T. Minasian et al. / Case Reports in Clinical Medicine 2 (2013) 348-3 50 349
disseminate via the bloodstream to the brain, meninges,
bone marrow, and skin. Bone involvement, usually os-
teolytic, is documented in 5% - 10% of patients with
cryptococcal infection. Differential diagnosis must be
determined to rule out neoplastic lesions or osseous tu-
berculosis [4-6]. Moreover, diabetes mellitus can in-
crease incidence rates of infection with Cryptococcus
neoformans. This infection is common in adults with an
average age of 60 to 62 years old, affecting males more
so than females, with a predominance of 55% - 75% [1].
The yeast is known for its opportunistic infection, es-
pecially in those who are immunosuppressed and immu-
nocompromised. Infection in the United States prior to
1980 with Cryptococcus neoformans was less than one
case per million persons per year. In the 1980’s during
the AIDS epidemic, the incidence in creased to 5% - 10%
of AIDS patients. With advances in antiretroviral therapy,
the annual incidence rate has decreased to seven cases
per 1000 people in the year 2000 [7]. It is very rare for
immunocompetent patients to be afflicted with this
disease, with amounts estimated to be 0.2 per million per
year [2]. There have been few documented cases re-
porting thoracic vertebral cryptococcus with cord com-
pression [8]. However, to our knowledge and extensive
research, there have been no previously documented
presentations of an isolated lumbar vertebral crypto-
coccosis [9].
We are reporting a case of an unusual presentation of a
pathologically proven case of isolated cryptococcosis
infection to a single level lumbar vertebral body in an
immunocompetent patient.
2. CASE REPORT
A 51-year-old Pakistani male presented with low back
pain and fever for 15 days associated with chills and
night sweats. Other symptoms reported include urinary
hesitancy, dysuria, and fatigue. He described the severity
of his pain as 10/10, sharp, increasing with movement,
and located in the mid-lumbar region. However, he
denied any weight loss, headaches, dizziness, blurred
vision, cough, or nasal discharge. He also denied sore
throat, neck stiffness, chest pain, hematuria, or loss of
balance. The patient denied pain, paresthesias, or weak-
ness radiating into the bilateral lower extremities, saddle
anesthesia, or bladder or bowel incontinence.
The patient’s past medical history was significant for
Type II Diabetes Mellitus for ten years and he had been
on Metformin. The patient reported chewing tobacco for
16 years with no use in the previous 10 years. The patient
lived in Virginia and was employed as a truck driver.
Patient denied illicit drug us e.
Upon physical examination, the patient was awake,
alert, and oriented to person, place, time, and event. Vital
signs were stable except sinus tachycardia. No lympha-
denopathy was noted. His exam was significant for
tenderness to palpation along Lumbar 2, 3, 4 spinous
processes with no tenderness to percussion. Normal
muscle tone was present, and no atrophy noted. No evi-
dence of trauma to the lumbar region. He had 5/5 muscle
strength bilaterally in his upper and lower extremities.
Normal deep tendon reflexes were noted, without any
long tract signs. Rectal exam was intact.
Differential diagnosis for a 51-year-old immunocom-
petent male presenting with an isolated lumbar vertebral
body lytic lesion must include an infectious etiology, but
given the location of the lesion in addition to the pa-
tient’s complaint of urinary hesitancy/urgency, a meta-
static lesion from the prostate to the vertebral body must
be excluded.
Laboratory workup revealed a WBC count of 8.2, HgB
of 14.1, Hct of 42.1, and Platelet count of 240. ESR and
CRP values were elevated, 77 and 4.26, respectively. His
tumor markers (AFP, CEA, CA 19-9, CA 125, B-HCG,
and PSA) were all neg ative. His HIV and Hepatitis p anel
were also negative. Blood cultures were negative on
three separate occasions. His urinalysis was positive for
2+ glucose but urine culture was ne gat i ve.
CSF was clear with WBC 61, RBC 3, Lymphocytes
100, Glucose 92 and Protein 81. His Cryptococcus anti-
gen, Histoplasmosis, and India Ink all came back nega-
tive. Microbiology culture was po sitive for Cryptococcus
neoformans. The patient was found to have a negative
protein electrophoresis for multiple myelo ma.
A CT chest/abdomen/pelvis was performed and no
masses or other sources of primary neoplasm were iden-
tified. Other studies including dedicated spine CT were
performed and a lytic lesion was identified in the L4
vertebral body. There was no evidence of canal compro-
mise on MR imaging. An Interventional Radiology CT
guided L4 vertebral lytic lesion biopsy was performed.
Microsections demonstrated diffuse acute and chronic in-
flammatory exudate with non-caseating granulomas. No
normal hematopoiesis tissue was present. There were nu-
merous small to intermediate size encapsulated yeast
forms occurring singly and occasionally as narrow-based
budding yeasts. The microorganisms were morphologi-
cally suggestive of Cryptococcus by fungal stain (GMS
with adequate controls) (Figure 1).
3. DISCUSSION
Certain predisposing factors make the vertebral co-
lumn a suitable site for infection, including the lack of
epiphyseal growth, voluminous, yet slow blood supply,
and the presence of bone marrow within the vertebral
body. Approximately 40% of the cases of vertebral os-
teomyelitis lack an obvious port of entry [1].
Cryptococcus can infect any organ in the body, but has
a predilection for the lung and central nervous system
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