Abstract:
Background: Candida albicans spondylodiscitis is an uncommon but potentially serious infection that can be difficult to diagnose because of its insidious presentation and similarity to bacterial spinal infection. Patients receiving immunotherapy and those with recent critical illness may be at increased risk of invasive fungal infections. We present a case of Candida albicans spondylodiscitis in a patient with multiple sclerosis receiving ocrelizumab, initially unresponsive to prolonged empirical antibacterial therapy.
Methods: A case of a man in his 40s with longstanding multiple sclerosis on ocrelizumab was reviewed following a prolonged hospital admission. His admission was complicated by acute appendicitis requiring appendectomy, COVID-19 pneumonia requiring intensive care admission and mechanical ventilation, and subsequent critical care myopathy. Twelve weeks after transfer to a rehabilitation facility, he developed severe progressive back pain and worsening lower limb weakness without fever or other systemic symptoms. MRI demonstrated infective spondylodiscitis. Initial investigations included blood cultures, HIV testing, QuantiFERON-TB, Brucella testing and fungal cultures. A CT-guided spinal biopsy was performed, followed by empirical antibacterial therapy. Following clinical deterioration and failure to respond, repeat tissue sampling was undertaken.
Results: Initial microbiological investigations were negative, while CT-guided biopsy demonstrated acute fibrinous exudate without granulomas or malignancy. The patient received cefepime and teicoplanin, subsequently changed to daptomycin, with approximately two months of antibacterial therapy. Despite treatment, he experienced worsening back pain and lower limb weakness and required readmission. An open excisional biopsy performed by neurosurgery subsequently identified Candida albicans osteomyelitis. Antifungal therapy with fluconazole was commenced for a planned three-month course. The patient demonstrated significant improvement in back pain, lower limb strength and mobility, with follow-up demonstrating sustained improvement and return towards his baseline functional status.
Conclusion: Candida albicans spondylodiscitis should be considered in patients with persistent or progressive spinal symptoms despite appropriate antibacterial therapy, particularly following critical illness and in patients receiving immunomodulatory treatment. The absence of fever or positive blood cultures does not exclude fungal infection. Failure to respond to empirical therapy should prompt reconsideration of the diagnosis and, where clinically appropriate, repeat tissue sampling. Early multidisciplinary collaboration is important for achieving a microbiological diagnosis and guiding targeted treatment.
Biography:
Dr Rayan Saeed Mahmoud is an Internal Medicine Trainee in the United Kingdom. She graduated from the University of Medical Sciences and Technology in Sudan and has clinical experience across a range of medical specialties. She has a particular interest in infectious diseases, acute and general internal medicine, medical education and clinical research. She has experience teaching medical students and has worked as a co-investigator on clinical trials, alongside involvement in clinical audit, quality improvement and academic case reporting.
