A 62-year-old female was admitted to our department because of a rise of back pain. She had a history of mantle cell lymphoma. She had been treated with chemotherapy for 2 years prior to admission. The Follow-up studies have not revealed any evidence of recurrence. About 2 months before visiting our clinic, her back pain developed. At that time, she visited local pain clinics and was treated with medication and injection. Her intercostal neuralgia aggravated during the period of conservative treatment. Then, she received thoracic magnetic resonance imaging (MRI) (Fig.1) and the result of the exam showed hypointense at T4 vertebral body, right pedicle and lamina in T1-weighted image. In addition, computed tomography (CT) showed osteolytic lesion in T4 right vertebral body, pedicle and facet joint. (Fig.1) Based on imaging studies, metastatic tumor was highly suspected. For a further examination and therapy, the patient was referred to our spine clinic.
Treatment
After admission to our clinical, chest and abdominal CT were checked to evaluate the disease status. There was no evidence of distant metastasis to internal organ or thorax. Lab examinations showed slight elevation of C-reactive protein (CRP) (38.40 mg/L; normal range, 0–5 mg/L). However, antibody of aspergillus (IgG), galactomannan(GM)and Fungal D-glucan tests were all negative. CA-724 was the only one tumor marker that mildly elevated (47.93ng/ml, normal range, 0–6.9 ng/ml). percentage of Lymphocyte and monocytes were 15.80% (normal rage,20-50) and 10.40% (normal rage 3-10), respectively. White blood cell (WBC) count was 3360/µL (normal range, 4000-10000/µL). Because she had a mantle cell lymphoma at this time, slight elevation of CRP was thought to be reasonable. In that period, her intercostal neuralgia aggravated and systemic symptom such as fever was not given enough attention. Because the patient has severe chest pain and intercostal neuralgia and is unable to sleep, he needs oral oxycodone tablets 40mg, twice a day, as well as morphine injection to assist in analgesia. And her SINS score was about 9, there was spinal instability, there were signs of surgical intervention, so we decided to give the patient surgical treatment.
The operation was performed with a posterior approach. First, posterior pedicle screw fixation was performed from T2.3 .5.6. Second, decompression was followed. T4 spinous process resection and right laminectomy were performed for decompression. Soft tissue invasion of right lamina, pedicle, right facet joint and right transverse facet joint were found during the operation. Fully scrape out the diseased tissue, saw rich blood supply, fully wash and implant allogeneic bone strips. Definitive pus-like discharge was not found, and soft material was identifiable in the center of T4 vertebral body. We obtained those materials and requested for pathologic examination. Before suturing the incision, we routinely washed the incision with saline more than 3000ml.Postoperative administration of common antibiotics to prevent infection.
Outcomes
Final pathologic result showed small yeast-like organisms with Gomori methenamine silver, Fontana Masson, periodic acid-Schiff and Alcian blue stains (Fig.2). No tumor cells were shown by cytokeratin immunohisto chemical staining. Amphotericin B (50 mg/day) and fluconazole (800 mg/day) were applied intravenously for about 1 week until disseminated cryptococcosis was ruled out. Then, fluconazole (450 mg/day) was applied orally for about 1 year. At the 3-months follow-up, back pain disappeared without any complications, and no specific abnormal findings were observed in plain radiographs (Fig.3).