case_images: PMC10794653_01
case_images: (A) The clinical timeline of the patient; (B) Lumbar sagittal T1-weighted MRI image at admission showed hypointensity of L4/5 vertebral bodies and intervertebral disc; (C) Lumbar sagittal T2-weighted image and (D) T2-weighted fat-suppression image at admission showed hyperintensity of L4/5 vertebral bodies and intervertebral disc; (E) Axial T2-weighted image at the level of L4/5 showed paravertebral soft tissue swelling and slight paraspinous abscess; (F) H&E staining showed massive inflammatory cells infiltration with some degree of purulent inflammation and necrosis (scale bar=20mum; magnification=10x); (G) Periodic acid-Schiff staining revealed septate fungal hyphae in the cartilage area; arrow indicates fungal hyphae (scale bar=20mum; magnification=40x); (H) Morphology features observed on the Sabouraud dextrose agar at 28 C after 5 days of incubation; and (I) Microscopic image of the subculture of the isolate following lactophenol cotton blue staining (magnification, 400x).
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case_images: PMC10794653_01_fcimb-13-1269352-g001.jpg
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case_images: The patient was then admitted to the rheumatology and immunology department of our hospital ( Figure 1A ). Lumbar MRI at our hospital revealed abnormalities in the L4/5 vertebral bodies, intervertebral disc and surrounding soft tissues ( Figures 1B-E ). H&E staining showed massive inflammatory cells infiltration with some degree of purulent inflammation and necrosis ( Figure 1F ). Periodic acid-Schiff staining revealed septate fungal hyphae ( Figure 1G ). One week after operation, biopsy culture ( Figure 1H ) and microscopy of isolate ( Figure 1I ) revealed A. terreus, which was also identified in a subculture of the isolate using the VITEK matrix-assisted laser desorption ionization time of-flight mass spectrometry (MALDI-TOF MS) system (BioMe rieux, France); in addition, her galactomannan (GM) testing of biopsy specimen was positive with a value of 0.35. Supplementary Figures 1A-G ). Since her inflammation was alleviated after voriconazole treatment, conservative medical treatment was continued.
case_images: MRI and CT findings at approximately 24 days after antifungal therapy. (A) Sagittal T1-weighted image; (B) Sagittal T2-weighted image; (C) Sagittal T2-weighted fat-suppression image; (D) Axial T2-weighted image at the level of L4/5; (E) Sagittal CT image; (F) Coronal CT image; (G) Axial CT image; (H) Preoperative CT three-dimensional reconstruction image.
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case_images: Twenty-four days after antifungal therapy, although her inflammatory indictors (CRP of 7.52 mg/L, IL-6 of 69.86 pg/ml, white blood cells of 8.21x109/L, and ESR of 29 mm/h) were further declined, her L4/5 vertebral bodies' destruction still existed ( Figures 2A-H ). One week later, surgeries including L4/5 intervertebral disc debridement, spinal canal decompression, PLIF with allogeneic fibula ring fusion cages, and posterior pedicle screw fixation were successfully performed under general anesthesia ( Supplementary Figures 2A-H ).
case_images: MRI, CT and X ray findings at six month follow-up. (A) Sagittal T1-weighted image; (B) Sagittal T2-weighted image; (C) Axial T2-weighted image at the level of L4/5; (D) Sagittal CT image; (E) Coronal CT image; (F) Axial CT image; (G) Lateral X ray image; (H) Anteroposterior X ray image; (I) CT three-dimensional reconstruction image. Imaging findings revealed that: the pedicle screws and cages were inserted in the right place, without cracked or displacement; there was no evidence of spinal infection; a certain level of L4/5 interbody fusion was observed.
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case_images: Imaging findings at one-month ( Supplementary Figures 3A-H ) and six-month ( Figures 3A-I ) follow-up demonstrated that the patient was successfully treated.