1
|
Tsantes AG, Koutserimpas C, Naoum S, Drosopoulou LP, Papadogeorgou E, Petrakis V, Alpantaki K, Samonis G, Veizi E, Papadopoulos DV. Diagnosis, Treatment, and Outcome of Coccidioidal Osseous Infections: A Systematic Review. J Fungi (Basel) 2024; 10:270. [PMID: 38667941 PMCID: PMC11050809 DOI: 10.3390/jof10040270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Extrapulmonary infections by Coccidioides spp., though rare, can occur via dissemination, affecting singular or multiple sites, including the skin and musculoskeletal system. Skeletal involvement often manifests as osteomyelitis, particularly in the axial skeleton. The present systematic review evaluates all documented cases of skeletal coccidioidomycosis to assess the diagnostic and treatment strategies alongside the outcomes, drawing insights from an analysis of 163 verified cases. A systematic review following PRISMA guidelines identified all studies reporting skeletal infections by Coccidioides spp. up to 2023 from the PubMed and Scopus databases. Eligible studies evaluated osteoarticular infections from Coccidioides spp. Data extraction included demographics, microbiological data, diagnostic methods, and treatment outcomes. Of the 501 initially identified records, a total of 163 patients from 69 studies met the inclusion criteria. Most cases were from the USA, predominantly males, while the median age of the population was 36 years. Diabetes mellitus was the common comorbidity (14.7%). C. immitis was the most prevalent pathogen. The spine and hand were common sites of infection (17.5% and 15.1%, respectively). Osteomyelitis by Coccidioides spp. was diagnosed, in most cases, by positive cultures (n = 68; 41.7%), while, in 49 (30.9%), both the histological examination and cultures yielded the fungus. Surgical debridement was performed in 80.9% of cases. A total of 118 (72.3%) patients were treated with monotherapy, while combination therapy with two or more antifungal agents was reported in 45 (17.7%). Amphotericin B (either liposomal or deoxycholate) was the most commonly given agent as monotherapy in 51 (31.2%) patients, while 30 (18.4%) patients received itraconazole as monotherapy. The rate of infection's resolution was higher in patients undergoing surgical debridement (79.5%), compared to those treated only with antifungal agents (51.6%, p = 0.003). Treatment outcomes showed complete resolution in 74.2% of patients, with a mortality rate of 9.2%. Coccidioidal osseous infections present diagnostic and therapeutic challenges. Surgical intervention is often necessary, complementing antifungal therapy. Vigilance for Coccidioides spp. infections, especially in regions with endemicity, is crucial, particularly when bacterial cultures yield negative results.
Collapse
Affiliation(s)
- Andreas G. Tsantes
- Laboratory of Hematology and Blood Bank Unit, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece;
| | - Christos Koutserimpas
- Orthopaedic Surgery and Sports Medicine Department, Croix-Rousse Hospital, University Hospital, 69317 Lyon, France;
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece
| | - Symeon Naoum
- Department of Trauma and Orthopedics, Royal Berkshire Hospital, Reading RG1 5AN, UK;
| | | | - Ellada Papadogeorgou
- Department of Orthopedics, Interbalkan Medical Center, 55535 Thessaloniki, Greece;
| | - Vasileios Petrakis
- 2nd University Department of Internal Medicine, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68131 Alexandroupolis, Greece;
- Department of Infectious Diseases, HIV Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68131 Alexandroupolis, Greece
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, “Venizeleion” General Hospital of Heraklion, 71409 Iraklio, Greece;
| | - George Samonis
- First Department of Medical Oncology, Metropolitan Hospital of Neon Faliron, 18547 Athens, Greece;
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Yıldırım Beyazıt University, Ankara City Hospital, 2367 Ankara, Turkey
| | - Dimitrios V. Papadopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, National & Kapodistrian University of Athens, 14233 Athens, Greece;
| |
Collapse
|
2
|
Guo X, Ruan Q, Jin J, Zheng J, Shao L, Li N, Zhu L, Zhang W, Hu Y, Chen M. Disseminated coccidioidomycosis in immunocompetent patients in non-endemic areas: a case series and literature review. Eur J Clin Microbiol Infect Dis 2022; 41:925-939. [PMID: 35546215 DOI: 10.1007/s10096-022-04447-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
Coccidioidomycosis is caused by the dimorphic fungi Coccidioides species which is endemic in the Western hemisphere. Reports on the characteristics of travel-related disseminated coccidioidomycosis in immunocompetent patients are rare, especially in non-endemic regions. The multifaceted symptoms of this condition present a diagnostic challenge to clinicians. This study aimed to review immunocompetent patients diagnosed with disseminated coccidioidomycosis in a tertiary hospital in Eastern China and other non-endemic areas, and to emphasize the importance of combining travel history with clinical manifestations and proper diagnostic examinations. This study retrospectively reviewed a case series of disseminated coccidioidomycosis diagnosed in an academic hospital in Eastern China. We conducted a global literature review of disseminated coccidioidomycosis in immunocompetent patients with travel history. We identified six patients in our case series and reviewed 42 cases in the literature. Travel history included Mexico, Arizona, California, and regions of low endemicity. Extrapulmonary sites of infection, which presented with diverse signs and symptoms, involved the skin and soft tissue, musculoskeletal system, lymph nodes, and central nervous system. Misdiagnoses and diagnostic delays were common. Next-generation sequencing substantially promoted precise diagnosis in our series. The overall prognosis for immunocompetent individuals was positive, mainly benefited from long-term azole therapies. The patients that succumbed had either central nervous system involvement or multiorgan dissemination. Progressive pneumonia with varied symptoms and travel history should alert healthcare professionals in non-endemic areas to consider the possibility of Coccidioides species infection. We recommend detailed history-taking and hypothesis-free detection of pathogens for cases with diagnostic delay.
Collapse
Affiliation(s)
- Xiaoxiao Guo
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qiaoling Ruan
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jialin Jin
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianming Zheng
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lingyun Shao
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ning Li
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liping Zhu
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenhong Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Medical Molecular Virology (MOE/MOH) Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuekai Hu
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Mingquan Chen
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
- Department of Emergency, Huashan Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
3
|
Koutserimpas C, Naoum S, Raptis K, Vrioni G, Samonis G, Alpantaki K. Skeletal Infections Caused by Coccidioides Species. Diagnostics (Basel) 2022; 12:diagnostics12030714. [PMID: 35328269 PMCID: PMC8947487 DOI: 10.3390/diagnostics12030714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/12/2022] [Accepted: 03/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Coccidioidomycosis represents an endemic and challenging disease, with rare extrapulmonary manifestations. The present review of all published cases of core and extremities osseous coccidioidomycosis aims to describe epidemiology, patients’ characteristics, symptoms as well as medical and surgical treatment options and their effectiveness. Methods: A thorough review of all published skeletal core and extremity infections due to Coccidioides species was conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical management as well as the infection outcome was recorded. Results: A total of 92 cases of Coccidioides spp. skeletal infections were recorded in 87 patients. The patients’ mean age was 35.3 years. The most common site of infection was the spine (82.6%), followed by the foot (6.5%), while the predominant symptom upon presentation was pain (29.9%). Immunosuppressive conditions and/or medications were observed in 21 patients (24.1%). Regarding imaging methods, indicating diagnosis, plain X-rays or CT scans were performed in most patients (50.6%), followed by magnetic resonance imaging (MRI) (47.1%). Most cases were diagnosed through histopathology (62; 71.3%), followed by serology testing (36; 42.4%) and by cultures (35; 40.2%). In 32 cases (36.8%), Coccidioides immitis was cultured, while in the remaining 55 cases (63.2%) the fungus was not further characterized. Regarding AFT, amphotericin B was the preferred agent (52.9%), followed by fluconazole (43.3%). In most cases (78.2%) surgical treatment was also performed. Treatment was successful in 80.5% of cases. Conclusions: Skeletal core and extremity infections due to Coccidioides spp. represent a severe disease. With the available data, the combination of prolonged proper AFT with surgical intervention seems to be the optimal current therapeutic approach.
Collapse
Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (S.N.); (K.R.)
| | - Symeon Naoum
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (S.N.); (K.R.)
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (S.N.); (K.R.)
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - George Samonis
- Department of Internal Medicine, University of Crete, 71500 Heraklion, Greece
- Correspondence: ; Tel.: +30-6948712130
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, “Venizeleion” General Hospital of Crete, 71409 Heraklion, Greece;
| |
Collapse
|
4
|
Ramírez Zamora JA, Delgadillo Vargas JA, Medina González R, Hayakawa Dávila VC, Acevedo Rodarte AY, Arellano Pérez Vertti RD. Coccidioidomycosis Osteomyelitis of Distal Tibia in a Preschool Girl: A Case Report. J Orthop Case Rep 2022; 12:66-69. [PMID: 36660146 PMCID: PMC9826543 DOI: 10.13107/jocr.2022.v12.i05.2820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/12/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Coccidioides immitis is a fungus that develops in endemic areas characterized by dry climates, with little rainfall and easy aerial dissemination. The most common form of infection is pulmonary coccidioidomycosis, although it is often asymptomatic. There are non-respiratory forms of this disease. Osteomyelitis is an extrapulmonary manifestation of C. immitis infection. Symptoms are usually nonspecific and radiographic findings are often confused with bone tumors. Treatment of coccidioidal osteomyelitis is often challenging. Case Presentation We report a case of a 3-year-old preschool girl from an endemic area for coccidioidomycosis who presented with pain and swelling on her left ankle. Initially, antibiotic treatment is administered for a suspected insect bite. However, her symptoms worsened and X-rays showed a lytic-like lesión. She was admitted to the hospital for biopsy and drainage surgery. The histopathological study confirms coccidioidomycosis osteomyelitis. She was started on long-term anti-fungal treatment. At 6-month follow-up, symptoms and signs of infection have been solved and X-ray image shows evidence of bone healing. Conclusion It is important to take into account aspects related to exposure to this fungus, such as the patient's place of residence and recent trips so that the diagnostic and therapeutic approach is appropriate. Coccidioidal osteomyelitis is an infrequent pathology, especially in patients without other comorbidities. Treatment is complex and often requires not only antifungal drugs but also surgical debridement.
Collapse
Affiliation(s)
- José Arturo Ramírez Zamora
- Department of Orthopaedic Surgery, Universidad Autónoma de Coahuila, Facultad de Medicina Torreón, Torreón, Coahuila, Mexico
| | - José Abraham Delgadillo Vargas
- Department of Orthopaedic Surgery, Universidad Autónoma de Coahuila, Facultad de Medicina Torreón, Torreón, Coahuila, Mexico
| | - Roberto Medina González
- Department of Orthopaedic Surgery, Universidad Autónoma de Coahuila, Facultad de Medicina Torreón, Torreón, Coahuila, Mexico
| | | | | | - Rubén Daniel Arellano Pérez Vertti
- Department of Orthopaedic Surgery, Universidad Autónoma de Coahuila, Facultad de Medicina Torreón, Torreón, Coahuila, Mexico,Address of Correspondence: Dr. Rubén Daniel Arellano Pérez Vertti, Department of Orthopaedic Surgery, Universidad Autónoma de Coahuila, Facultad de Medicina Torreón, Avenida Morelos 900 Oriente, Zip Code 27000, Torreón Coahuila, Mexico. E-mail:
| |
Collapse
|
5
|
Sherpa N, Shah R, Nordstrom B, Palmares C, Heidari A, Johnson R. Locus Minoris Resistentiae in Coccidioidomycosis: A Case Series. J Investig Med High Impact Case Rep 2019; 7:2324709619858110. [PMID: 31220927 PMCID: PMC6589960 DOI: 10.1177/2324709619858110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Locus minoris resistentiae refers to decreased resistance in any internal organ or external body region, leaving it more vulnerable to disease processes than other regions. These changes, either congenital or acquired, alter the defense capacity. The concept of locus minoris resistentiae is widely accepted in the medical field and presents itself across specialties. Antecedent trauma is a known risk factor for hematogenous dissemination of infection; this also applies to coccidioidal species. In this article, we describe 2 patients who suffered from pulmonary coccidioidomycosis with subsequent trauma resulting in osseous dissemination to the site of injury.
Collapse
|
6
|
|
7
|
A Case of Osteomyelitis of the toe caused by Coccidioidomycosis in a 17 year-old with Diabetes Insipidus. IDCases 2017; 9:14-16. [PMID: 28560172 PMCID: PMC5440283 DOI: 10.1016/j.idcr.2017.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/21/2017] [Accepted: 04/21/2017] [Indexed: 11/20/2022] Open
Abstract
We report a case of a 17-year-old male who presented with pain in his right first toe. His pain and swelling had worsened and x-rays of his foot revealed erosive changes of the great toe distal phalanx suggesting possible osteomyelitis. His co-morbidities were morbid obesity and diabetes insipidus. He was admitted to the hospital, blood cultures were drawn, and he was started on vancomycin for presumed bacterial osteomyelitis. He underwent incision and drainage of the fluctuant abscess of the toe, where a culture of the wound was taken. Preliminary results grew fungi. Being located in an endemic area, he was started on anti-fungal treatment for presumed disseminated coccidioidomycosis; culture was positive for Coccidiodes immitis. He also had serology positive for coccidioidomycosis titers. He had uneventful hospital stay and was discharged on long-term oral antifungal therapy.
Collapse
|