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Koutserimpas C, Chamakioti I, Raptis K, Alpantaki K, Vrioni G, Samonis G. Osseous Infections Caused by Aspergillus Species. Diagnostics (Basel) 2022; 12:diagnostics12010201. [PMID: 35054368 PMCID: PMC8774735 DOI: 10.3390/diagnostics12010201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Osteomyelitis caused by Aspergillus spp. is a severe, but rare, clinical entity. However, clear guidelines regarding the most effective medical management have not yet been established. The present study is a literature review of all such cases, in an effort to elucidate epidemiology, as well as the therapeutic management and the infection’s outcome. Methods: A thorough review of all reports of osteomyelitis of the appendicular and the axial skeleton, without the skull and the spine, caused by Aspergillus spp. was undertaken. Data about demographics, imaging techniques facilitating diagnosis, causative Aspergillus, method of mold isolation, antifungal treatment (AFT), surgical treatment, as well as the infection’s outcome were recorded and evaluated. Results: A total of 63 cases of osseous infection due to Aspergillus spp. were identified. The studied population’s mean age was 37.9 years. The most commonly affected site was the rib cage (36.8%). Most hosts suffered immunosuppressive conditions (76.2%). Regarding imaging methods indicating diagnosis, computer tomography (CT) was performed in most cases (42.9%), followed by plain X-ray (41.3%) and magnetic resonance imaging (MRI) (34.9%). The most frequent isolated mold was Aspergillus fumigatus (49.2%). Cultures and/or histopathology were used for definite diagnosis in all cases, while galactomannan antigen test was additionally used in seven cases (11.1%), polymerase chain reaction (PCR) in four cases (6.3%), and beta-d-glucan testing in three cases (4.8%). Regarding AFT, the preferred antifungal was voriconazole (61.9%). Most patients underwent surgical debridement (63.5%). The outcome was successful in 77.5%. Discussion: Osteomyelitis due to Aspergillus spp. represents a severe infection. The available data suggest that prolonged AFT in combination with surgical debridement is the preferred management of this infection, while identification of the responsible mold is of paramount importance.
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Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (K.R.)
| | - Ifigeneia Chamakioti
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (K.R.)
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (K.R.)
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, “Venizeleion” General Hospital of Heraklion, 17121 Heraklion, Greece;
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, 71500 Heraklion, Greece
- Correspondence: ; Tel.: +30-6948712130
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Foong B, Wong KPL, Jeyanthi CJ, Li J, Lim KBL, Tan NWH. Osteomyelitis in Immunocompromised children and neonates, a case series. BMC Pediatr 2021; 21:568. [PMID: 34895166 PMCID: PMC8665553 DOI: 10.1186/s12887-021-03031-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteomyelitis in immunocompromised children can present differently from immunocompetent children and can cause devastating sequelae if treated inadequately. We aim to review the aetiology, clinical profile, treatment and outcomes of immunocompromised children with osteomyelitis. METHODS Retrospective review of all immunocompromised children aged < 16 years and neonates admitted with osteomyelitis in our hospital between January 2000 and January 2017, and referred to the Paediatric Infectious Disease Service. RESULTS Fourteen patients were identified. There were 10 boys (71%), and the median age at admission was 70.5 months (inter-quartile range: 12.3-135.0 months). Causal organisms included, two were Staphylococcus aureus, two were Mycobacterium bovis (BCG), and one each was Mycobacterium tuberculosis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia pseudomallei and Rhizopus sp. One patient had both Clostridium tertium and Clostridium difficile isolated. Treatment involved appropriate antimicrobials for a duration ranging from 6 weeks to 1 year, and surgery in 11 patients (79%). Wherever possible, the patients received treatment for their underlying immunodeficiency. For outcomes, only three patients (21%) recovered completely. Five patients (36%) had poor bone growth, one patient had recurrent discharge from the bone and one patient had palliative care for underlying osteosarcoma. CONCLUSIONS Although uncommon, osteomyelitis in immunocompromised children and neonates can be caused by unusual pathogens, and can occur with devastating effects. Treatment involves prolonged administration of antibiotics and surgery. Immune recovery also seems to be an important factor in bone healing.
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Affiliation(s)
- Bryan Foong
- Singapore General Hospital, Singapore, Singapore.
| | - Kenneth Pak Leung Wong
- Department of Orthopedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Carolin Joseph Jeyanthi
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Deparment of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jiahui Li
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Infectious Disease Service, Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin Boon Leong Lim
- Department of Orthopedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Natalie Woon Hui Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Infectious Disease Service, Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Perna A, Ricciardi L, Fantoni M, Taccari F, Torelli R, Santagada DA, Fumo C, Tamburrelli FC, Proietti L. Spontaneous Vertebral Aspergillosis, the State of Art: A Systematic Literature Review. Neurospine 2020; 18:23-33. [PMID: 33211946 PMCID: PMC8021829 DOI: 10.14245/ns.2040338.169] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/23/2020] [Indexed: 01/07/2023] Open
Abstract
Objective Vertebral aspergillosis is quite rare conditions, often misdiagnosed, that requires long-term antibiotic therapy, and sometimes, surgical treatments. The present investigations were aimed to investigate the epidemiology, clinical-radiological aspects, treatment protocols, and outcomes of Aspergillus-mediated vertebral osteomyelitis.
Methods A systematic review of the pertinent English literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. The research was conducted on Cochrane library, MEDLINE, PubMed, and Scopus using as search-terms “Aspergillus,” “vertebral osteomyelitis,” “spondylodiscitis,” “spine infection.” A case of vertebral aspergillosis conservatively managed was also reported.
Results Eighty-nine articles were included in our systematic review. Including the reported case, our analysis covered 112 cases of vertebral aspergillosis. Aspergillus fumigatus was isolated in 68 cases (61.2%), Aspergillus flavus in 14 (12.6%), Aspergillus terreus in 4 (3.6%), Aspergillus nidulans in 2 (1.8%). Seventy-three patients (65.7%) completely recovered at the last follow-up evaluation; in 7 patients (6.3%) radiological signs of chronic infection were reported, whereas 32 patients (28.8%) died during the follow-up.
Conclusion This systematic review summarized the state of the art on vertebral aspergillosis, retrieving data on clinical features, diagnostic criteria and current limitations, treatment alternatives, and their outcomes.
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Affiliation(s)
- Andrea Perna
- UOC Chirurgia Vertebrale, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Rome, Italy
| | - Luca Ricciardi
- UO di Neurochirurgia, Pia fondazione di Culto e Religione Cardinal G. Panico, Tricase, Italy.,UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Facoltà di Medicina e Psicologia, Sapienza, Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Dipartimento di Sicurezza e Bioetica, Università Cattolica S. Cuore, Rome, Italy
| | - Francesco Taccari
- Dipartimento di Sicurezza e Bioetica, Università Cattolica S. Cuore, Rome, Italy
| | - Riccardo Torelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Domenico Alessandro Santagada
- UOC Chirurgia Vertebrale, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Rome, Italy.,Istituto di clinica ortopedica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Caterina Fumo
- UOC Chirurgia Vertebrale, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Rome, Italy
| | - Francesco Ciro Tamburrelli
- UOC Chirurgia Vertebrale, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Rome, Italy.,Istituto di clinica ortopedica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Proietti
- UOC Chirurgia Vertebrale, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Rome, Italy.,Istituto di clinica ortopedica, Università Cattolica del Sacro Cuore, Rome, Italy
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Gupta D, Raghav S, Kaushal M. Frontal swelling in adult male: Cytological consideration of an uncommon diagnosis. Cytojournal 2020; 17:5. [PMID: 32395149 PMCID: PMC7210467 DOI: 10.25259/cytojournal_79_2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/27/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Deepika Gupta
- Department of Pathology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sonia Raghav
- Department of Pathology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Manju Kaushal
- Department of Pathology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Menon A, Rodrigues C, Soman R, Sunavala A, Agashe VM. Aspergillus Osteomyelitis of the Ribs in Immunocompetent Hosts: Report of Two Rare Cases. J Orthop Case Rep 2017; 7:61-64. [PMID: 29181357 PMCID: PMC5702709 DOI: 10.13107/jocr.2250-0685.854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Osteomyelitis is rarely caused by fungi, most common among them being Candida. Aspergillus is a rare cause of fungal osteomyelitis mimics tuberculous osteomyelitis. Aspergillus osteomyelitis (AO) of the ribs is relatively uncommon, with an incidence rate of only 9% among all reported cases of AO. With mortality rates of almost 25%, AO is on the rise attributed to increasing numbers of immunocompromised individuals. There are very few case reports of AO of ribs in immunocompetent individuals. We report two such cases. Case Report Case 1: A 51-year-old male developed spontaneous chest pain along right costal margin with a low-grade fever. High-resolution computed tomography chest revealed osteomyelitis of anterolateral chest wall. He did not improve with empirical antitubercular therapy, and subsequent debridement showed polymicrobial pyogenic infection which was managed with appropriate antibiotics elsewhere. Samples were not sent for fungal culture. He presented to us 3 months later, and surgical debridement showed growth of Aspergillus flavus which was managed with oral voriconazole. The lesion healed with no recurrence at 24-month follow-up. Case 2: A 40-year-old male presented to our institute with left-sided chest pain, low-grade fever, and loss of appetite. There was a history of injury with a sharp piece of wood 2 years earlier. Magnetic resonance imaging defined the lesion which was biopsied under ultrasound guidance. Cultures grew A. flavus which was treated with oral voriconazole. He had complete clinical improvement at 16-month follow-up. Conclusion More number of AO cases are being reported in immunocompetent individuals. Variability in clinical picture, rarity, misdiagnosis, empirical therapy, and failure to send deep tissue samples for fungal cultures are some of the reasons for the high mortality rates. It is paramount in today's scenario of atypical presentations, to obtain deep tissue for all cultures including fungal culture and histopathology, either surgically or under image guidance to achieve good clinical outcomes. Our study highlights that following the strict protocol of obtaining tissue for fungal culture, systemic antifungal therapy, and surgical debridement where necessary can help to diagnose and treat this rare pathology and ensure the good clinical outcome.
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Affiliation(s)
- Aditya Menon
- Department of Orthopedics, P.D. Hinduja Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India
| | - Camilla Rodrigues
- Department ofMicrobiology, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Rajeev Soman
- Department of Internal Medicine, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ayesha Sunavala
- Department of Internal Medicine, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vikas M Agashe
- Department of Orthopedics, P.D. Hinduja Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India
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Section J, Gibbons SD, Barton T, Greenberg DE, Jo CH, Copley LAB. Microbiological culture methods for pediatric musculoskeletal infection: a guideline for optimal use. J Bone Joint Surg Am 2015; 97:441-9. [PMID: 25788299 DOI: 10.2106/jbjs.n.00477] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Culture results affect the diagnosis and treatment of children with musculoskeletal infection. To our knowledge, no previous large-scale study has assessed the relative value of culture methods employed during the evaluation of these conditions. The purpose of this study was to identify an optimal culture strategy for pediatric musculoskeletal infection. METHODS Children with musculoskeletal infection were retrospectively studied to assess culture results from the infection site or blood; culture type, including aerobic, anaerobic, fungal, and acid-fast bacteria (AFB); antibiotic exposure history; and clinical history of children with positive culture results. RESULTS We studied 869 children, including 353 with osteomyelitis, 199 with septic arthritis, forty-two with pyomyositis, and 275 with abscess. The 4537 cultures processed included 1303 aerobic, 903 anaerobic, 340 fungal, 289 AFB, and 1702 blood. Of 3004 specimens sent during initial work-up, positive results occurred in 677 of 1049 aerobic cultures (64.5%), 140 of 763 blood cultures (18.3%), eighteen of 722 anaerobic cultures (2.5%), five of 251 fungal cultures (2.0%), and two of 219 AFB cultures (0.9%). Staphylococcus aureus was the most common pathogen isolated, from 428 (50.7%) of 844 children for whom blood or infection-site culture material was sent (methicillin-resistant S. aureus, 252; and oxacillin-sensitive S. aureus, 176). Cultures were negative in 206 (29.0%) of the 710 children for whom culture material from the site of infection was sent. Children with true-positive anaerobic, fungal, or AFB cultures had a history of immunocompromise, penetrating inoculation, or failed primary treatment. Antibiotic exposure prior to culture-sample acquisition did not interfere with aerobic culture results from the site of infection. CONCLUSIONS Our findings suggest that anaerobic, fungal, and AFB cultures should not be routinely performed during the initial evaluation of children with hematogenous musculoskeletal infection. These cultures should be performed for children with immunocompromise, clinical suspicion of penetrating inoculation, or failed primary treatment.
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Affiliation(s)
- Jarren Section
- University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9113. E-mail address for J. Section: . E-mail address for S.D. Gibbons: . E-mail address for D.E. Greenberg:
| | - Steven D Gibbons
- University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9113. E-mail address for J. Section: . E-mail address for S.D. Gibbons: . E-mail address for D.E. Greenberg:
| | - Theresa Barton
- Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Avenue, C.0630.56, Houston, TX 77030. E-mail address:
| | - David E Greenberg
- University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9113. E-mail address for J. Section: . E-mail address for S.D. Gibbons: . E-mail address for D.E. Greenberg:
| | - Chan-Hee Jo
- Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address:
| | - Lawson A B Copley
- Children's Medical Center Dallas, 1935 Medical District Drive, Dallas, TX 75235. E-mail address:
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Raj KA, Srinivasamurthy BC, Nagarajan K, Sinduja MGI. A rare case of spontaneous Aspergillus spondylodiscitis with epidural abscess in a 45-year-old immunocompetent female. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 4:82-4. [PMID: 24744568 PMCID: PMC3980562 DOI: 10.4103/0974-8237.128538] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vertebral osteomyelitis and discitis are mainly due to bacterial infections though fungal infections are one of the important causes of morbidity and mortality in immunocompromised patients. Aspergillus involving intervertebral disc space is extremely rare. We report a case of aspergillosis of intervertebral L5-S1 disc space with spinal epidural abscess in an immunocompetent 45-year-old female which can add on to a few case reports described in literature as well as an insight for clinicians regarding this rare spontaneous infection in an immunocompetent patient.
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Affiliation(s)
- K Ambedkar Raj
- Department of Pathology, Sri Manakula Vinayagar Medical College, Puducherry, India
| | | | - Krishnan Nagarajan
- Department of Radiology, Sri Manakula Vinayagar Medical College, Puducherry, India
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Tobal JM, Balieiro MEDSF. Role of carbonic anhydrases in pathogenic micro-organisms: a focus on Aspergillus fumigatus. J Med Microbiol 2014; 63:15-27. [DOI: 10.1099/jmm.0.064444-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprophytic fungus responsible for organic material decomposition, and plays an important role in recycling environmental carbon and nitrogen. Besides its important role in the environment, this fungus has been reported as one of the most important fungal pathogens in immunocompromised patients. Due to changes in CO2 concentration that some pathogens face during the infection process, studies have been undertaken to understand the pathogenic roles of carbonic anhydrases (CAs), well-known CO2 hydration catalytic enzymes. As a basis for a discussion of the possible roles of CAs in A. fumigatus pathogenicity, this review describes the main characteristics of the A. fumigatus infection and the challenges for its treatment. In addition, it gathers findings from studies with CA inhibitor drugs as anti-infective agents in different pathogens.
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Affiliation(s)
- Jaqueline Moisés Tobal
- Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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D'sa SR, Singh S, Satyendra S, Mathews P. Case report of Aspergillus osteomyelitis of the ribs in an immunocompetent patient. J Glob Infect Dis 2013; 5:118-20. [PMID: 24049367 PMCID: PMC3766334 DOI: 10.4103/0974-777x.116875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aspergillus is a saprophytic fungus which is universally found in the environment. Most people breathe in the spores of Aspergillus every day without development of disease. It commonly affects immunocompromised hosts. There are only few reported cases in an immunocompetent host. It most commonly affects the respiratory system, causing superficial or invasive disease. It also affects the skin, brain and eye in severely immunocompromised patients. Aspergillosis of the bone is extremely rare. Amongst all the reported cases of invasive aspergillosis the incidence of osteomyelitis is less than three percent. In these cases commonly of the spine is reported. We present a case of Aspergillus osteomyelitis of the ribs in an immunocompetent host.
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Affiliation(s)
- Shilpa Reynal D'sa
- Department of Medicine, Christian Medical College and Hospital, Ida Scudder Road, Vellore, Tamil Nadu, India
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Abstract
Fungal infections are one of the important cause of morbidity and mortality in immunocompromised patients. Aspergillus vertebral osteomyelitis is extremely rare. We report two cases of aspergillus vertebral osteomyelitis in immunocompetent men in the absence of an underlying disorder. The clinical and radiological findings were suggestive of Pott's spine. The absolute CD4, CD8 counts and their ratio were normal. The HIV status was negative in both patients. Both patients underwent surgical decompression. The histopathology of tissue obtained were suggestive of aspergillus osteomyelitis. One patient had antifungal treatment for 3 months and was doing well at 1 year followup, whereas other patient did not turnup after 2 months.
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Affiliation(s)
- Somika Sethi
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India,Address for correspondence: Dr. Somika Sethi, Department of Pathology, Sir Ganga Ram Hospital, New Delhi – 110060, India. E-mail:
| | - Fouzia Siraj
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
| | - KL Kalra
- Department of Orthopedics, Sir Ganga Ram Hospital, New Delhi, India
| | - P Chopra
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
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