Candida glabrata arthritis: case report and review of the literature of Candida arthritis

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Candida glabrata-Induced Refractory Infectious Arthritis: A Case Report and Literature Review

The incidence of deep fungal infection due to non-albicans Candida species (especially Candida glabrata) has significantly increased in recent decades. Candida glabrata is an opportunistic pathogen of low virulence which mainly invades the gastrointestinal, genitourinary, and respiratory tracts, but has rarely been reported as complication of articular surgery in the literature. We present a case of knee fungal arthritis caused by C. glabrata after a minimally invasive arthroscopic surgery. In this case, the patient's knee got infected after arthroscopic treatment for a recurrent popliteal cyst, and she was unable to be cured by either debridement or antifungal drugs. Mycological and molecular identification of the necrotic tissues isolate revealed C. glabrata as etiologic agent. We originally planned to conduct a debridement once again, but it was found that the articular cartilage was extensively damaged during the operation. Besides, the magnetic resonance imaging of the affected knee also showed that the infection had invaded the subchondral bone. So we treated this case with a two-stage primary total knee arthroplasty with an antibiotic-laden cement spacer block. After a 10-month follow-up, the patient had completely recovered and has not experienced any recurrence to date. In addition, we review 21 cases of C. glabrata-induced infectious arthritis described to date in the literature.

Candida Arthritis: Analysis of 112 Pediatric and Adult Cases

Background. Candida arthritis is a debilitating form of deeply invasive candidiasis. However, its epidemiology, clinical manifestations, management, and outcome are not well understood.

Methods. Cases of Candida arthritis were reviewed from 1967 through 2014. Variables included Candida spp in joint and/or adjacent bone, underlying conditions, clinical manifestations, inflammatory biomarkers, diagnostic imaging, management, and outcome.

Results. Among 112 evaluable cases, 62% were males and 36% were pediatric. Median age was 40 years (range, <1–84 years). Most patients (65%) were not pharmacologically immunosuppressed. Polyarticular infection (≥3 joints) occurred in 31% of cases. Clinical manifestations included pain (82%), edema (71%), limited function (39%), and erythema (22%) with knees (75%) and hips (15%) most commonly infected. Median erythrocyte sedimentation rate was 62 mm/hr (10–141) and C reactive protein 26 mg/dL (0.5–95). Synovial fluid median white blood cell count was 27 500/µL (range, 100–220 000/µL) with 90% polymorphonuclear neutrophils (range, 24–98). Adjacent osteomyelitis was present in 30% of cases. Candida albicans constituted 63%, Candida tropicalis 14%, and Candida parapsilosis 11%. Most cases (66%) arose de novo, whereas 34% emerged during antifungal therapy. Osteolysis occurred in 42%, joint-effusion in 31%, and soft tissue extension in 21%. Amphotericin and fluconazole were the most commonly used agents. Surgical interventions included debridement in 25%, irrigation 10%, and drainage 12%. Complete or partial response was achieved in 96% and relapse in 16%.

Conclusion. Candida arthritis mainly emerges as a de novo infection in usually non-immunosuppressed patients with hips and knees being most commonly infected. Localizing symptoms are frequent, and the most common etiologic agents are C albicans, C tropicalis, and C parapsilosis. Management of Candida arthritis remains challenging with a clear risk of relapse, despite antifungal therapy.

Treatment of fungal myositis with intra-lesional and intravenous itraconazole: a case report

Introduction

Fungal myositis is very uncommon, even in patients who are immunocompromised. Because of its rarity and a lack of clinical experience, no consensus has been reached about the best means of treating fungal myositis. To the best of our knowledge this is the first description of the treatment of fungal myositis with simultaneous intravenous and intra-lesional itraconazole.

Case presentation

A 35-year-old Chinese woman with acute myelomonocytic leukemia developed Candida krusei fungemia and fungal myositis in the right biceps brachii after chemotherapy. A course of intravenous itraconazole and subsequently intravenous voriconazole was initiated and her blood cultures became sterile; however, our patient remained febrile and the myositis did not resolve. Intravenous itraconazole was restarted simultaneously with low-dose intra-lesional itraconazole. The pyrexia settled after 48 hours and within 10 days the lesion could be seen to be resolving. After the course of intravenous and intra-lesional anti-fungals was complete, oral itraconazole was administered as maintenance therapy.

Conclusions

To the best of our knowledge this is the first case in which fungal myositis was successfully treated with intravenous and intra-lesional itraconazole in a patient with acute myelomonocytic leukemia. The efficacy and safety of locally-administered itraconazole to treat intractable soft tissue infections requires further evaluation.

Candida Arthritis after Arthroscopic Arthroplasty in a Patient without Predisposing Factors

Because candidiasis is usually associated with immunosuppression, candida arthritis in an immunocompetent patient is rare. The symptoms of candidiasis are similar to bacterial infections, tuberculosis, and autoimmune diseases. In our patient with no predisposing factors, candida arthritis was initially excluded because the probability of occurrence was low. The patient had no leukocytosis, the acid-fast bacteria (AFB) stain was negative, and the autoimmune antibody screen was negative. After Candida parapsilosis was cultured in the synovial fluid, the patient was treated with amphotericin B (0.7 mg/kg/day) and oral fluconazole (400 mg/day). The treatment was successful and there were no side effects of the medications.

Micro-CT analysis of experimental Candida osteoarthritis in rats

Experimental osteoarthritis induced by Candida albicans in rats was studied using micro-computed tomography (micro-CT). When C. albicans cells at a nonlethal dose were intravenously injected into 40 rats, joint swelling was induced in 24 rats. Two or more joints were affected in 10 of the 24 rats. Tarsal regions of the hind paw were affected most frequently, followed by elbows of the fore paw. Micro-CT analysis in vivo showed that erosions of the affected tarsal joint bones were apparent several days after the onset of swelling. Thereafter, severe surface roughness and disintegration in the joint bones progressed during the development of arthritis. Three-dimensional (3D) trabecular microstructures and changes in 3D bone parameters were characterized ex vivo with calcanei from affected hind paws. Three-dimensional morphology showed coarsening of the trabecular distribution and weakening of the trabecular connectivity in arthritic bones. These morphological changes were quantitatively confirmed by changes in 3D bone parameters measured from consecutively scanned bone slices. Micro-CT has been shown to be useful for quantifying morphological changes occurring in Candida arthritic bones.

Candida lusitaniae septic arthritis: case report and review of the literature

Candida lusitaniae is an infrequently encountered Candida species that has been associated with resistance to amphotericin B. We present a case of septic arthritis with C. lusitaniae and provide a brief review of the organism, especially in regard to current information about its pattern of resistance to antifungal agents.

Fungal arthritis and osteomyelitis

Fungal arthritis and osteomyelitis are uncommon diseases and generally present in an indolent fashion. The incidence of fungal bone and joint dis-ease is increasing with an increase in the prevalence of factors predisposing to invasive fungal disease, such as the use of central venous catheters, broad spectrum antibiotics, immunosuppression, and abdominal surgery. Definitive diagnosis relies on bone or synovial culture or biopsy. Successful management has traditionally consisted of amphotericin B in combination with surgical debridement. Given the rarity of this disease, treatment is not well defined, but reports of success with the use of azole antifungal agents, including itraconazole, fluconazole, voriconazole, and posaconazole, are promising.

Candida glabrata periprosthetic infection: a case report and literature review

We present a case of an immunocompromised host who developed a Candida glabrata infection 20 years after her total knee arthroplasty. She was treated with extensive irrigation and debridement, followed by placement of an amphotericin B cement spacer supplemented with 2 months of oral variconazole. She ultimately underwent an above-knee amputation.