Cryptococcosis of lumbar vertebra in a patient with rheumatoid arthritis and scleroderma: case report and literature review

Abstract

BackgroundAlthough cryptococcosis mainly occurs in the central nervous system and lungs in immunocompromised hosts, it can involve any body site or structure. Here we report the first case of primary cryptococcosis of a lumbar vertebra without involvement of the central nervous system or lungs in a relatively immunocompromised individual with rheumatoid arthritis and scleroderma.Case presentationA 40-year-old Chinese woman with rheumatoid arthritis diagnosed 1 year beforehand and with a subsequent diagnosis of scleroderma was found to have an isolated cryptococcal infection of the fourth lumbar vertebra. Her main complaints were severe low back and left leg pain. Cryptococcosis was diagnosed by CT-guided needle biopsy and microbiological confirmation; however, serum cryptococcal antigen titer was negative. After 3 months of antifungal therapy with fluconazole the patient developed symptoms and signs of scleroderma, which was confirmed on laboratory tests. After taking fluconazole for 6 months, the progressive destruction of the lumbar vertebral body had halted and the size of an adjacent paravertebral mass had decreased substantially. On discharge symptoms had resolved and at an annual follow-up there was no evidence of recurrence on the basis of symptoms, signs or imaging investigations.ConclusionAlthough cryptococcosis of the lumbar vertebra is extremely rare, it should be considered in the differential diagnosis for patients with lumbar vertebral masses to avoid missed diagnosis, misdiagnosis and diagnostic delay. Early treatment with antifungals proved to be a satisfactory alternative to surgery in this relatively immunocompromised patient. Any residual spinal instability can be treated later, once the infection has resolved.

Skeletal cryptococcosis from 1977 to 2013

“…In addition, the incidence of chronic diseases such as diabetes mellitus and hypertension has increased (Jain et al, 1999 ; Witte et al, 2000 ; Bruno et al, 2002 ). The number of patients with cryptococcal disease and who are classified as immunocompetent has risen greatly since 2004 and is estimated to increase by 0.2 per million every year (Zhang et al, 2012 ; Jain et al, 2013 ; Zhou et al, 2013 ). This increase was most likely due to the CNVG outbreak that originated in 1999 and resurged in 2004 (Chaturvedi and Chaturvedi, 2011 ).…”

“…Therefore, a systematical retrospective analysis of skeletal cryptococcosis is crucial for understanding this disease. Unfortunately, however, almost all of the current studies regarding this disease have been presented as case reports (Ramkillawan et al, 2013 ; Zhou et al, 2013 ), which provides little and indirect insight for understanding of skeletal cryptococcosis. Thus, a systematic, retrospective analysis of all published cases of skeletal cryptococcosis reported between April 1977 and the present time was conducted to clarify its clinical features, treatments, and prognoses—all of which are critical issues for fully understanding this disease.…”

Diagnosis and treatment of nonadjacent cryptococcal infections at the L1 and S1 vertebrae

“…Since 1955, some researchers have reported fungal spine infections (typically involving Aspergillus or Candida ), although no reports described cryptococcal infections until a 2013 study by Zhou et al. [6], who examined cryptococcal lumbar infections in patients with rheumatoid arthritis. Furthermore, Wang et al.…”

Neuropsychiatric manifestations in rheumatoid arthritis

“…Many different agents were described in patients with RA, with especial attention for tuberculosis, neurolues, fungal and viral infections [44][45][46][47][48]. Patients taking TNF-α inhibitors and others biologic agents (such as infliximab, adalimumab, golimumab, etanercept and certolizumab) are at great risk for serious infections events such as tuberculosis and infections caused by opportunistic agents (histoplasmosis, coccidiodomycosis and Pneumocystis pneumonia are the most frequent agents) [49].…”

“…Meningoencephalitis. The treatment of RA patients with immunosuppressive drugs and DMARDS increases the susceptibility of opportunistic central nervous system infections [1,[44][45][46]. Symptoms of CNS infections have a wide range of presentation, such as fever, weight loss, focal neurological deficits, seizures, among others [1].…”