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Spinal Epidural Aspergillosis in an HIV Positive Patient Resulting from Long-Standing (3 years) Lung Infection 2007

General Spine

Ryan D Murtagh, MD, MBA,
Judith Post, MD, ASSR Member
Joycelyn Bruce, MD, Non ASSR Member
Kathryn K Post, , Non ASSR Member

Excerpta Extraordinaire

Excerpta

Severe cord compression from invasive, long-standing pulmonary aspergillosis in a well-controlled HIV positive patient.

Purpose

To describe the serial magnetic resonance imaging (MRI) findings in a rare case of severe cord compression due to epidural extension of invasive aspergillus of the right upper lobe in a patient with well-controlled HIV.

Methods & Materials

This is a 41 year-old male who has been HIV positive for 10 years. He presented to Jackson Memorial Hospital in 2003 with symptoms of cough and right arm pain. He was well controlled on his anti-retroviral medications, with undetectable viral load and CD4 count of 535. At the time of presentation he was found to have right upper lobe opacity on chest x-ray. Computed tomography (CT) of the chest was performed, showing a right upper lobe mass without definite chest wall or mediastinal invasion. At that time, this was felt to most likely represent neoplasm. Two CT-guided biopsies were performed in December, 2003, both of which revealed only chronic inflammation without malignancy or infectious agent. Bronchoscopy and video-assisted thoracic surgery (VATS) were performed in January of 2004, both of which were inconclusive. He was followed over a two year period, at which time he presented with increasing right shoulder and arm pain. MRI was performed in February of 2006, showing an invasive mass in the right lung apex with involvement of the T1 and T2 vertebral bodies and minimal extension into the ventral epidural space. There was no cord compression at that time. He again underwent bronchoscopy and VATS with inconclusive results. He was lost to follow up for several months, but returned in September of 2006 with severe back pain and myelopathic symptoms. MRI was performed at that time, showing extension into the epidural space with severe cord compression. He underwent emergent T1-3 laminectomy. Pathology demonstrated large amounts of dense connective tissue with marked acute and chronic inflammation, as well as fungal organisms with pseudohyphae. Special staining of the specimens showed that the fungal elements were consistent with aspergillosis. Culture of the specimen grew A. fumigatus species.

Results

Initial non-contrast CT demonstrates a large right apical mass without definite invasion of the chest wall and no spinal canal involvement. MRI performed two years later shows a large right apical mass with invasion of T1 and T2 bodies, the posterior elements, and minimal extension into the epidural space. The mass was isointense on both T1 and T2 weighted images and enhanced avidly. There was no cord compression at that time. Patient returned seven months later due to increasing pain and myelopathic symptoms. Repeat MRI showed progression, now with invasion of T3, widening of the right neural foramina at T1-2 through T3-4, and extension into the epidural space with severe cord compression from T1-3.

Conclusion

Pulmonary aspergillosis, both invasive and semi-invasive, is being seen with increasing frequency due to rising numbers of immunocompromised patients. We present a case of long-standing pulmonary aspergillosis in an HIV positive patient causing direct epidural cord compression. Of particular interest is the presence of isointense T2 signal intensity in the epidural mass. We postulate that this might be explained by the large amount of dense connective tissue seen on pathologic examination. This is likely a result of this HIV positive patient being able to mount a sufficient inflammatory response because of his well controlled HIV infection. We conclude that fungal disease should be included in the differential diagnosis of a spinal epidural lesion in a well controlled HIV positive patient.

References

Go BM, Ziring DJ, Kountz DS.
Spinal epidural abscess due to Aspergillus sp in a patient with acquired immunodeficiency syndrome.
South Med J. 1993 Aug;86(8):957-60.

Wagner DK, Varkey B, Sheth NK, DaMert GJ.
Epidural abscess, vertebral destruction, and paraplegia caused by extending infection from an aspergilloma.
Am J Med. 1985 Mar;78(3):518-22.

Dietz R, Huber G, Thetter O, Volkmer I. Aspergillosis of the lung with osteoclasis and paraplegia. Neuroradiology. 1982;23(4):219-21

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