lNTRODUCTlON

() is a rare and aggressive filamentous fungus widely distributed in contaminated water, wetlands, decaying plants, stagnant water, and potted plants in hospitals[1,2]. Immunocompetent individuals become vulnerable to this fungus following near drowning events[3]. In the case reported here, the patient had not experienced a recent near drowning event and had not been exposed to contaminated water or decaying plants.infection occurs in patients with organ transplantation, acquired immunodeficiency syndrome (AIDS), long-term use of immunosuppressants, immune dysfunction of other causes, and invasion of the lung, bone, joints, eyes, brain, skin, and other organs[4-7] (Table 1). There have been no previous case reports ofinfection of lumbar vertebrae; most reports have focused on infection of the lung.

CASE PRESENTATlON

Chief complaints

An otherwise healthy 60-year-old man presented with a 4-mo history of lumbosacral pain, stooped back, and restricted walking with no obvious cause. The symptoms had become significantly aggravated 10 d prior to hospitalization.

History of present illness

This patient had a 4-mo history of lumbosacral pain with no obvious cause, along with stooped and restricted walking. He had visited a local hospital and received Chinese medicine. The patient’s lumbosacral pain worsened, and oral pain medication was not effective. 10 d before admission, the symptoms were further aggravated and radiating pain developed in the back of his left lower leg, which was so strong he could not walk. The patient again visited a local hospital, and lumbar vertebrae computed tomography (CT) showed lumbar vertebral infection. The patient was referred to our hospital due to lumbar vertebral infection.

When Sonali came home from school, I let her play for an hour before I told her the news. I wanted to savor8 the innocence9 of her not knowing Daddy was dead. When she heard Alan s plane had crashed and he was not coming home, she wailed10 a cry so deep and heartbreaking, a cry I pray I will never hear again from any living being. She sobbed11 for an hour straight, and then she looked me in the eyes and said, I am so sad. But I m not the saddest girl in the world. Some children have lost their mommy and their daddy, and I still have you.

History of past illness

The patient had no relevant past medical history.

Personal and family history

No special personal and family history.

Physical examination

But he didn t take the huntsmen into the wood with him, and they were well enough pleased to remain behind, for the wild boar had often received them in a manner which did not make them desire its further acquaintance

Laboratory examinations

At admission, his laboratory data were as follows:Erythrocyte sedimentation rate (ESR) 120 mm/h (normal range 0-15 mm/h), C-reactive protein (CRP) 8.33 mg/dL (＜ 0.8 mg/dL), fibrinogen (FIB) 8.26 g/L (1.8-3.5 g/L), fibrinogen degradation products (FDP) 9.2 μg/mL (0-5 μg/mL), and D-dimer 3.5 mg/L (0-0.55 mg/L). However, tumor markers, brucellosis agglutination, tuberculosis cell immunoassay, and sputum acid-fast bacilli smear were negative.

Imaging examinations

After 1 wk of hospitalization, the patient underwent surgical intervention. After induction of general anesthesia, a surgical incision was made at the median of the lower back, starting at the spinous process of the L3 vertebra and ending at the spinous process of the S1 vertebra (length about 15 cm). The right vertebral lamina and zygapophysial joint of the L3 to S1 vertebrae were first revealed. Next, the left L3 to S1 vertebral zygapophysial joint was exposed (Wiltze approach). After positioningX-ray fluoroscopy, appropriately sized pedicle screws were implanted on both sides of the L3 to S1 vertebrae. Fluoroscopy showed that the individual pedicle screws were suitably positioned, and the L3/L4 and L5/S1 right hemivertebrae were sequentially decompressed and the articular processes of the lower right parts of the L3 and L5 vertebrae were resected. This showed destruction of the L3/L4 and L5/S1 discs and soft granulation-like tissue formation at the L3 and L5 vertebrae. In addition, destruction of endplates at the upper border of the lower, L4 and S1 vertebral bodies was evident. The lesion tissues in the intervertebral space were cleaned and sent for bacterial culture and pathological examination. This created a good bone graft surface, and medical gel foam mixed with isoniazid, rifamycin, and vancomycin was implanted into the intervertebral space. An appropriate amount of left iliac bone was removed through the incision and cut into bone blocks of appropriate size and mixed with allogeneic bone and bone induction material (recombinant human bone morphogenetic protein-2). During the operation, X-ray imaging showed sufficient bone grafting in the L3/L4 and L5/S1 intervertebral spaces. Next, we connected the bilateral posterior longitudinal connecting rod and fixed the lumbar vertebrae. Postoperative lumbar X-ray and CT imaging indicated good positioning of the lumbar internal fixation, and that bone graft placement was adequate in the L3/L4 and L5/S1 intervertebral spaces (Figure 2AE). Pathological examination results showed a large number of inflammatory cells in the tissues examined, and staining revealed PAS (+), and acid resistance (-) (Figure 2F). Tissue culture on blood agar medium was performed twice (30°C, 7 d). The resultant colonies were cashmere-like and the back was gray-black (Figure 2G). Under the microscope (× 400), lactic acid phenol cotton blue staining showed that most of the hyphae were irregularly branched, producing round or oval lateral and terminal conidia (Figure 2H) (Table 1). Three microbiologists in our hospital confirmed the culture and microscopic examination results, and all agreed on the identification as. The patient was given voriconazole (Pfizer, United States) 200 mg ivgtt every 12 h for antifungal treatment and cefoperazone sodium sulbactam (Pfizer, United States) 3 g ivgtt every 8 h to prevent postoperative infection. After 10 d, there were no abnormalities found during routine blood and biochemical analyses. The ESR was 34 mm/h (normal range 0-15 mm/h), CRP was 1.09 mg/dL (＜ 0.8 mg/dL), and PCT and interleukin-6 (IL-6) were within the respective normal ranges. The patient continued to take voriconazole for 6 mo.

CT revealed bone destruction and hyperplasia at the relative margins of the L3, L4, L5 and S1 vertebra, a small amount of low-density shadow encircling the paravertebral spaces, and bone destruction at the right sacroiliac joint surface (Figure 1B).

On magnetic resonance imaging (MRI), the bone signals of L3, L4, L5 and S1 vertebra were abnormal, showing long T1 and mixed long T2 signals. A small amount of equal-T2 signals surrounded the paravertebral space. The T2 weighted imaging signal of each intervertebral disc was weak. Annular soft tissue shadows were seen at the edges of the L3/L4, L4/L5 and L5/S1 vertebral discs. A soft tissue shadow with prominent limitations was evident at the posterior margin, and the corresponding spinal canal was slightly narrowed (Figure 1C-F).

FlNAL DlAGNOSlS

Chinese People’s Liberation Army Medical Technology Youth Training Program, No. 20QNPY071.

TREATMENT

X-ray analysis showed hyperostosis, sclerosis, and tapering of the fifth lumbar (L5) vertebra and the first sacral (S1) vertebral margins. The third lumbar (L3) vertebra to S1 vertebral margins showed local nonunion with slightly rough margins. The posterior border of L5 and S1 vertebra was incomplete, and L5 vertebra was displaced slightly posteriorly, not exceeding one quarter of the anterior posterior diameter of the S1 vertebra; the L5/S1 intervertebral space was narrowed (Figure 1A).

OUTCOME AND FOLLOW-UP

Thecomplex consists of,,,, and, of which the former three cause human infection[8].is distributed worldwide, but infections are rare. The clinical manifestations and imaging results differ according to the site of infection. Most doctors are unfamiliar withinfection, resulting in a risk of misdiagnosis. X-ray, CT, MRI, and other imaging examinations have limited diagnostic utility, typically showing only abscess formation; these modalities are mainly used for surgical planning and follow-up evaluation. Before surgery, histopathological and pathological examination, the patient was mistakenly believed to haveinfection based on the imaging findings. The diagnosis ofinfection was made by histocytology and pathology, and by isolation of the fungus in culture. Its pathological manifestations are similar toandinfection[9,10].colonies grow rapidly, and are cashmere like, white at first and subsequently gray black. Production of pigment or brown conidia, leads to gray/brown or black mature colonies. Microscopically, mosthyphae are irregularly branched, producing round or oval lateral and terminal conidia[11,12]. We analyzed lesional tissue removed at surgeryculture and microscopy, and the results were similar to those of previous reports. In immunocompetent patients, the diagnosis ofinfection is delayed by almost 6 mo; significantly longer than in near drowning patients[13,14]. If hospital facilities are inadequate or the physician has insufficient experience, the probability of misdiagnosis increases significantly.can form a fungal ball in human tissue due to fungal invasion and intravascular thrombosis, resulting in tissue necrosis[15,16].

DlSCUSSlON

At the 6-mo follow-up, the ESR, CRP, PCT, and IL-6 were all within the respective normal ranges. X-ray and MRI of the lumbar vertebrae showed that the fixation position of the L3-S1 vertebral body was good, and the density in the L3/L4 and L5/S1 intervertebral spaces was increased, showing a short T1 signal on MRI (Figure 3). The patient was able to move with the assistance of a lumbar brace. However, the activity of the lumbar spine was limited, with anterior flexion of approximately 50°, posterior extension of about 15°, left-right scoliosis, and rotational activities of about 20°; nonetheless, walking and daily life were unaffected. The patient was satisfied with the outcome, but unfortunately refused further follow-up despite being informed of the risk of recurrence.

The patient was able to stand using crutches and did not have scoliosis. Movement of the lumbar spine was significantly limited, with approximately 30° anterior flexion, kyphosis, left-right scoliosis, and rotational mobility of about 10° and tenderness of the spinous processes of the lumbar 3-5 vertebrae bilaterally. Cutaneous sensation of both lower extremities was unremarkable, muscle tone was normal, and muscle strength was class IV. Range of motion was essentially normal at the hips, knees, and ankles bilaterally, although the movements were slowed by pain. Κnee and Achilles tendon reflexes were normal bilaterally and the Babinski sign was negative.

The sites ofinfection vary and the treatment modality differs according to site. In cases of limited infective focus and feasible surgical intervention, surgical removal of the infective focus improves the prognosis. We performed surgical intervention on the diseased lumbar vertebrae of this patient, cleared the infected lesion, and performed stable fixation of the diseased vertebral body using a lumbar internal fixation device, which restored spinal stability.is resistant to most antifungal drugs, which makes treatment difficult and the prognosis poor. It is most sensitive to voriconazole, followed by posaconazole, itraconazole, and amphotericin B[17,18]; voriconazole is the first-line therapy[19-21] (Table 1). Due to the lack of prospective clinical studies, the dosage and duration of voriconazole for the treatment ofinfection are unclear. We typically decide on treatments by following the drug manufacturer’s instructions and the advice of clinical pharmacists. Our patient was discharged and took voriconazole tablets (200 mg po q12h) for 6 mo, and no drugrelated adverse effects were observed. In addition, imaging revealed no evidence of recurrence. Micafungin is the second-line agent for the treatment of. The combination of micafungin and voriconazolehas a significant effect on[22,23]. Our patient did not receive the micafungin and voriconazole combination but achieved a satisfactory outcome.

If the peri-king allows this favour, we two will manage to be your anointers, and we will put an oil on you such that if you were a thousand years in the fire not a trace of burning would remain

CONCLUSlON

infection can occur in immunocompetent individuals with no history of near drowning. Infection involving multiple vertebral bodies, intervertebral spaces, and paravertebral tissues cannot be diagnosed by imaging alone, and surgical intervention is the first-line treatment. Lesion tissues should be removed for cytological and pathological examination, and an accurate diagnosis is needed to prevent mistreatment. Multidisciplinary treatment promotes rehabilitation. Voriconazole is effective for the treatment of lumbar vertebrae infection by.

If your majesty goes out there alone, fasting, before sunrise, and takes the middle one of the three buds, and eats it, then in six months you will bring a princess into the world

Informed written consent was obtained from the patient for the publication of this report and any accompanying images.

infection of the lumbar vertebrae.

Today we buried our 20-year-old son. He was killed instantly in a motorcycle accident on Friday night. How I wish I had known when I talked to him last that it would be the last time. If I had only known I would have said, Jim, I love you and I m so very proud of you.

Shi XW, Li ST, Lou JP, and Zhang T provided the concept for the study and drafted the manuscript; Xu B, Wang X, and Wang J provided the images; Liu H, Li SΚ, Zheng P, and Zhang T performed the operations; all authors have read and approved the content of the manuscript.

The authors declare that they have no conflict of interest.

This time the dove knew better, and she answered boldly, Indeed, I shall do nothing of the sort, though her heart beat wildly with fear when she saw the jackal preparing for a spring

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

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In Brother and Sister, the tale blatantly135 makes the stepmother the evil witch who persecutes136 the children. There is no differentiation137 between the stepmother and the witch. Return to place in story.

China

In the morning, they awke outside another Howard Johnson s,and this time Vingo went in. The girl insisted that he join them. He seemed very shy, and ordered black coffee and smoked nervously5 as the young people chattered6 about sleeping on beaches. When they returned to the bus, the girl sat with Vingo again, and after a while, slowly and painfully, he told his story. He had been in jail in New York for the past four years, and now he was going home.

Xue-Wen Shi 0000-0001-8360-3453; Sheng-Tang Li 0000-0002-6004-1934; Jin-Peng Lou 0000-0002-7901-8320; Bo Xu 0000-0001-7259-9057; Jian Wang 0000-0002-3483-4092; Xin Wang 0000-0002-2623-7669; Hua Liu 0000-0003-0593-9001; Song-Kai Li 0000-0002-9200-2390; Ping Zhen 0000-0003-2864-971X; Tao Zhang 0000-0003-2308-094X.

Chen YL

Webster JR

Chen YL