A 32-year-old male with a history of intravenous drug use and hepatitis B and C presented with a 2-month history of progressive limited cervical range of motion, neck pain, bilateral upper extremity weakness, and paresthesias. His examination revealed mild 4/5 bilateral upper extremity weakness, right greater than left, with mild bilateral hyperreflexia, and significant kyphosis.
The computed tomography (CT) scan demonstrated severe bony erosion of the C6-C7 vertebral bodies with kyphosis and retropulsion of bone into the central canal, resulting in marked cord/root compression [Figure 1a]. The magnetic resonance imaging (MRI) demonstrated extensive prevertebral swelling, while contrast enhancement showed erosive lesions involving the C6 and C7 vertebral bodies with epidural phlegmon extending from C4 to C7-T1 [Figure 1b-d].
Laboratory studies demonstrated nonspecific markers of inflammation (e.g., erythrocyte sedimentation rate [ESR] of 24 mm/h, and C-reactive protein [CRP] of 23.1 mg/L). Blood cultures before antibiotic or antifungal therapy were negative. The patient tested negative for human immunodeficiency virus and tuberculosis.
The patient underwent a C6 and C7 anterior corpectomy with instrumented fusion (e.g., placement of an expandable cervical cage and C5 to thoracic [T] 1 anteriorly). Intraoperatively, frank pus was noted within the C6-C7 disc space and was accompanied by thick prevertebral and epidural phlegmon extending from C5 to T1. Three days later, a C6-C7 laminectomy with C4-T2 posterior instrumented fusion was performed [Figure 2]. Intraoperative cultures again grew only Candida albicans. He was treated with intravenous micafungin followed by 6-12 months of 400 mg fluconazole. Three months postoperatively, the patient is doing well without complication but is continuing his oral antifungal therapy along with physical therapy.