HAl. 3UJ. England. C. Jones. FRCS. Senior. Orthopaedic. Registrar ..... Erickson. DL, Chou. SN,. Seljeskog. EL. A.spergi//us infections of the lumbar disc spaces:.
PARAPLEGIA SUCCESSFUL
DUE
TO
CONSERVATIVE BARRY
From
ASPERGILLOSIS
TREATMENT
FERRIS.
Westminster
OF
CLEDWYN
Children’s
TWO
CASES
JONES
Hospital,
London
Aspergilus infection of the spine is rare; for it to lead to paraplegia is still more rare. When this does it is usually treated by decompression and antifungal agents, but the results have usually been poor. We report two cases of successful conservative treatment of Aspergilus paraplegia in patients with chronic
occur
granulomatous
Infection in man.
disease.
by fungi The usual
of the genus site ofinfection
is uncommon is the lungs but spread
to other organs can occur and there have been reports intervertebral disc infection, vertebral osteomyelitis extradural
abscess.
There
tion and multiple
Aspergillus
have
been
very
few
of and
reports
of
a bilateral discharging
extensor sinuses
three months foot drop.
report responded
a number of further mal neurology; his
infections, vertebral
were
quiescent
3).
Case
2. An
cases of to antifungal
paraplegia
Aspergil!us
treatment.
CASE REPORTS Case 1. A six-year-old boy was referred minster Children’s Hospital for a bone plant. months,
He
was an adopted had developed
bone after a trivial multiple infections, drainage.
until,
which
to the marrow
child who, osteomyelitis
at the age of six of the occipital
graze. Thereafter he requiring antibiotics
at the age
Westtrans-
of I 5 months,
suffered from and surgical
chronic
granulo-
matous disease was diagnosed. A further series of infections followed and at the age of five years he developed a right-sided empyema with a subphrenic extension. This was aspirated and Aspergil!usfumigatus was cultured. He was
treated
with
clotrimazole
to eradicate osteomyelitis
the infection of the upper
nosed
I and
(Figs
2). He
and
this
failed
and at the age of seven thoracic vertebrae was
years diag-
received
plant with amphotericin transplant was unsuccessful. At the he was
age
found
of eight
B. Ferris. Northwick HAl 3UJ.
FRCS. Wellcome Park Hospital. England.
Research Watford
C. Jones. Westminster England.
FRCS.
Requests
for reprints
1985 British 0301 620X85 (
800
a bone
marrow cover,
he presented paraplegia
with with
transbut
the
incontinence;
sparing
Fellow Road,
Harrow,
of sensa-
Middlesex
be sent
Editorial Society 5171 S2.00
to Mr
of Bone
London
B. Ferris. and
Joint
Surgery
SW1P
later,
At the latest
infections sented and
an
the review
(Fig. adopted
since with
abscess
only
residual
when
He he
had was
aged
was
14 he had
a
had
but there was no abnorinfection and his sinuses boy
suffered
At the
of the
abnormality
he was
Italian
infancy.
pneumonia
abscess was lusfiit;zigatu.s-
age
ofthe
upper
right
side
from
of five
recurrent
years
he pre-
lobe
ofhis
right
lung
of his
chest
wall.
The
drained and culture of the pus grew Aspergiland Aspergi/lu.siiigei’. He was treated with
amphotericin B and 5-fluorocytosine. Further investigations revealed that he had chronic granulomatous disease and. after granulocyte transfusion, he was referred for a bone marrow had paraplegia. with sparing
transplant. On admission he of sensation and sphincter
control,
extensor
and
Radiographs vertebrae extradural
a
bilateral
showed collapse (Figs 4 and 5) and block
intravenous daily) for
(Figs
amphotericin three months
plantar
of several a myelogram
5 and
6).
He
B at maximum and then with
response.
upper thoracic revealed an
was
treated
with
doses ( 1 mg/kg oral miconazole
(1 g daily). The weakness improved after eight days and by the fourth month he was able to walk. He was fitted with a brace and by the seventh month had regained full function; the only remaining abnormality was a bilateral extensor plantar Four years ology
Orthopaedic Registrar Dean Ryle Street, should
but
antibiotic
to have
Senior Hospital,
emetine,
response. hack and
almost moribund. He was treated with intravenous amphotericin (0.25 mg/kg bodyweight daily rising to I mg/kg daily) and the paraplegia slowly improved until.
paraplegia secondary to Aspergi!!us infection and, in a search of the literature, we have found no report of successful conservative treatment of this condition. We two
plantar on his
(Fig.
response. later he was
well
with
no abnormal
neur-
7).
2AP.
DISCUSSION Infection
by A.s’peigi//u.s-
becomes although
invasive in the presence of debilitating there are reports of patients in whom THE
is rare.
JOURNAL
The
OF
BONE
fungus
AND
usually
JOINT
only
disease. there was SURGERY
PARAPLEGIA
Fig.
DUE
I
Fig.
Fig. (‘ase I . Figure vertebrae. The Figure 2-Lateral and lytic areas:
VOl..
67 B. No.
5. NOVEMBER
1985
801
TO ASPERGILLOSIS
3
1 -This patient had destruction of several upper thoracic second and third right ribs show lytic areas and are expanded. tomogram of upper thoracic vertebrae showing sclerosis note the absence ofsequestrum formation. Figure 3-Radiograph eight years after presentation.
2
802
B. FERRIS,
Fig.
4
C. JONES
Fig.
5
Case 2. Figure 4-Radiograph showing vertebrae. Figures 5 and 6-Myelogram from the fifth thoracic vertebra (Fig. 5) (Fig. 6). Figure 7-Radiograph four
Fig.
destruction of upper showing an extradural to the sixth cervical years after presentation.
THE
6
thoracic block vertebra
JOURNAL
OF
BONE
AND
JOINT
SURGERY
PARAPLEGIA
no underlying
cause
(Grossman
and Lerner 1977). Many described as pathogenic, A.
tiaras.
1974:
A.
nidulans
Grossman of these
I 977);
1975) A
and
A.
. flimigatus
Predisposing surgery and
factors radiotherapy.
link
infection
between
1975;
Seligsohn,
species ofAspergi!lus such as A. fumigatus, (Bujak, Kwon-Chung is
Rippon
the
use
et
neoplasia, reports of
a!.
cardiac imply a
oral
803
TO ASPERGILLOSIS
one died (Seres, Ono and Benner Dietz ci a!. 1982; Chee and Poh
have been A. niger, and Chusid
terreus (Seligsohn the commonest.
include Several and
DUE
contracep-
paraplegia from prognosis. In children, infection (Bujak
of ci a!.
an
epidural
of
five
granulomatous
X-linked
deficiency
abscess
reported
the spine 1974; Tack
chronic
1972; Byrd 1983). Clearly.
without
cases
disease. of the
This
enzyme
enzyme needed for destroying nisms such as Staphylococcus
also are at risk (Byrd. Weiner and McGee 1982), as are diabetics (Mawk et a!. 1983). In addition, there have been reports of infection during pregnancy (Dietz et a!. 1982) and in patients with chronic granulomatous
Several antifungal agents are ing amphotericin B, 5-fluorocytosine. conazole and miconazole these, such as amphotericin
disease
and
hepatic
ment
continues. In conclusion,
ing
(Bujak et a!. 1974; The organism usually pneumonia, although
Tack et a!. 1982). gains entry via the lung, causit may lie dormant only to
become active later, as reported in a patient who developed paraplegia during pregnancy (Dietz et a!. 1982). In the presence of pneumonia. dissemination to the heart, kidney and tion rarely
gut is said spreads
Haematogenous
to occur to bone
spread
occurs
spread to bone is usually (Grossman 1975; Tack two
cases.
sinus
Clinically formation
though dense
new
bone
difficulty. small
Reviewing the literature A.s-pergil/us paraplegia which spine
in adults
tenor
decompression
a!.
lytic
lesions
1983).
paraplegia
VOL.
67 B. No.
Four which
patients did
5. NOVEMBER
1985
despite
believe
but
with
and
is
report of treated by
of the pos-
Six were
abscesses treatment,
all
and
be
recessive an orgaspp.
available, clotrimazole,
includketo-
whilst
Aspergi!lus
Dr
Terrett
treatis a rare
mortality.
poor.
but
antifungal
The
in children
agents
K.
Hugh-Jones
for
typing
iS, Kwon-Chung Ki, Chusid Mi. in a boy with chronic granulomatous by a mutant strain of Aspergi//u.s1974:61 :361-7.
Byrd
BF Ill, Weiner MH, McGee abscess.JAMA l982;248:3l38
Chee
YC,
Poh
obstructive
Dietz
R, Huber osteoclasis
Grossman Mawk
pri-
had
a
died had
formation.
now
that to
and
Linda
is
a significant
with
P. Aichroth
cases,
abscess
Bujak
features
infection treated
agents.
epidural
improve
Mr
these
four children
for
the
can
be
permission
to
manuscript.
REFERENCES
a notable
1979),
we could find no was successfully
we
treatment
thank
Aspergi!!us
to be monitored
appears
SC. Aspergillus airway disease.
Convent L, Van de Meirop sis. Acta Orthop Be/g
antifungal
with not
conservative successful.
poor
(Convent ci a!. 1979). Some of B, are toxic, so that renal
need
in adults
report
manly disc infections; four recovered (one of whom had a paraplegia which resolved) and two died (Grossman 1975; Seligsohn ci a!. 1977; Convent ci a!. 1979; Mawk ci al.
function
of
peroxide-producing aureus and Aspergi!lus and
the lung in our
there
and
c/ a!.
in granuloma
of paraplegia,
outlook
We
in children
Radiologically
Ten cases of Aspergi!!us have been reported. all and
infec1977).
results
cause
infection of bone results in the fungus may be cultured,
absence of sequestration (Convent which were present in our two cases.
conservatively.
but
by direct invasion from 1982) as happened
with with
in adults,
but
ci a!.
Aspergillu.s’ from which
sometimes
in 25% ofcases, (Seligsohn et
This
a
myeloperoxidase,
addictive drugs and intravenous catheterisation (Seligsohn et a!. 1977; Convent, Van de Meirop and Blijweert 1979). Patients on immunosuppressive therapy tives.
carries
paraplegia 1982). These
ci al.
a!. 1982; in adults
ci
G, and
M. Aspergillosis
JL, Ono compression:
Tack KJ, Rhame litis: report 1982;73:295
H,
epidural Po.stgrad
Aspergillus
spinal
epidural
abscess in a patient MedJ 1983:59:43 5. ofvertebral
BrJ
Radio/
1975:48:57
with
aspergillo-
Volkmer I. Aspergillosis of the lung Neuroradio/ogv I 982 : 23 : 2 19 2 1.
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DL, disc
Seligsohn R, Rippon Arch Intern Med
Seres
0,
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Erickson of the lumbar 58:270-4.
ZA. 9.
L, Blijweert D. A case 1979:45: l4l 50.
Thetter
JR,
Osteomyelitis and pneumonia disease ofchildhood caused nidu/an.s-. Am J C/in Pat/w/
with
9.
Chou SN, Seljeskog EL. A.spergi//us infections spaces: report of 3 cases. J Neuro.s-urg 1983:
Lerner
JW,
l977:
SA. Aspergillus 137:9 I8 20.
Benner EJ. Aspergillosis case report. J Neurosurg
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RC
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