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Krastev 1
Krastev 1
2, pp 66-72, 2008
Copyright © 2007 Trakia University
Available online at:
http://www.uni-sz.bg
ISSN 1312-1723 (print)
ISSN 1313-3551 (online)
Case Report
VERTEBRAL OSTEOMYELITIS DUE TO CANDIDA ALBICANS IN A DOG
Sv. Krastev1, G. Simeonova1*, V. Urumova2, R. Simeonov3
1
Department of Veterinary Surgery;
2
Department of Veterinary Microbiology, Infectious and Parasitic Diseases;
3
Department of General and Clinical Pathology,
Faculty of Veterinary Medicine, Trakia University, Stara Zagora, Bulgaria
ABSTRACT
Candida species uncommonly cause vertebral osteomyelitis both in animals and human. We
present a case of lumbar vertebral osteomyelitis in a dog caused by Candida albicans. The
dog was 3-year-old female kurtzhaar weighing 19kg. The patient had a history of loss of
appetite and weight, and several fistulas on the left lumbar area for three months that
appeared after injury. Clinical signs were related to neurological dysfunction but were
observed later in the course of the disease. The diagnosis was made on the basis of history,
clinical symptoms, x-ray examination, cytology and cultural conformation. The treatment
was successful after surgical debridement and oral ketoconazole for 35 days.
Key Words: vertebral osteomyelitis, Candida albicans, dog
INTRODUCTION available.
Systemic candidiasis is very
Candidal vertebral osteomyelitis is a rare
devastating disease with high mortality rate
disease. Candida albicans is a normal fungal
whereas local mycoses have favourable
inhabitant of the gastrointestinal, upper
prognosis. The successful treatment of
respiratory, and genital mucous membranes
candidal vertebral osteomyelitis was reported
of dogs Opportunistic infections may develop
in 85% of the cases with prolonged
1
Table 1. Results of haematological and biochemical investigations of a dog with candidal vertebral
osteomyelitis.
Morphological Detected Reference Biochemical Detected Reference
parameter value values parameter value values
Hgb, g/L 136 120-180 Total 66 51-72
PCV, l/l 0.44 0.37-0.55 protein, g/L 16 19-59
RBC, T/L 5.39 5.5-8.5 ALT, U/L 25 20-50
MCV, fl 63.1 60-77 AST, U/L 2.19 2.5-11.4
WBC, G/L 9.4 6-17 BUN, 46.1 41-121
Seg,G/L 6.016 3.6-11.5 mmol/l
Bands, G/L 0.282 0-0.3 Creatinine,
Metamyelo, 0.188 0 µmol/l
G/L 0 0
Myelo, G/L 0.376 0.01-1.25
Eos, G/L 0 0-0.1
Basos, G/L 2.256 1-4.8
Lymphs, G/l 0.282 0.15-1.35
Monos, G/L
and grass-seed foreign body penetration with The changes of the normal microbial
secondary infection (8). Other organisms flora, that occur in prolonged antibiotic use,
reported in dogs and cats include some and immunosuppression after steroid use,
anaerobes - Actinomyces viscosum, surgery, parvovirus and feline panleucopaenia
Bacteroides spp., Clostridium vilosum (9), virus infection, and diabetes has been
Actinobacillus spp. (10), Pseudomonas spp., implicated in the susceptibility to a
Pasteurella spp. and various mycotic haematogenous spread of mycoses (15, 7, 16,
organisms, particularly Aspergillus spp. (11). 3).
Candida species uncommonly cause As in our case, a history of trauma was
vertebral osteomyelitis but 62% of all candidal noted in the most of cases with osteomyelitis
vertebral osteomyelites are due to C. albicans (9, 17) and the trauma was considered a
(2). Candida species are typically considered contributing factor of susceptibility to disease
commensal organisms and a part of the normal localization. Direct extension of an infective
microflora. Candidiasis is an opportunistic process through foreign body migration from a
infection and principally manifests as a percutaneous entrance or through the bowel
superficial mycosis of mucous membranes wall has been described (8, 18).
such as oral mucosa, and skin. Systemic Diskospondylitis (diskitis) has occurred after
candidiasis is less common and may affect disk surgery in humans and in dogs after
several organs including lymph nodes, prophylactic disk fenestration (4).
kidneys, pancreas, prostate gland, spleen, Age at presentation was generally less
thyroid glands, heart, and spine and very often than 4 years but was reported to range from 8
lead to dead (3). months to 10 years. Large and giant breed dogs
The nidus arises from haematogenous predominate, with affected males
spread (12), from migrating foreign bodies, outnumbering females approximately 2 to 1
penetrating bite or gunshot wounds, or and purebred dogs, especially German
previous surgery (11). In our case the shepherds and Great Danes were most often
presumed source of infection was also a soft represented (4, 5).
tissue injury of the lumbar region. The clinical and laboratory
Possible sources for a septicaemia and characteristics of patients with candidal
haematogenous access include dental vertebral osteomyelitis were similar to those
extraction - 66% of dogs and 80% of humans described for patients with bacterial and
(13), genitourinary infection, and some Aspergillus vertebral osteomyelitis (2). The
diagnostic procedures such as endoscopy, signs vary in severity and may mimic other
biopsy, urinary catheterisation, which may diseases. Spinal pain and neurological deficit
damage the respiratory, digestive, or urogenital are readily recognized, but the subtleties of
mucosa, that harbour a saprophytic microbial depression, sometimes fever, loss of appetite,
flora. According to Cabassu and Moissonnier and weight loss (4) may be confusing early in
(12) haematogenous osteomyelitis is very rare the course of the disease. Back pain is the
whereas Walker et al. (14) claimed that primary and may be the only sign of
infection of the spine via the bloodstream was spondylitis and discospondylitis (19). We also
the most common route in dogs. The presence found a back pain in the present case. Fistulas
of fungi in bone alone is not enough to cause are typical for the presence of foreign body but
disease. Several risk factors were associated such was not found.
with fungaemia and invasive candidiasis, Neurological signs occur later as an
including local and systemic conditions. aftermath of the infection. If the disease
Alterations in the vertebral progresses and involves the nerve roots and
microcirculation, which occur in trauma and spinal cord, more definitive signs referable to
surgery, are important cofactors in the nervous system are noticeable, primarily as
development of a vertebral focus of infection. paresis/paralysis caudal to the lesion. The latter
Microorganisms tend to accumulate in seldom occurs in the absence of pathologic
vertebral circulation, because of reduced fractures. We observed neurological signs later
concentration of phagocyte cells here, the in the course of the disease comprising of an
presence of nonanastomotic branches of increased muscle tone and proprioceptive
capillary loops, and easy microtrombus deficit of hind limbs,
formation (11).
dorsal deviation of the trunk, depressed anal Blood chemical and haematological
sphincter reflex, and loss of superficial values are usually normal, as we observed,
sensation caudal to L4-L5. A stilted gait or although a nonspecific leukocytosis may be
arched back are considered nonspecific, present. In human, an elevated erythrocyte
because they could be caused by numerous sedimentation rate was frequently found (2)
conditions from intervertebral disk disease to but it was not measured in our case.
prostatitis, renal or urethral calculi, to hip Because of the number of bacteria,
dysplasia. In children with intervertebral disk actinomycetes, mycobacteria, and fungi are
inflammation, the most common symptoms are capable of causing spondylitis, an exact
back or hip pain and a refusal to walk (20). discovery of the cause is very important.
Reluctance to walk in a dog with no pre- Moreover, these causative agents require vastly
existing or documented musculoskeletal or different therapies and some are associated
neurological problems could be an early with toxicities.
premonitory sign but was not observed in this The definitive microbiological diagnosis
case. The severity of the lesion does not of candidal vertebral osteomyelitis is made by
always correspond to the clinical signs. The culturing of biopsy specimen or histo-
duration of signs prior to presentation vary but cytological examination (1). Bone and blood
usually last at least 1 month. isolates have similar identical sensitivities (22),
The diagnosis of candidal vertebral which provides reasonable assurance that the
osteomyelitis is based on the clinical signs, organism from the bone is the causative agent.
radiographic confirmation of a compatible Both the microbiologic and histological results
lesion, and identification of the etiological confirmed the presence of Candida spp. in the
agent. affected vertebra in our case.
The radiographic changes are essential The treatment of patients with candidal
to obtain the diagnosis and reflect the vertebral osteomyelitis consisted of both
underlying pathophysiologic processes but the surgical and medical interventions. The
radiographic changes may not occur until 4 to primary surgical interventions were
6 weeks after the infection is established (21). debridement and if necessary bone grafting,
The most common site affected are lower vertebral fusion, or prosthetic support (2). An
thoracic and lumbosacral spine (2). Plain accurate microbiologic diagnosis followed by
radiographs show varying degrees of vertebral appropriate antimycotic therapy is extremely
lysis, sclerosis, and proliferative bony changes, important. The specific Candida species
which lead to vertebral body deformation and should also be definitively identified to guide
shortening with possible fractures or therapy, because antifungal susceptibilities of
instability. In the present case, radiographic Candida species are variable. C. albicans is
examination revealed afore mentioned routinely susceptible to fluconazole and
characteristics of spondylitis. ketoconazole, whereas C. krusei is routinely
The disease should be differentiated resistant (23). C. albicans was the predominant
from diskospondylitis, vertebral alterations organism responsible for the most cases of
associated with plant-derived foreign bodies candidal vertebral osteomyelitis (2).
and bone neoplasia. The classic appearance of Antifungal therapy should last for at
diskospondylisis was bony destruction on both least 4 to 6 weeks. Some authors recommend
sides of the disk with irregular end-plates` systemic application of amphotericin B
surfaces and widening or narrowing of the disk initially, followed by oral azole treatment (2).
space (4), which was not obvious in our case. Because of its high nephrotoxicity
Plant-derived foreign bodies tend to migrate amphotericin B is not recommended for long-
along fascial planes, because of their shape and term treatment in dogs. Ketoconazole alone
aided by active muscle contractions. They has been used successfully to treat even
induce typical radiographic images disseminated candidiasis after drug abuse in
characterized by osseous proliferations along human (24). Fluconazole is often selected as
the ventral surfaces of the vertebral bodies the first line treatment because it is effective,
from L2 to L4. The letter two diseases were has low incidence of adverse effects and is
excluded later by histological examination and cost-effective (1).
surgical exploration of the sinus tracks.
The prognosis for patients with candidal 8. Johnston, D.E. and Summers, B.A.
vertebral osteomyelitis is good. The majority Osteomyelitis of the lumbar vertebrae of
of patients had an outcome profile similar to dogs caused by grass-seed foreign bodies.
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13. Harari, A.P., Besser, T.E., Gustafson, S.L.,
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