Disseminated Fusarium oxysporum neurospinal infection
A 60-year-old female patient was admitted with altered sensorium and fever for 2 weeks. The patient was drowsy with severe neck stiffness. She was a known case of type II diabetes mellitus and systemic hypertension.\nRoutine blood examination revealed polymorphonuclear leucocytosis (TC 12400, DC P97, L02, M01) and normal erythrocyte sedimentation rate (ESR). Lumbar puncture was performed, cerebrospinal fluid (CSF) study showed lymphocytic pleocytosis with elevated protein and normal glucose. Computed tomography (CT) brain showed small ring enhancing lesions in bilateral frontal lobes and features suggestive of meningoencephalitis. Magnetic resonance imaging (MRI) brain [] showed multiple well-defined enhancing lesions in both cerebral hemispheres and left cerebellum with pial enhancement. Treatment was started presuming bacterial/tuberculous meningitis with a broad spectrum antibiotic and anti tuberculous therapy. CSF culture was negative for any organisms. She was discharged after 3 weeks with the diagnosis of chronic meningitis with cerebral granuloma, type II diabetes mellitus and systemic hypertension.\nOne month later, she came with hypoglycemia, hypotension and fever. She was diagnosed with urinary tract infection with extended-spectrum beta-lactamase Klebsiella and was appropriately treated. Repeat MRI brain was done which showed no new lesions; anti TB treatment was continued.\nShe was readmitted after 5 months with vomiting, poor intake, fatigue and generalized body ache. She had developed right parieto-occipital infarct, so low- molecular- weight heparin and antiplatelets were started. MRI brain now showed persistence of lesions with only mild resolution of edema surrounding the lesions. She showed mild symptomatic improvement. Hence, she was further evaluated with tumor markers and CT thorax and abdomen. This showed a collapse at D8-D9 vertebral level. MRI spine with contrast showed spondylodiscitis at the D8-D9 level [Figure and ]. Patient underwent laminectomy, debridement of discovertebral infection and fusion. The lesion was approached through the posterior midline. Pedicle screws were applied at D6, D7 and D10, D11 levels. D8, D9 laminectomy was done as an approach to the infected site and D8/9 disc space was curetted []. Pus and granulation tissue were sent for histopathology and microbiological studies. The space was packed with grafts taken from the transverse process and stabilized with rods. Histopathology examination revealed chronic nonspecific granulomatous inflammation. Microbiology tests showed fungal hyphae on culture and the fungus was identified as F. oxysporum.\nShe was diagnosed as having meningospondylodiscitis due to F. oxysporum and was started on intravenous voriconazole 200 mg 12 hourly for 3 weeks, then changed to oral voriconazole 200 mg twice daily for a period of 7 weeks. In the meantime, tuberculosis (TB) polymerase chain reaction from the spinal tissue was found to be negative. Hence, ATT was stopped. At the time of discharge, 2 months later, she was asymptomatic and ambulant with the support of a brace. She was followed up regularly in the outpatient department with X rays and laboratory tests (ESR 13, TLC 9000), which showed reduction in infection and a progressive spine fusion [] X ray shows bony trabeculae crossing the fusion site and clinically there is no tenderness at the site. At her last followup, 36 months after the surgery, she was doing well, living an independent life [].