Aspergillus osteomyelitis of the proximal humerus: a case report

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review

Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.

Osseous Infections Caused by Aspergillus Species

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.

Native Joint Infections by Aspergillus Species

Background: Septic arthritis due to Aspergillus spp. represents a rare, but severe disease. Nevertheless, clear guidelines regarding most effective medical treatment have not yet been established. The present study is a literature review of all reported cases of fungal septic arthritis due to Aspergillus spp, in order to clarify epidemiology, as well as the medical and operative management and their outcome. Methods: A meticulous review of all published septic arthritis infections due to Aspergillus has been conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical intervention, as well as the infection’s outcome were recorded and evaluated. Results: A total of 30 Aspergillus spp. strains from 29 hosts have been studied. The patients’ mean age was 45.8 years. The most commonly affected joint was the knee (45.7%), while the predominant symptom was joint pain (62%). Most patients were immunocompromised (72.4%). Diagnosis was established through cultures and/or histopathology. Aspergillus fumigatus was the most common responsible fungi (63.3%), followed by A. flavus (16.6%) and A. terreus (10%). Regarding AFT, the preferred agent proved to be Amphotericin B (14 cases; 48.3%), followed by voriconazole (11; 37.9%), while the mean AFT duration was 5.6 months. In most cases surgical treatment was also performed (in 4 cases no surgery was reported). Treatment was effective in 20 cases (69%). Conclusions: Septic arthritis caused by Aspergillus spp. represents a severe clinical entity. It seems that, with the available data, prolonged AFT along with surgical intervention is the preferred management of this infection, while identification of the responsible fungus is of utmost importance.

Aspergillus Osteomyelitis of the Scapula: A Case Report

CASE

A 52-year-old man known for a recent cardiac transplantation presented with 6 weeks of incapacitating left shoulder pain with normal x-rays and CT scans. MRI revealed bone edema of the coracoid and glenoid neck with a supraspinatus abscess. Biopsy of the coracoid demonstrated Aspergillus osteomyelitis of the scapula.

CONCLUSION

Aspergillus osteomyelitis is a rare manifestation of invasive aspergillosis and mostly manifests as spondylodiscitis. In this report, we describe a case of Aspergillus osteomyelitis of the scapula treated with combined antifungal therapy and surgery.

Investigating clinical characteristics and prognostic factors in patients with chronic osteomyelitis of humerus

Background

Chronic osteomyelitis in the humerus, which has complex neuroanatomy and a good soft tissue envelope, represents a unique clinical challenge. However, there are relatively few related studies in the literature. This article retrospectively reviewed a large case series with the aims of sharing our management experiences and further determining factors associated with the outcomes.

Methods

Twenty-eight consecutive adult patients with a mean age of 36 years were identified by reviewing the osteomyelitis database of our clinic centre. The database was used to prospectively identify all osteomyelitis cases between 2013 and 2017, and all data then was retrospectively analysed.

Results

The mean follow-up period was 35 months (range 24–60). The aetiology was trauma in 43% (12) of the patients and haematogenous in 57% (16) of the patients, and Staphylococcus aureus was a solitary agent in 50% (14) of the patients. Host-type (Cierny’s classification) was IA in 8, IIIB in 11 and IVB in 9 patients. All patients required debridement followed by the placement of a temporary antibiotic-impregnated cement spacer (rod). Seventeen patients received a cement-coated plate for internal fixation after debridement, and 13 patients needed bone grafts when the spacer was staged removed. All patients attained an infection-free bone healing state at the final follow-up. The final average DASH (disabilities of the arm, shoulder and hand) score was 18.14 ± 5.39, while 6 patients (two developed traumatic olecranarthritis, four developed radial nerve injuries) showed the lowest levels of limb function (p = 0.000) and were unemployed. Three patients (type I; significant difference between type I versus type III and type IV patients, p < 0.05) experienced recurrence after debridement and underwent a second revision, which was not related to the bone graft (p = 0.226) or plate fixation (p = 0.050).

Conclusions

Humeral chronic osteomyelitis can be treated with general surgery and anti-infective therapy; medullary (type I) infection presents a challenge, and the antibiotic-coated cement plate provides favourable fixation without increasing recurrence of infections. Clinicians should be aware of potential iatrogenic nerve injuries when treating these patients with complicated cases, and an experienced surgeon may improve the outcome.

Histopathological implications of Aspergillus infection in lung

This paper opens with a discussion on the significance of invasive fungal infections in advanced contemporary medicine, with an emphasis on the intractability of disease management and the difficulties of diagnosis. This is followed by a discussion concerning classification, histopathological features, and pathophysiology. While it has been largely accepted that Aspergillus species is recognized by cellular receptors and attacked by neutrophils, the radiological and macroscopic findings linking infection with neutropenia remain unconfirmed. In an effort to gain a better understanding of the pathophysiology and pathogenesis of invasive aspergillosis, we wish to emphasize the utility of radiological and histopathological examinations since these can provide detailed information on the extremely complex interaction between the causative microbes and tissue responses. A review of noninvasive or semi-invasive aspergillosis is also provided, with particular emphasis on chronic necrotizing pulmonary aspergillosis, which is recognized as a transition form of simple pulmonary aspergilloma and invasive pulmonary aspergillosis, although few findings have been reported in this area.

Osteomyelitis caused by Aspergillus species: a review of 310 reported cases

Aspergillus osteomyelitis is a rare infection. We reviewed 310 individual cases reported in the literature from 1936 to 2013. The median age of patients was 43 years (range, 0-86 years), and 59% were males. Comorbidities associated with this infection included chronic granulomatous disease (19%), haematological malignancies (11%), transplantation (11%), diabetes (6%), pulmonary disease (4%), steroid therapy (4%), and human immunodeficiency virus infection (4%). Sites of infection included the spine (49%), base of the skull, paranasal sinuses and jaw (18%), ribs (9%), long bones (9%), sternum (5%), and chest wall (4%). The most common infecting species were Aspergillus fumigatus (55%), Aspergillus flavus (12%), and Aspergillus nidulans (7%). Sixty-two per cent of the individual cases were treated with a combination of an antifungal regimen and surgery. Amphotericin B was the antifungal drug most commonly used, followed by itraconazole and voriconazole. Several combination or sequential therapies were also used experimentally. The overall crude mortality rate was 25%.