ABSTRACT
Candida glabrata is a low virulent commensal fungal organism that, rarely, can cause osteomyelitis. Diagnosis of such an infection is often difficult as the case typically presents with an insidious onset of back pain and minimally elevated biomarkers of inflammation. Furthermore, it is difficult to eradicate and often resistant to common antifungals. A 61-year-old man presented with an eight-month history of persistent low back pain which had unsuccessfully been managed by his primary care physician. He had a past surgical history of gastric by-pass complicated by adhesions, ulceration, and perforation with an infection of Candida glabrata that had been treated with intravenous micafungin. Radiological examination showed degenerative changes with suspicion of osteomyelitis and a computerized tomography (CT)-guided biopsy provided tissue samples with subsequent positive cultures for Candida glabrata. The patient was admitted for fungal osteomyelitis with Candida glabrata, treated with intravenous micafungin, and his infection was resolved after six months. At two-year follow-up his back pain has been resolved and no infection was present. In a patient with osteoarticular pain and a previous history of candidal infection with possible candidemia, one should maintain suspicion for fungal osteomyelitis.
ABSTRACT
Chance fractures by definition are a type of flexion-distraction injury with concomitant vertebral body fracture. Although uncommon in the pediatric population, they are associated with motor vehicle accidents and typically involve the thoraco-lumbar spine. Injury occurs when the spine rotates about a fixed axis, such as a lap belt. Our case reports the management of a five-year-old girl involved in a head-on collision who suffered a purely ligamentous flexion-distraction injury (Chance-type injury, without bone involvement) at the L2-L3 vertebral level. Previously these injuries were managed conservatively with serial casting; however, we present a case in which surgical management was used. A five-year-old girl sustained multiple injuries after being involved in a high-speed motor vehicle accident. At presentation, there was obvious abdominal bruising with a seat-belt sign and marked kyphosis of the spine with severe tenderness at the L2-L3 level. She required immediate exploratory laparotomy for her intraabdominal injuries. After stabilization, an orthopedic consult was deemed necessary. She was found to have occipital-cervical injury with mild anterolisthesis of C2 on C3 and disruption of the apical ligament. There was evidence of bilateral dislocation of the L2-L3 facet joints with marked disruption of the posterior ligaments and a hematoma sack. She required open reduction and internal fixation with an L2-L3 laminectomy, pedicle screw and rod placement. The kyphotic deformity was reduced using a compression device and stable alignment was achieved intraoperatively. This was a rare and difficult case with limited evidence on the appropriate management of such an injury. Due to the severe instability of her injury, a surgical approach was taken. At two years postoperative, the patient is neurologically intact and pain free. Imaging revealed stable alignment of her lumbar hardware. Ultimately, this has resulted in an excellent outcome at the current follow-up.