Candida arthritis. A manifestation of disseminated candidiasis

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.

Olecranon Bursitis Caused by Candida parapsilosis in a Patient with Rheumatoid Arthritis

Septic bursitis is usually caused by bacterial organisms. However, infectious bursitis caused by fungi is very rare. Herein, we present a 68-year-old woman with long-standing rheumatoid arthritis who developed pain, erythema, and swelling of the right olecranon bursa. Aspiration of the olecranon bursa showed a white blood cell count of 3.1 × 10(3)/μL (41% neutrophils, 30% lymphocytes, and 29% monocytes). Fluid culture was positive for Candida parapsilosis. She was treated with caspofungin 50 mg intravenously daily for 13 days followed by fluconazole 200 mg orally daily for one week. She responded well to this treatment but had recurrent swelling of the bursa. Bursectomy was recommended but she declined this option. This case, together with other reports, suggests that the awareness of uncommon pathogens, their presentation, and predisposing risk factors are important to establish an early diagnosis and prevent long-term complications.

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.

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.

Invasive Candidiasis

Invasive candidiasis remains an important nosocomial infection that continues to present major diagnostic and therapeutic challenges to the clinician. Changes in the epidemiology of this disorder have occurred for many reasons, and included especially the extensive use of prophylactic antifungal agents, broad-spectrum antibacterial agents, and medical devices (eg, chronic indwelling intravascular catheters). The diagnosis of IC remains elusive in many patients, and there is a critical need for improved diagnostics that will provide clinicians the opportunity to intervene earlier in the course of disease. Newer antifungal agents offer promise in the treatment of candidemia and other forms of IC, but the optimal use of these agents, particularly in the approach to non-albicans Candida infections, needs to be explored in more detail. Furthermore, despite an overwhelming amount of data concerning risk factors and excess mortality associated with the development of IC, there is no consistent approach to treatment and primary prevention among individuals who are deemed to be at highest risk for this complication. Research that focuses on these important clinical areas could provide valuable insights into the diagnosis and management of this common and evolving infection.

Staged reimplantation of total knee arthroplasty after Candida infection

Prosthetic joint infection with Candida is uncommon. Only 28 cases have been reported in the English literature. Successful reimplantation after eradication of Candida infection has been reported in 3 hip joints and only 1 knee. We present the case of a 68-year-old woman with chronic Candida parapsilosis infection of a prosthetic knee joint. Removal of the prosthesis, thorough débridement, and antifungal therapy treated the infection successfully. Antifungal therapy included 6 weeks of parenteral administration of fluconazole followed by 4 weeks of oral fluconazole. The involved knee joint was reimplanted 3 months after initial treatment. The prosthetic joint was pain free and functioned satisfactorily during the ensuing 4 years. No recurrence of infection was noted. The principle in treating Candida prosthetic infection generally has been the same as that of bacterial prosthetic infection. In chronic cases, removal of implants, thorough débridement, and effective antifungal therapy are mandatory for the eradication of infection. Reimplantation of the prosthesis can be performed successfully in a staged surgical procedure with the interval between the 2 stages shortened to 3 months.

Candida albicans prosthetic arthritis treated with fluconazole alone

Conventional treatment of Candida prosthetic joint infection usually includes surgery followed by a long period of antifungal medication. We report a case of Candida albicans prosthetic arthritis successfully treated with fluconazole alone.

Fungal sacral osteomyelitis as the initial presentation of Crohn's disease of the small bowel: report of a case

We report a unique case of Candida albicans sacral osteomyelitis in a 48 year-old female with previously undiagnosed Crohn's disease. The patient was ill for one year with fatigue, weakness, and a 60-lb weight loss. At the time of presentation, she developed chills, fever, right lower quadrant abdominal pain, and right knee pain. Physical examination was significant for a palpable right lower quadrant abdominal mass. A computed tomographic scan of the abdomen and pelvis identified a large right-sided retroperitoneal mass, severe right hydronephrosis, and air within the right sacrum. Findings at laparotomy included small-bowel changes consistent with Crohn's disease, a multiloculated retroperitoneal abscess, and evidence of sacral osteomyelitis. A right hemicolectomy with sacral debridement and placement of presacral drains was performed. Bone cultures from the sacrum demonstrated a predominance of C. albicans, in addition to coliforms and enterococcus. The patient was placed on amphotericin B and intravenous antibiotics. Because serial computed tomographic scans of her pelvis demonstrated progression of her pelvic osteomyelitis to include the sacrum, right ilium, right acetabulum, and right femoral head, a repeat debridement with resection of the right femoral head was performed. After 12 months of follow-up, she was doing well without medications and had no constitutional symptoms or radiographic evidence of disease progression. This report illustrates a unique case of Crohn's disease presenting as sacral osteomyelitis secondary to small-bowel fistulization. Aggressive multidisciplinary surgical and medical management were the key to the successful management of this difficult case.

Candida tropicalis arthritis in a patient with acute myeloid leukemia successfully treated with fluconazole: case report and review of the literature

The case of a 77-year-old woman with acute myeloid leukemia who developed Candida tropicalis septic arthritis of the knee after remission-inducing chemotherapy is reported. A literature review of C. tropicalis non-prosthetic arthritis is included. The isolate was susceptible to fluconazole (MIC 0.25 mg/l). She was treated with fluconazole (400 mg orally) and frequent relieving synovial aspirations. After 1 month of antifungal therapy the synovial fluid became culture negative. Fluconazole concentration in the synovial fluid and serum were 20 mg/l and 19.4 mg/l, respectively. The patient was treated for a total of 7 months and made a full recovery. This is the first report of the successful use of fluconazole in the treatment of septic arthritis due to C. tropicalis.

Candida albicans arthritis one year after successful treatment of fungemia in a healthy infant

Fungal arthritis in pediatric patients is rare and is most often associated with hematogenous spread to the affected joint. It is generally seen concomitant with, or shortly after, fungemia. We report a case of an immunocompetent patient in whom candidal arthritis developed 1 year after initial fungemia. The initial candidiasis was considered to be adequately treated with amphotericin B. The Candida isolates from the neonatal fungemia and subsequent arthritis were the some as identified by electrophoretic karyotype, restriction fragment length polymorphism analysis, and antifungal susceptibility testing. Pediatric candidal fungemia, arthritis, and their treatments are discussed.

Septic bursitis

Nine cases of septic bursitis are presented, and the literature on the subject comprehensively reviewed, with an emphasis on the clinical manifestations of septic bursitis in various anatomic locations. Physical activities associated with increased susceptibility to septic bursitis and systemic conditions that increase the severity of septic bursitis are catalogued. Analysis of the microbiology of cases reported in the literature demonstrates that greater than 80% of cases of septic bursitis are caused by Staphylococcus aureus and other gram-positive organisms. However, a wide variety of gram-negative microorganisms, fungi, and other infectious agents have been reported to cause septic bursitis and may lead to complications in diagnosis and treatment. The nine cases reported here demonstrate the potential severity of septic bursitis and emphasize that significant systemic complications may result from this common musculoskeletal infection. Indications for hospitalization and/or intravenous antibiotic therapy for septic bursitis include the presence of fulminant local infection, evidence for systemic toxicity, or infection in an immunocompromised patient. Patients who fail to respond to intravenous antibiotics and percutaneous aspiration of the bursa may require surgical drainage or bursectomy by one of several methods that have been proposed. There is some recent evidence that intrabursal corticosteroid injection for therapy of nonseptic subcutaneous bursitis may be more effective than systemic antiinflammatory medication or simple bursa aspiration.

Fungal arthritis. A review

Fungal arthritis (FA) due to a candida infection was reviewed in English literature and described in 45 cases. The increasing use of potent antibiotics, immunosuppressives, and especially the use of artificial joints, predisposed to the infection. Weightbearing joints, particularly the knees, were most frequently affected. Symptoms were described as a warm, tender and swollen joint, and the duration of symptoms prediagnosis was described as being up to 4 years. Amphotericin B was the treatment drug of choice, and in cases of no response, supplemented with either flucytosine or ketoconazole. Local FA healed in all cases. FA in an artificial joint resulted in all cases in removal of the prostheses. Mortality in systemic fungal infections including FA was 50%.

Candida arthritis in adult patients who are not intravenous drug addicts: report of three cases and review of the literature

Candida species are an uncommon cause of infectious arthritis, although the frequency has increased during recent years. Three cases of septic arthritis caused by Candida species are reported, and the literature is reviewed. The first patient developed a popliteal cyst infected by Candida albicans after multiple intravenous antibiotic treatments. The second patient had acute myelogenous leukemia and experienced knee arthritis after chemotherapy, and the third suffered oligoarthritis after a second heart transplantation. All patients received treatment with a standard dose of intravenous amphotericin B. Responses were achieved only in the first two cases; the third patient died despite therapy. Thirty-six previously reported Candida arthritis cases are reviewed, and epidemiologic, diagnostic, therapeutic, and prognostic features are analyzed. Cases are divided into two categories: direct inoculation of fungus and hematogenously disseminated disease; these two categories are compared in terms of sex, age, pathogen species, treatment, and survival. Arthritis induced through direct inoculation of fungus is seen in older individuals, is more frequently produced by species other than C albicans (Candida parapsilosis especially), and has a better prognosis than arthritis caused by disseminated candidiasis. Arthritis can be resolved even in the persistence of the systemic disease. It is believed that the first case of Baker's cyst infected by C albicans and the first case of Candida arthritis in a heart transplant patient are reported here.

Prosthetic joint infection due to Candida parapsilosis in the UK: case report and literature review

Candida infection of joint replacements is a rare but increasingly reported phenomenon. A case of Candida parapsilosis prosthetic knee joint infection occurring in the UK is described. Cure followed removal of the prosthesis and treatment, first with a combination of amphotericin and 5-fluorocytosine, then ketoconazole.

Candidal pyarthrosis in an AIDS patient

The unusual occurrence of a case of indolent Candida albicans pyarthrosis arising as a late complication in a 57-year-old male patient with AIDS, despite prior treatment with amphotericin B for candidemia, is reported. The case is discussed in the context of candidal pyarthrosis and of the rarely reported other fungal arthridites in AIDS patients.

Candidiasis

Candida spp. are the most common fungal pathogens isolated in immunocompromised hosts, particularly cancer patients. Numerous clinical manifestations of candidiasis have been recognized, including localized infection such as oropharyngeal candidiasis or focal hepatic candidiasis, and disseminated infection resulting from hematogenous spread, with or without documented fungemia. Granulocytopenic patients are particularly at risk. Candida albicans is isolated in approximately 40% of cases of fungemia, other Candida spp. now also commonly being isolated. The rate of morbidity and mortality secondary to candidiasis is still significant despite numerous attempts to develop better diagnostic techniques, and more effective means of chemoprophylaxis and therapy. Currently, new antifungal agents and galenic preparations of amphotericin B are being evaluated with the aim of improving the prognosis of candidiasis in immunocompromised hosts.

Transient fungemia and Candida arthritis due to Candida zeylanoides

A 37 year old man developed transient fungemia caused by Candida zeylanoides following a kidney and pancreas transplant. For the next seven months the patient had signs and symptoms of right knee arthritis. Candida zeylanoides was finally identified as the aetiological agent. Treatment with intravenous amphotericin B was successful. To our knowledge this is the first report of Candida zeylanoides arthritis.

Candida krusei infectious arthritis. A rare complication of neutropenia

Candida krusei infections are increasing in neutropenic patients. This is the first report of a case of C. krusei arthritis in a neutropenic leukemic patient. The organism colonized the patient's respiratory tract and most likely seeded the right knee by hematogenous spread. Knee swelling and tenderness were minimal. Joint fluid Gram stain and fungal smears did not show the organism despite positive results on cultures. With therapy, the joint fluid converted from neutrophilic predominance to lymphocytic predominance. Despite sterilization of knee fluid, clinical relapse occurred after therapy with 256 mg of systemic amphotericin B; the infection was cured after a total dose of 456 mg.

Candida vertebral osteomyelitis: report of three cases and a review of the literature

We have recently treated three patients with Candida vertebral osteomyelitis. In each patient there was at least one characteristic prodromal condition, including trauma, multiple antibiotics following bowel surgery, and acute nonlymphocytic leukemia. All patients were treated successfully with amphotericin B. Based on our findings and a review of the literature, we would recommend a 1.0-1.2 gm total dosage of amphotericin B. Alternative therapeutic choices such as 5FC and/or ketoconazole, under specific clinical conditions, have been successfully employed. However, cure can best be confirmed by post-treatment biopsy.

Predisposing factors, bacteriology and antibiotic therapy in 35 cases of septic bursitis

In a retrospective study the etiology was verified in 35/52 patients with suspected septic prepatellar or olecranon bursitis. Staphylococcus aureus was the most common pathogen and 86% of them were penicillinase-producing. Other strains were streptococci. Mean age was 47 (18-83) years and males predominated (91%). Predisposing factors were seen in most cases. Preceding trauma was found in 27 and/or associated diseases (e.g. diabetes mellitus) in 11 patients. Hyperglycemia was found in 38% of the patients. Treatment with antimicrobial agents, mostly penicillins, and bursal drainage were successful in 32 cases. Two patients had local spread of the infection and 1 patient chronic bursitis.

Two unusual strains of Candida arthritis

Candida arthritis is an uncommon cause of infectious arthritis that may occur in seriously ill or immunosuppressed patients. This report describes two patients, one who developed Candida tropicalis arthritis and another patient who developed C. parapsilosis arthritis. One patient developed nephrogenic diabetes insipidus secondary to amphotericin B therapy and was successfully treated with intravenous miconazole. The other was unsuccessfully treated with both intraarticular and intravenous amphotericin B.

Candida infection of a prosthetic shoulder joint

A heroin addict developed a Candida parapsilosis infection in a prosthetic shoulder joint. Radiographs showed loose fragments of cement with prosthetic loosening. The patient was treated with removal of the prosthesis and intravenous amphotericin B followed by oral ketoconazole.

Neonatal and infantile candidal arthritis with or without osteomyelitis: a clinical and radiographical review of 21 cases

Four cases of candidal arthritis and osteomyelitis are presented and 17 others are reviewed from the literature. The clinical and radiographic aspects of the entity are discussed in detail and compared with those of bacterial septic arthritis. The role of predisposing factors are elaborated. An increase in the incidence of the disease is anticipated and the diagnostic difficulties are enumerated.

Miconazole therapy for systemic candidiasis in a conjoined (Siamese) twin and a premature newborn

A 2.5 kg thoracopagus (Siamese) twin and a 0.73 kg premature newborn developed systemic candidiasis and were treated with intravenous miconazole. The conjoined twin was in a state of severe metabolic acidosis, respiratory distress, jaundice, anuria, abdominal distension, and shock. The 0.73 kg premature infant was also in a state of severe metabolic acidosis, respiratory distress, and oliguria. Miconazole was used in this desperate situation for the treatment of life-threatening candidiasis. Both infants responded well to treatment and recovered. All parameters of their diseases improved during therapy despite pre-existing multiple organ dysfunction. Miconazole can be a safe alternative to amphotericin B for the treatment of systemic candidiasis in neonatal infants, including those with impaired renal function.