Musculoskeletal Imaging • Original Research

Lee et al.
MRI of Candida Spondylitis

Musculoskeletal Imaging
Original Research
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Candida Spondylitis: Comparison

of MRI Findings With Bacterial and
Tuberculous Causes
Sheen-Woo Lee1 OBJECTIVE. Candida spondylitis is relatively uncommon and is usually encountered
Sang Hoon Lee2 as an opportunistic infection. We analyzed the MRI characteristics of biopsy-proven cases
Hye Won Chung2 of Candida spondylitis, and compared the findings with bacterial or tuberculous spondylitis.
Min Jee Kim 3 MATERIALS AND METHODS. The study included patients with infectious spondyli-
Min Jeong Seo 4 tis who underwent MRI and biopsy from 1998 to 2011 (60 patients; mean age 56 ± 18 years).
MR images were analyzed with respect to the number of involved vertebrae, contrast en-
Myung Jin Shin2
hancement pattern, signal intensity of spinal inflammatory masses on T2-weighted imaging,
Lee SW, Lee SH, Chung HW, Kim MJ, Seo MJ, paraspinal abscess size, intervertebral disk destruction, subligamentous spread, and skip le-
Shin MJ sions. The Fisher exact test and analysis of variance were used for statistical analysis.
RESULTS. There were 10 cases of Candida spondylitis, and 29 and 21 cases of bacterial and
tuberculous spondylitis, respectively. On MRI, disk destruction was seen in 50%, 93%, and 30%
of Candida, bacterial, and tuberculous cases, respectively. Subligamentous spread of infection
was noted in 22%, 10%, and 85%. Paraspinal inflammatory masses were seen in 100%, 100%,
and 76%, and abscesses in 100%, 66%, and 90%, of Candida, bacterial, and tuberculous cases,
respectively. Paraspinal inflammatory masses contained low T2 signal intensity portions in 80%,
21%, and 67%, and skip lesions were seen in 0%, 10%, and 14%, respectively. Small abscesses
were noted in 100%, 76%, and 35% of Candida, bacteria, and tuberculosis infections, respec-
tively. Candida involved 2.3 ± 0.4 vertebrae compared with 2.3 ± 0.9 and 3.0 ± 1.7 in bacterial
and tuberculous, respectively. Differences in the three groups were statistically significant (p <
Keywords: Candida, fungus, infectious spondylitis, MRI, 0.05) except for the number of involved vertebrae, and skip lesions.
opportunistic infection CONCLUSION. Candida spondylitis can be suspected when infectious lesions contain
low-signal spinal inflammatory masses on T2-weighted imaging, small paraspinal abscesses,
DOI:10.2214/AJR.12.10344 and in immunocompromised patients.
Received November 20, 2012; accepted after revision

T
February 1, 2013. he risk of fungal infection is
closely related with the immuno-
Presented at the 2008 annual meeting of the Radiological compromised state [1]. Although
Society of North America.
the CT and MRI findings of pyo-
1
Department of Radiology, Gachon University Gil Medical genic or tuberculous spondylitis are well
Center, Inchoen, Korea. known, those of fungal spondylitis are not
well characterized in the literature [2]. Fun-
2
Department of Radiology, Asan Medical Center, gal spondylitis is difficult to diagnose clini-
University of Ulsan College of Medicine, 388-1 Pungnap-2
dong, Songpa-gu, Seoul, Korea. Address correspondence
cally or pathologically, and thus, treatment is
to S. H. Lee (shlee@amc.seoul.kr). commonly delayed [1].
Fungal spondylitis occurs primarily as an
3
Department of Radiology, Seoul Medical Center, Seoul, opportunistic infection [1], and Candida and
Korea.
Aspergillus species are the most common
4
Department of Radiology, Seoul Veteran’s Hospital, causative fungal organisms. Few cases of Can-
Seoul, Korea. dida spondylitis have been reported and little
is known of its MRI characteristics. Further-
AJR 2013; 201:872–877
more, no study has systematically compared
0361–803X/13/2014–872 the imaging characteristics of Candida spon-
dylitis and those of bacterial and tuberculous
© American Roentgen Ray Society spondylitis. In this article, the MRI character-
istics of biopsy-proven cases of Candida in-
fection are analyzed and compared with those
of the other more common causes of infec-
tious spondylitis. Our objective was to iden-
tify the MRI characteristics of Candida spon-
dylitis, and thus aid in its diagnosis.
Materials and Methods
With approval from our institutional review board,
we retrospectively studied 352 patients who were
admitted into our institute for infectious spondylitis
from 1998 to 2011. Medical records were reviewed
and clinical data and histopathologic findings were
investigated. The inclusion criteria were as follows:
prebiopsy MRI, including T1- and T2-weighted sag-
ittal and axial imaging and contrast-enhanced stud-
ies; CT-guided percutaneous needle biopsy or open
surgical biopsy of the infected spine area; and a pos-
itive pathogen yield by the biopsy. Patients whose
medical record was unavailable; those without MRI;

872 AJR:201, October 2013


or those with limited MR image quality, such as
shading artifact by spine coil or who had a negative
result on the direct biopsy, were excluded. The final
study cohort consisted of 60 patients (23 women and
37 men) of mean age 56 ± 18 years.
The MRI systems and pulse sequences used
were varied because some of the imaging stud-
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ies were performed at outside institutions, but all
studies were performed using a 1.5-T magnet. Im-
aging sequences included spin-echo T1-weighted,
T2-weighted without fat suppression, and gado-
linium-enhanced T1-weighted with or without fat
suppression. Imaging included axial and sagittal
planes in all cases.
Two musculoskeletal radiologists with 12 and
4 years of experience analyzed the MR images by
consensus. The following MRI data were evaluat-
ed for each patient: the locations of involved bones,
number of involved vertebra, presence of interver-
tebral disk destruction, subligamentous spread of
inflammation, skip lesions, contrast enhancement
pattern of the paraspinal soft-tissue lesion, signal
intensity of the spinal inflammatory mass by T2-
weighted imaging, and paraspinal abscess size.
Intervertebral disk destruction was defined as
breach of the subchondral cortex by extension of the
infectious lesion through the endplate into the disk,
with loss of the disk height on sagittal images. Sub-
ligamentous spread of inflammation was defined as
an inflammatory mass or abscess under the anteri-
or longitudinal ligament. Skip lesion was defined
as spondylitis at different vertebral levels without
intervening level involvement. The numbers of in-
volved vertebrae were determined by counting in-
volved vertebral bodies. Contrast enhancement
patterns of the paraspinal soft-tissue lesions were
assessed by reviewing the axial set of T1-weight-
ed, T2-weighted, and contrast-enhanced images.
The soft-tissue lesions outside the vertebral body
showing low signal intensity on T1-weighted im-
aging and diffuse enhancement were categorized as
paraspinal inflammatory masses, and those with a
TABLE 1: Underlying Diseases of Patients With Candida Spondylitis
Patient No.
1 Paraplegia due to bursting fracture of thoracic spine
2 Bedridden due to intestinal adhesion and fracture after motor vehicle accident
3 Chemotherapy due to lung cancer
4 After colon cancer operation
5 After colon cancer operation
6 After fusion and revision for spinal stenosis
7 Hepatocellular carcinoma, alcoholic liver cirrhosis
8 After diskectomy
9 Esophagus and lung cancer
10 Spine anesthesia for bladder tumor removal, 20-year history of diabetes mellitus
AJR:201, October 2013 873
MRI of Candida Spondylitis
rim-enhancing component were categorized as ab-
scesses. Further analyses of the paraspinal inflam-
matory mass and abscess were done in the follow-
ing manner. Paraspinal inflammatory lesions were
analyzed and categorized as diffusely high or heter-
ogeneously low signal intensity compared with the
adjacent muscle on axial T2-weighted imaging. The
abscess size was categorized into large or small ac-
cording to whether the individual cavity exceeded
half of the diameter of the vertebral body. MR im-
ages were also reviewed twice by a radiologist un-
aware of causative organisms.
Statistical differences between the three patho-
genically different spondylitis types were ana-
lyzed using the Fisher exact test and analysis of
variance. The correlation coefficient (R2) was cal-
culated to find out the possibility of association
between the low signal intensity on T2-weighted
imaging and the symptom duration or the patient’s
age. Analysis was performed using SPSS for Win-
dows, version 12.0. Statistical significance was ac-
cepted for p values of < 0.05.
Results
There were 10 cases of Candida spondy-
litis, 29 cases of bacterial spondylitis, and 21
cases of tuberculous spondylitis. The cervical
spine was not involved in any patients with
Candida spondylitis or tuberculous spondyli-
tis but was involved in two patients with bac-
terial spondylitis. The thoracic spine was in-
volved in one Candida, three bacterial, and
five tuberculous spondylitis patients. The
thoracolumbar junction was involved in one
bacterial and one tuberculous spondylitis pa-
tient, and the lumbar spine was involved in
10 Candida, 21 bacterial, and 16 tuberculous
spondylitis patients.
A review of clinical data showed that 90%
of the Candida spondylitis patients were im-
munocompromised or had other long-stand-
ing debilitating disease due to cancer treat-
Underlying Disease
ment or prolonged hospitalization associated
with burst fracture or intestinal adhesion (Ta-
ble 1). On the other hand, 10% of the pyo-
genic spondylitis patients and none of the
tuberculous spondylitis patients had such
conditions. Ten percent of the Candida spon-
dylitis patients had undergone a recent inva-
sive spinal procedure, such as, epidural in-
jection or spine surgery, whereas 48% and
5% of pyogenic and tuberculous spondylitis
patients, respectively, had done so. The re-
spective durations of symptoms were 21 ± 44
months (median, 4 months), 2.0 ± 2.0 months
(median, 1 month), and 14 ± 26 months (me-
dian, 5 months) in Candida and bacterial and
tuberculous spondylitis patients, respective-
ly. Mean patient age was 60 years (45–73
years) in the Candida spondylitis group, 60
years (15–82 years) in the bacterial spondy-
litis group, and 47 years (12–83 years) in the
tuberculous spondylitis group.
On MRI, intervertebral disk destruction was
observed in 50%, 93%, and 30% of Candida,
bacterial, and tuberculous cases (Fig. 1), and
subligamentous spread of infection was noted
in 22%, 10%, and 85% of Candida, bacterial,
and tuberculous cases, respectively. A skip le-
sion was present in 10% of pyogenic and 14%
of tuberculous spondylitis cases. Candida
spondylitis involved 2.3 ± 0.4 vertebrae com-
pared with 2.3 ± 0.9 in bacterial spondylitis and
3.0 ± 1.7 in tuberculosis. Diffusely enhancing
paraspinal inflammatory masses were seen in
100%, 100%, and 76%, and rim-enhancing ab-
scesses in 100%, 66%, and 90%, of Candida,
bacterial, and tuberculous cases, respectively.
Low-signal-intensity paraspinal mass on T2-
weighted imaging was noted in 80%, 21%,
and 67% of Candida, bacterial, and tubercu-
lous cases, respectively (Fig. 2), whereas T2-
high-signal-intensity paraspinal lesions were
seen in 20%, 79%, and 24%, respectively (Fig.
2). Large confluent paraspinal abscesses were
seen in 24% and 65% of bacterial and tuber-
culous cases, but none in Candida spondyli-
tis (Figs. 2 and 3). Small abscesses were noted
in 100%, 76%, and 35% of Candida, bacteria,
and tuberculosis infections, respectively.
The correlation coefficient (R2) values be-
tween the T2 signal intensity and the symptom
duration or the patient’s age, calculated based
on the hypothesis that the longer the symptom
duration or the older the patient, the lower the
T2 signal intensity, were 0.215 and 0.001, re-
spectively. The low R2 values suggest that the
symptom duration or age does not cause sig-
nificant effect on the T2 signal intensity. A
summary of results is provided in Table 2.

Differences between the imaging findings
in the three groups were statistically signifi-
cant (p < 0.05) except for the number of in-
volved vertebrae (p = 0.09) and presence of
skip lesions (p = 0.54).
Discussion
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The incidences of fungal infections have
increased because of the greater use of im-
munosuppressants, prolonged use of broad-
spectrum antibiotics and indwelling cathe-
ters, and the higher prevalence of AIDS [1,
3]. Nevertheless, fungal spine infections still
have much lower incidences than bacterial
and tuberculous infections [4]. Knowledge of
the disease itself is limited, and the diagnosis
is based on exclusion rather than definite di-
agnostic criteria. In a clinical study, Frazier et
al. [1] analyzed 11 cases in three tertiary cen-
ters over the course of 16 years, causative or-
ganisms included Candida, Aspergillus, and
Coccidioides species. According to another
researcher, the initial clinical manifestations
of Candida infections are usually mild and
nonspecific. This report concluded that ear-
ly diagnosis of fungal spondylitis depends on
a high index of suspicion and clinical judg-
ment, especially in patients with a history of
immunosuppression or of travel to endemic
areas [5]. MRI can aid the diagnosis, but ra-
diologic findings have not been evaluated in
previous studies. Published imaging studies
of fungal spondylitis involve anecdotal re-
ports in the form of case studies, and the larg-
est report issued on the subject involved three
cases and no comparison with other causes of
infectious spondylitis [6].
In this study, we analyzed the MRI find-
ings of Candida spondylitis, the most com-
mon fungal spondylitis in the immunocom-
promised population, and we compared these
with the findings of pyogenic and tubercu-
lous spondylitis. Our results indicate that
Candida spondylitis should be suspected if
MRI shows spondylitis in two adjacent ver-
tebral bodies, with small paraspinal abscess,
or with phlegmon, which on T2-weighted
imaging is of lower signal intensity in con-
trast to the high signal intensity expected of
inflammatory lesions in cases with a pyogen-
ic or tuberculosis infection. Less interverte-
bral disk involvement may also suggest Can-
dida rather than pyogenic spondylitis.
The well-known differences between pyo-
genic and tuberculous spondylitis depend on
the virulence of the pathogen, aggressive prote-
olysis, and host-immune reactions. Variable
host interactions with bacteria of low virulence
874 AJR:201, October 2013
Lee et al.
TABLE 2: Spectrum of Imaging Findings of Candida Spondylitis, Bacterial
Spondylitis, and Tuberculous Spondylitis
MRI Findings
Intervertebral disk destruction
Subligamentous spread
Skip lesion
Contrast enhancement pattern of paraspinal lesion
Diffuse enhancing inflammatory mass
Rim-enhancing abscess
Low T2 signal intensity of inflammatory mass
No. of involving vertebrae (p = 0.09)
Large paraspinal abscess
Small paraspinal abscess
Note—Findings with statistical significance (p < 0.05) are in bold. All data are presented as percentages
except for number of involving vertebrae.
or weaker proteolysis will result in atypical
forms of spondylitis that can mimic tubercu-
losis or even a metastatic mass. For example,
if the pathogen is low in virulence or the host-
immune reaction is low, the inflammatory tis-
sue reaction will be low grade and long-stand-
ing, resulting in fibrosis in the inflammatory
mass and a low tissue-water component, and
the resulting signal intensity will be low on T2-
weighted imaging [7–9]. The pathologic diag-
noses of the cases in our study described chron-
ic inflammation and fibrosis and support our
hypothesis. Hence, chronic inflammation and
fibrosis in Candida spondylitis and formation
of paraspinal abscess cavities can resemble tu-
berculous spondylitis in some cases (Fig. 3). In
addition, some species of fungus have been re-
ported to synthesize paramagnetic substances,
such as, melanin (a T2-shortening substance),
which contributes to low signal intensity [10].
The list of pathologic reports of our Candida
spondylitis patients included chronic osteomy-
elitis, dense fibrous tissue with calcifications,
chronic granulomatous inflammation with ne-
crosis, fibrinous exudate, marrow fibrosis with
mild chronic inflammation, degenerated and
necrotic synovial tissue, extensive degeneration
of cartilage with granulation tissue, and chron-
ic granulomatous inflammation with necrosis.
In addition, underlying degenerative osteo-
phytosis may contribute to the T2 low signal
intensities of lesions in elderly patients. But
the R2 value in our study between the patients’
age and the T2 hypointensity, which can be
seen in degenerative spur formation, did not
indicate any relevance, suggesting that the ef-
fect of degenerative spine lesions may not be
Spondylitis
Candida Bacterial Tuberculous
50 93 30
22 10 85
0 10 14
100 100 76
100 66 90
80 21 67
2.3 2.3 3.0
0 24 65
100 76 35
as significant as the hypothesis. Further study
may be necessary in larger number of groups
comparing CT and MRI side by side.
The limitations of our study are as follows:
Only patients with a biopsy-proven pathogen
were included in this study. According to oth-
er researchers, infectious agents are found by
biopsy in fewer than 70% of infectious spon-
dylitis cases [11, 12]. In the current study, pa-
tients diagnosed with infectious spondylitis
by imaging without a definite pathogen yield
were treated with empirical antimicrobials,
and exclusion of these patients might have
led to selection bias and a higher proportion
of atypical and severe cases. The cases in our
study did not involve the cervical spine, but
our literature search shows that cervical spine
is not immune to Candida infection albeit un-
usual [1, 13–15]. The study was retrospective
in nature, and some of the clinical informa-
tion on the medical record, such as the histo-
ry of antibiotic therapy before the visit to our
tertiary medical center, was incomplete. Fur-
thermore, although our cases were collected
over 10 years, the sample size was small.
In conclusion, Candida spondylitis should
be considered when the infectious lesions in-
volve contiguous vertebrae without interver-
tebral disk destruction with paraspinal in-
flammatory mass of unusually low signal
intensity, and paraspinal abscess, when pres-
ent, is small. A clinical history of chronic ill-
ness would be helpful during the differential
diagnosis. These MRI findings may alert clini-
cians to the possibility of a rare cause of spon-
dylitis and thus aid antimicrobial selection and
patient management.
 MRI of Candida Spondylitis

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B
Fig. 1—Candida spondylitis.
A, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) show Candida spondylitis
infection in lumbar spine in 68-year-old man, with little intervertebral disk destruction (arrow).
B, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) show Candida spondylitis
infection in 59-year-old man with disk destruction (arrowhead). Intervertebral disk was destroyed in 50% of
Candida spondylitis patients compared with 93% of bacterial spondylitis patients and 28% of tuberculous
spondylitis patients.

AJR:201, October 2013 875

 Lee et al.
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C
Fig. 2—Candida spondylitis.
A–C, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) of Candida spondylitis in 68-year-old man (A), bacterial spondylitis in 15-year-old boy (B),
and tuberculous spondylitis in 41-year-old man (C). Axial images of Candida spondylitis show inflammatory mass in paraspinal soft tissue of mixed low signal intensity (thick
white arrow, A) interspersed with punctate nonenhancing component (thin white arrow, A) compared with bacterial paraspinal inflammatory mass that is high signal intensity
on T2-weighted image and diffusely enhanced (arrowhead, B) or thin rim-enhancing soft tissue abscess cavity of tuberculous spondylitis (curved arrow, C).

876 AJR:201, October 2013

 MRI of Candida Spondylitis
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D
Fig. 3—Paraspinal abscess and mass.
A, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) of 68-year-old man with Candida spondylitis show multiple small paraspinal abscesses
(thin arrow) and diffusely enhancing left paraspinal inflammatory mass that is low signal intensity on T2-weighted image (thick arrow).
B, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) of 15-year-old boy with bacterial spondylitis show paraspinal inflammatory mass that is
high signal intensity on T2-weighted image (double arrows).
C and D, MR images (T2-weighted, T1-weighted, and contrast-enhanced, respectively) of 68-year-old man (C) and 27-year-old man (D) with tuberculous spondylitis show
multiple small abscesses (black arrowhead) with T2-hypointense inflammatory mass (white arrowhead, C) and large confluent paraspinal abscess (curved arrow, D).

AJR:201, October 2013 877