revealed osfeomyelifis at the level of the eighth and ninth vertebrae with an intervertebral abscess. Following evacuation of the disc space during surgery, the organism was identified as Candida albicans. Treatment with amphofericin B and later fluconawle was initialed. Recovery was uneventful. The infecfion, probably of a haemafogenous origin, is the first such case reporfed in the literature to our knowledge.
Introduction Patients with bums are immunocompromised. They are frequently at risk from fungal infections, the most common of which is Can&da albicans (Becker et al., 1991). In non-bum cases, candida has been reported in scattered cases involving joints and bone, usually in immunocompromised patients but not previously in bum patients. In a literature review of cases of candida infection with osseous involvement, Fainstein et al. (1982) reported 19 cases in adults and 21 in children. The most commonly involved joint was the knee. A few isolated cases with involvement of the spine due to candida infection have been reported. To the best of our knowledge, this is the first reported case of Cundidu u&cans of the spine in a patient who had previously sustained extensive bums and candida septicaemia.
Case report A 38-year-old white-skinned male was burned in an ultralight plane crash. The patient was stabilized at another facility and subsequently transferred to Humana Hospital Bum Center in Augusta, Georgia. His past medical history and review of systems were only remarkable for heavy smoking and alcohol ingestion. Physical examination revealed a heavily sedated, orotrachealintubated, unresponsive, white-skinned male with extensive bums covering the face, neck, chest, abdomen, back, arms, buttocks, and patchy bums to the left lateral leg and right lower leg. The bum size was estimated to cover 59 per cent of the body surface, most 0 1993 Butter-worth-Heinemann 0305-4179/93/020174-03
Ltd
of which was full skin thickness bum. An inhalation injury was present. Shortly after admission, the patient received topical Travase and Silvadene to the left arm. Basic Dakin’s soaks were applied to all other burned areas. Fluid resuscitation was carried out uneventfully with Ringer’s lactate and Plasmanate. A tracheostomy was performed shortly after admission. Escharotomies and fasciotomies of the right arm and hand were performed. Cervical and thoracic spine films obtained on admission demonstrated no fractures. Lumbar spine films revealed a 25 per cent compression fracture of the first lumbar vertebral body. A CT scan showed a comminuted fracture with a fragment from the posterior aspect of the vertebral body displaced posteriorly in the spinal canal. Motor examination was intact to the lower extremities. No surgical intervention was carried out, the patient received bedrest and was turned only by log rolling. Ten operative procedures for debridement and grafting of the wounds were ultimately performed to achieve wound healing. Methicillin-resistant Stuphylococcus aurew was isolated in the bum wounds at this time, and i.v. Vancomycin was prescribed. On postbum day 19, blood cultures as well as bum wound cultures revealed C. albicans. Amphotericin B was given systemically. He received a total of 990mg of amphotericin B over a 35-day period. Adult respiratory distress syndrome developed on postburn day 25 which was attributed to the yeast septicaemia. On postbum day 27, acute renal failure developed and dialysis was begun 2 days later. Blood cultures remained positive for C. albicans until postbum day 32. Examination of the eyes revealed no evidence of candida endophthalmitis. On postbum day 53, a follow-up CT scan revealed that the spinal canal was less compromised. Another CT scan of the lumbrosacral spine on postbum day 102 revealed a stable Ll fracture. He was gradually weaned off the ventilator, and dialysis was discontinued. On postbum day 80, the patient began increased activity with a tortoise shell brace, and 7 days later he began ambulating. On postbum day 92, a follow-up CT scan indicated possible Neurosurgical consultation was developing hydrocephalus. obtained, and no surgical intervention was felt to be indicated. The patient was followed for development of normal pressure hydrocephalus. By postbum day 110,the patient was doing well and was discharged to a private home. On postbum day 127, he was seen as an outpatient. On postbum day 152, the patient seemed to have recovered well from his lumbar fracture. At this time, he was
Mullins et al.: Osteomyelitis
of the spine
175
Figure 2. CT scan reveals intervertebral soft tissue reaction (arrow).
defect with surrounding
Thorough irrigation of the wound with antibiotic solution and saline was performed. The wound was closed in layers, and chest tubes were brought out through separate stab wounds. The postoperative course was uneventful. He was free of back pain immediately and was protected with a polyethylene body jacket. All cultures grew large amounts of C. albicans. Antibiotics were stopped, and amphotericin B was begun. Shortly thereafter, the patient began to lose potassium and had difficulty in maintaining an adequate serum potassium level. Ultimately the amphotericin B was discontinued and replaced with Diflucan (fluconazole). His wound healed uneventfully. On postburn day 321, the patient had no further complaints of back pain and was discharged from the hospital on’Slow-K for potassium replacement. He has subsequently done well. Figure 1. X-ray reveals intervertebral postbum day 270.
defect at T8 (arrow) on
Discussion Cundidlz &cuns
has long been the most common fungal bum patients. This significant risk has been reported by Becker et al. (1991) and MacMillan et al. (1972). Therefore, it should not be surprising that haematogenous candida osteomyelitis might occur in burn patients, but no examples appear to be cited in the literature. Spinal involvement by candida appears to be quite rare, and to our knowledge, candida osteomyelitis of the spine has not been previously reported in a burn patient. In the review by MacMillan et al. (1972), 271 of 427 infection
instructed to discontinue his brace. In the following month, he began experiencing low-grade back pain which gradually worsened. On postburn day 277,the patient fell down a flight of stairs aggravating his back pain to the point that it rendered him inactive. He was seen as an outpatient by an orthopedist. Spinal radiographs revealed the possible development of an osteomyelitis at the eighth and ninth thoracic vertebrae. On postbum day 290, the patient was readmitted to the hospital for evaluation and treatment. Osteomyelitis of the vertebral bodies of the eighth and ninth thoracic vertebrae, and mediastinal widening suggestive of infectious infiltrative change was present on X-ray and CT scan (Fiyllres 1.2). Bacterial osteomyelitis was suspected. The patient was hospitalized and Azactam and vancomycin were ordered. At postbum day 2%. he was taken to surgery and placed in the right lateral decubitus position. A left thoracotomy was performed between the eighth and ninth ribs. A fusiform swelling was noted about the vertebral column. Entering the interspace between the eighth and ninth vertebrae, there was a small amount of milky fluid and a moderate amount of degenerated fragments of cartilage and bone. This material was cultured and submitted to pathology. The eroded end-plates were curetted and debrided sharply back to normal bleeding bone. A tricortical bone graft from the left iliac crest was obtained and packed tightly into the interspace.
involving
acutely burned patients were examined and found to have positive cultures for candida organisms at some site. Positive
blood cultures were present in 22 individuals, and disseminated candidiasis was found at autopsy in 14 of 65 patients who expired. In a review of autopsy material by Law et al. (1972), of 15 autopsies in which disseminated candida was felt to be the cause of death, cardiac candidal lesions were found in six, pulmonary lesions in eight, renal lesions in nine, intracranial involvement- in six, eschar involvement in eight, liver involvement in 12, and splenic involvement in all 15. Involvement of the bone marrow was present in seven of the eight patients in whom this was studied. Candida is not a common cause of osteomyelitis or pyarthrosis, but it has been reported previously. DuPont and Drouhet (1985) found 10 of 36 patients who were drug abusers
had osteoarticular
involvement.
In only
seven
of
these 10 patients was C. ulbicms isolated, the knee being the most
commonly
involved
joint.
In the one patient-
in the
Burns (1993) Vol. 19/No.
176
review, with spinal involvement, no organisms were identified. All were treated with oral ketoconazole, at least initially. A patient with involvement of the knee due to Candida tropic& was reported by Ferrell et al. (1977), and another patient with involvement of the knee by C. albic~ns has been reported by Umber et al. (1974). Candida infection involving the sternum and costicartilage has been reported by Thomas et al. (1976). Four patients with C. &cans osteomyelitis have been reported in cancer patients by Fainstein et al. (1982), all involving the knee. They also reviewed the literature reporting 19 examples of osteomyelitis in adults and 21 in children. In their review of the literature, the knee was the most commonly involved joint, being implicated in 15 instances. None of their reported cases involved the spine. Spinal involvement due to proven candida organisms does occur. In a letter to the Annals of Infernal Medicine, Candida g&eromondi of the cervical spine was reported by O’Connell et al. (1973). In a review by Holzman and Bishko (1971) four cases of osseous candidiasis were reported, with one involving the lumbar spine due to Candida sfellufoideu. All of the above cases were assumed to be of haematogenous origin. As indicated in the literature review, candida is not a
common cause of blood-borne osteomyelitis. In those patients where it does occur, there are often predisposing factors such as drug abuse and cancer. Our patient was a heavy user of alcohol, in addition to sustaining a severe bum. He had C. ulbicuns septicaemia early in his acute bum course which was treated with a full course of amphotericin B. He was then discharged with what was felt to be a complete recovery. The patient had also sustained fractures of the spine which were diagnosed at the time of his original injury; however, the spinal fracture was in the lumbar spine, not the thoracic spine area where the osteomyelitis developed. The diagnosis of late osteomyelitis was made when evaluation for back pain was carried out by the orthopaedist. The anticipated finding was a problem related to healing of his fractures and a recent fall. Instead, a lytic lesion was seen in the spinal column. Surgical intervention revealed an abscess which subsequently yielded C. &cans on culture. This was treated by debridement and packing with bone chips, and a second course of systemic
antifungal agents. Recovery has Candida osteomyelitis may complication following candida when treated with a full course
2
been essentially uneventful. apparently be a rare late sepsis in bum patients, even of amphotericin B.
References Becker W. K., Cioffi W. G., McManus A. T. et al. (1991) Fungal bum wound infection: a ten year experience. Arch. Surg. 126, 44. DuPont B. and Drouhet E. (1985) Cutaneous ocular and osteoartitular candidiasis in heroin addicts: new clinical and therapeutic aspects on thirty-eight patients. 1. Infect. Dis. 152, 5. Fainstein V., Gilmore C., Hopfer R. L. et al. (1982) Septic arthritis due to candida species in patients with cancer: report of five cases and review of the literature. Rev. Infect. Dis. 4, 78. Ferrell R. B., Person D. A. and Litsky M. D. (1977) Candida tropic& arthritis: assessment of amphotericin B therapy. J. Rhetrmalol. 5, 267. Holzman R. S. and Bishko F. (1971) Osteomyelitis in heroin addicts. Ann. Intern. Med. 75, 6. Law E. J., Kim 0. J., Stieritz D. D. et al. (1972) Experience with systemic candidiasis in the bum patient. 1. Traum 12,5. MacMillan B. G., Law E. J. and Holder I. A. (1972) Experience with candida infections in the bum patient. Arch. Surg. 104, 509. O’Connell C. J., Cherry A. V. and Zoll J. G. (1973) Osteomyelitis of the cervical spine: Candida guillieromondi. Letter to the Editor. Ann. Intern. Med. 79, 748. Thomas F. E., Martin C. E., Fisher R. D. et al. (1976) Candida albicans infection of the sternum and costal cartilages: combined operative treatment and drug therapy with 5-fluorocytosine Ann. fior. Surg. 23, 163. Umber J., Chapman M. W. and Drutz D. J. (1974) Candida pyarthrosis. 1. BoneJoint Surg. 56A, 15.
Paper accepted 26 October
1992.
Correspondence should be addressed to: Dr E. J. Law, 1220 George C. Wilson Drive, PO Box 3726, Augusta, GA 30914-3726, USA.
Bums (1993) 19,(2), 174-176 Printed in Great Britain
Osteomyelitis of the spine in a burn patient due to Candida albicans R. F. Mullins, J. M. Still Jr, J. Savage, J. B. Davis and E. J. Law Humana Hospital Center, Augusta,
Georgia, USA
A 38-year-old white-skinned male was burned in an ulfralighf plane crash and sustained a 59 per cent body surface area burn, mostly full thickness skin loss. A fracfure of the first lumbar vertebra was noted at admission which was treated without surgery. Candida sepficaemia was diagnosed and freated dun’ng the acufe phase of injury. Extensive grafting was required. Following discharge, the pafienf began expwiencing low-grade back pain which was aggravated on postbum day 2 77 by a fall down a fhght of stairs. Spinal radiographs obtained following this fall revealed osfeomyelifis at the level of the eighth and ninth vertebrae with an intervertebral abscess. Following evacuation of the disc space during surgery, the organism was identified as Candida albicans. Treatment with amphofericin B and later fluconawle was initialed. Recovery was uneventful. The infecfion, probably of a haemafogenous origin, is the first such case reporfed in the literature to our knowledge.
Introduction Patients with bums are immunocompromised. They are frequently at risk from fungal infections, the most common of which is Can&da albicans (Becker et al., 1991). In non-bum cases, candida has been reported in scattered cases involving joints and bone, usually in immunocompromised patients but not previously in bum patients. In a literature review of cases of candida infection with osseous involvement, Fainstein et al. (1982) reported 19 cases in adults and 21 in children. The most commonly involved joint was the knee. A few isolated cases with involvement of the spine due to candida infection have been reported. To the best of our knowledge, this is the first reported case of Cundidu u&cans of the spine in a patient who had previously sustained extensive bums and candida septicaemia.
Case report A 38-year-old white-skinned male was burned in an ultralight plane crash. The patient was stabilized at another facility and subsequently transferred to Humana Hospital Bum Center in Augusta, Georgia. His past medical history and review of systems were only remarkable for heavy smoking and alcohol ingestion. Physical examination revealed a heavily sedated, orotrachealintubated, unresponsive, white-skinned male with extensive bums covering the face, neck, chest, abdomen, back, arms, buttocks, and patchy bums to the left lateral leg and right lower leg. The bum size was estimated to cover 59 per cent of the body surface, most 0 1993 Butter-worth-Heinemann 0305-4179/93/020174-03
Ltd
of which was full skin thickness bum. An inhalation injury was present. Shortly after admission, the patient received topical Travase and Silvadene to the left arm. Basic Dakin’s soaks were applied to all other burned areas. Fluid resuscitation was carried out uneventfully with Ringer’s lactate and Plasmanate. A tracheostomy was performed shortly after admission. Escharotomies and fasciotomies of the right arm and hand were performed. Cervical and thoracic spine films obtained on admission demonstrated no fractures. Lumbar spine films revealed a 25 per cent compression fracture of the first lumbar vertebral body. A CT scan showed a comminuted fracture with a fragment from the posterior aspect of the vertebral body displaced posteriorly in the spinal canal. Motor examination was intact to the lower extremities. No surgical intervention was carried out, the patient received bedrest and was turned only by log rolling. Ten operative procedures for debridement and grafting of the wounds were ultimately performed to achieve wound healing. Methicillin-resistant Stuphylococcus aurew was isolated in the bum wounds at this time, and i.v. Vancomycin was prescribed. On postbum day 19, blood cultures as well as bum wound cultures revealed C. albicans. Amphotericin B was given systemically. He received a total of 990mg of amphotericin B over a 35-day period. Adult respiratory distress syndrome developed on postburn day 25 which was attributed to the yeast septicaemia. On postbum day 27, acute renal failure developed and dialysis was begun 2 days later. Blood cultures remained positive for C. albicans until postbum day 32. Examination of the eyes revealed no evidence of candida endophthalmitis. On postbum day 53, a follow-up CT scan revealed that the spinal canal was less compromised. Another CT scan of the lumbrosacral spine on postbum day 102 revealed a stable Ll fracture. He was gradually weaned off the ventilator, and dialysis was discontinued. On postbum day 80, the patient began increased activity with a tortoise shell brace, and 7 days later he began ambulating. On postbum day 92, a follow-up CT scan indicated possible Neurosurgical consultation was developing hydrocephalus. obtained, and no surgical intervention was felt to be indicated. The patient was followed for development of normal pressure hydrocephalus. By postbum day 110,the patient was doing well and was discharged to a private home. On postbum day 127, he was seen as an outpatient. On postbum day 152, the patient seemed to have recovered well from his lumbar fracture. At this time, he was
Mullins et al.: Osteomyelitis
of the spine
175
Figure 2. CT scan reveals intervertebral soft tissue reaction (arrow).
defect with surrounding
Thorough irrigation of the wound with antibiotic solution and saline was performed. The wound was closed in layers, and chest tubes were brought out through separate stab wounds. The postoperative course was uneventful. He was free of back pain immediately and was protected with a polyethylene body jacket. All cultures grew large amounts of C. albicans. Antibiotics were stopped, and amphotericin B was begun. Shortly thereafter, the patient began to lose potassium and had difficulty in maintaining an adequate serum potassium level. Ultimately the amphotericin B was discontinued and replaced with Diflucan (fluconazole). His wound healed uneventfully. On postburn day 321, the patient had no further complaints of back pain and was discharged from the hospital on’Slow-K for potassium replacement. He has subsequently done well. Figure 1. X-ray reveals intervertebral postbum day 270.
defect at T8 (arrow) on
Discussion Cundidlz &cuns
has long been the most common fungal bum patients. This significant risk has been reported by Becker et al. (1991) and MacMillan et al. (1972). Therefore, it should not be surprising that haematogenous candida osteomyelitis might occur in burn patients, but no examples appear to be cited in the literature. Spinal involvement by candida appears to be quite rare, and to our knowledge, candida osteomyelitis of the spine has not been previously reported in a burn patient. In the review by MacMillan et al. (1972), 271 of 427 infection
instructed to discontinue his brace. In the following month, he began experiencing low-grade back pain which gradually worsened. On postburn day 277,the patient fell down a flight of stairs aggravating his back pain to the point that it rendered him inactive. He was seen as an outpatient by an orthopedist. Spinal radiographs revealed the possible development of an osteomyelitis at the eighth and ninth thoracic vertebrae. On postbum day 290, the patient was readmitted to the hospital for evaluation and treatment. Osteomyelitis of the vertebral bodies of the eighth and ninth thoracic vertebrae, and mediastinal widening suggestive of infectious infiltrative change was present on X-ray and CT scan (Fiyllres 1.2). Bacterial osteomyelitis was suspected. The patient was hospitalized and Azactam and vancomycin were ordered. At postbum day 2%. he was taken to surgery and placed in the right lateral decubitus position. A left thoracotomy was performed between the eighth and ninth ribs. A fusiform swelling was noted about the vertebral column. Entering the interspace between the eighth and ninth vertebrae, there was a small amount of milky fluid and a moderate amount of degenerated fragments of cartilage and bone. This material was cultured and submitted to pathology. The eroded end-plates were curetted and debrided sharply back to normal bleeding bone. A tricortical bone graft from the left iliac crest was obtained and packed tightly into the interspace.
involving
acutely burned patients were examined and found to have positive cultures for candida organisms at some site. Positive
blood cultures were present in 22 individuals, and disseminated candidiasis was found at autopsy in 14 of 65 patients who expired. In a review of autopsy material by Law et al. (1972), of 15 autopsies in which disseminated candida was felt to be the cause of death, cardiac candidal lesions were found in six, pulmonary lesions in eight, renal lesions in nine, intracranial involvement- in six, eschar involvement in eight, liver involvement in 12, and splenic involvement in all 15. Involvement of the bone marrow was present in seven of the eight patients in whom this was studied. Candida is not a common cause of osteomyelitis or pyarthrosis, but it has been reported previously. DuPont and Drouhet (1985) found 10 of 36 patients who were drug abusers
had osteoarticular
involvement.
In only
seven
of
these 10 patients was C. ulbicms isolated, the knee being the most
commonly
involved
joint.
In the one patient-
in the
Burns (1993) Vol. 19/No.
176
review, with spinal involvement, no organisms were identified. All were treated with oral ketoconazole, at least initially. A patient with involvement of the knee due to Candida tropic& was reported by Ferrell et al. (1977), and another patient with involvement of the knee by C. albic~ns has been reported by Umber et al. (1974). Candida infection involving the sternum and costicartilage has been reported by Thomas et al. (1976). Four patients with C. &cans osteomyelitis have been reported in cancer patients by Fainstein et al. (1982), all involving the knee. They also reviewed the literature reporting 19 examples of osteomyelitis in adults and 21 in children. In their review of the literature, the knee was the most commonly involved joint, being implicated in 15 instances. None of their reported cases involved the spine. Spinal involvement due to proven candida organisms does occur. In a letter to the Annals of Infernal Medicine, Candida g&eromondi of the cervical spine was reported by O’Connell et al. (1973). In a review by Holzman and Bishko (1971) four cases of osseous candidiasis were reported, with one involving the lumbar spine due to Candida sfellufoideu. All of the above cases were assumed to be of haematogenous origin. As indicated in the literature review, candida is not a
common cause of blood-borne osteomyelitis. In those patients where it does occur, there are often predisposing factors such as drug abuse and cancer. Our patient was a heavy user of alcohol, in addition to sustaining a severe bum. He had C. ulbicuns septicaemia early in his acute bum course which was treated with a full course of amphotericin B. He was then discharged with what was felt to be a complete recovery. The patient had also sustained fractures of the spine which were diagnosed at the time of his original injury; however, the spinal fracture was in the lumbar spine, not the thoracic spine area where the osteomyelitis developed. The diagnosis of late osteomyelitis was made when evaluation for back pain was carried out by the orthopaedist. The anticipated finding was a problem related to healing of his fractures and a recent fall. Instead, a lytic lesion was seen in the spinal column. Surgical intervention revealed an abscess which subsequently yielded C. &cans on culture. This was treated by debridement and packing with bone chips, and a second course of systemic
antifungal agents. Recovery has Candida osteomyelitis may complication following candida when treated with a full course
2
been essentially uneventful. apparently be a rare late sepsis in bum patients, even of amphotericin B.
References Becker W. K., Cioffi W. G., McManus A. T. et al. (1991) Fungal bum wound infection: a ten year experience. Arch. Surg. 126, 44. DuPont B. and Drouhet E. (1985) Cutaneous ocular and osteoartitular candidiasis in heroin addicts: new clinical and therapeutic aspects on thirty-eight patients. 1. Infect. Dis. 152, 5. Fainstein V., Gilmore C., Hopfer R. L. et al. (1982) Septic arthritis due to candida species in patients with cancer: report of five cases and review of the literature. Rev. Infect. Dis. 4, 78. Ferrell R. B., Person D. A. and Litsky M. D. (1977) Candida tropic& arthritis: assessment of amphotericin B therapy. J. Rhetrmalol. 5, 267. Holzman R. S. and Bishko F. (1971) Osteomyelitis in heroin addicts. Ann. Intern. Med. 75, 6. Law E. J., Kim 0. J., Stieritz D. D. et al. (1972) Experience with systemic candidiasis in the bum patient. 1. Traum 12,5. MacMillan B. G., Law E. J. and Holder I. A. (1972) Experience with candida infections in the bum patient. Arch. Surg. 104, 509. O’Connell C. J., Cherry A. V. and Zoll J. G. (1973) Osteomyelitis of the cervical spine: Candida guillieromondi. Letter to the Editor. Ann. Intern. Med. 79, 748. Thomas F. E., Martin C. E., Fisher R. D. et al. (1976) Candida albicans infection of the sternum and costal cartilages: combined operative treatment and drug therapy with 5-fluorocytosine Ann. fior. Surg. 23, 163. Umber J., Chapman M. W. and Drutz D. J. (1974) Candida pyarthrosis. 1. BoneJoint Surg. 56A, 15.
Paper accepted 26 October
1992.
Correspondence should be addressed to: Dr E. J. Law, 1220 George C. Wilson Drive, PO Box 3726, Augusta, GA 30914-3726, USA.