Fungal arthritis and osteomyelitis

Coccidiomycosis septic arthritis presenting as ankle monoarthritis in a patient with presumed psoriatic arthritis

A man in his 50s with a history of psoriasis was evaluated for acute on chronic left ankle pain. His symptoms were attributed to psoriatic arthritis, and he tried several immunosuppressive regimens without improvement. Further diagnostic workup confirmed Coccidioides immitis/posadasii septic monarthritis thought secondary to a known remote history of Valley fever while residing in Arizona and subsequent reactivation in the setting of immunosuppression. The patient ultimately required prolonged anti-fungal therapy and multiple surgical debridements.Although psoriatic arthritis can present as monarthritis, it is uncommon, with more likely differential considerations including crystal arthropathies, trauma and both typical and atypical infections. Acute monarthritis should always prompt concern for a septic joint, even in a patient with autoimmune disease. The specific history elicited from the patient, including residence in an endemic region, and known prior Coccidioides infection, increased suspicion for Coccidioides and led to the correct diagnosis and management.

Fungal Osteomyelitis of the Hip with Septic Arthritis: Case Report

Fungal osteomyelitis, especially associated with septic arthritis, is uncommon in Brazil; therefore, sometimes it is difficult to diagnose and treat it. We report the case of a young patient, with no immunosuppressive risk factor, with osteomyelitis leading to septic arthritis of the hip. The diagnosis was performed after surgical drainage and visualization of Cryptococcus neoformans at pathological anatomy. Antifungal treatment resulted in complete remission of the symptoms. Since there is no consensus on the treatment of fungal osteomyelitis, this case report aims to inform orthopedists about the importance of hip arthritis differential diagnosis and the good evolution of clinical treatment after drainage and pathogen isolation.

Management of the Septic Wrist: A Systematic Review of Etiology and Therapeutic Strategies

Septic arthritis of the wrist can have severe deleterious effects on cartilage and bone if not promptly addressed. Expedient diagnosis and early medical intervention are important. The most effective strategy involves immediate arthrocentesis of the infected joint, enabling precise antibiotic selection based on joint fluid analysis. Diagnostic imaging is important in excluding fractures and identifying abscesses. This review explores the etiologic factors underlying septic wrist joint, identifying risk factors, and delineating optimal diagnosis and treatment approaches. The overarching goal is to impart valuable insights and guidance in the management of septic wrist joint, ensuring the highest quality patient care and optimal clinical outcomes.

The Septic Elbow Joint: Treatment Approaches for Improved Patient Outcomes

Septic arthritis of the elbow is a serious problem requiring prompt, accurate diagnosis and urgent surgical intervention. Achieving successful patient outcomes depends heavily on early diagnosis and efficient streamlined surgical treatment. Essential tactics for treating the septic elbow joint include immediate joint irrigation and debridement in addition to administration of appropriate antibiotics. This comprehensive review delves into the cause of the septic elbow joint, identifies associated risk factors, and provides a comprehensive approach encompassing the diagnosis and treatment of the septic elbow. The aim of this review is to optimize patient care and outcomes.

Fungal Osteomyelitis: A Systematic Review of Reported Cases

Fungal osteomyelitis is considered a rare disease, and the published literature mainly comprises case reports, case series and narrative reviews. A systematic review was undertaken to provide a practice-based global perspective on this disease, focusing on epidemiology and treatment strategies. We searched MEDLINE, EMBASE and Cochrane Library between the 3rd and 8th of March 2023 using a predefined search string. We included studies with at least one patient with a diagnosis of fungal osteomyelitis published before the 1st of January 2023. We included all study designs except for reviews, and we excluded non-English languages and grey literature. After exclusion, 678 studies, mostly case reports, were included. Descriptive analysis was performed on 1072 patients. The most common aetiological agent was Aspergillus (26.5%), followed by Candida (20.7%) and Mucor (16.8%), and the bones most frequently involved were the vertebrae. We described the characteristics of patients divided by site of infection, and we found that diabetes mellitus, disseminated fungal infection, surgery and local lesion were major risk factors. We also successfully associated duration of treatment with outcome. We provided a general overview of this rare disease, and we highlighted the need for high-quality investigations on the subject.

Endemic mycoses in children in North America: a review of radiologic findings

Clinically significant endemic mycoses (fungal infections) in the United States (U.S.) include Blastomyces dermatitidis, Histoplasma capsulatum, and Coccidioides immitis/posadasii. While the majority of infections go clinically unnoticed, symptomatic disease can occur in immunocompromised or hospitalized patients, and occasionally in immune-competent individuals. Clinical manifestations vary widely and their diagnosis may require fungal culture, making the rapid diagnosis a challenge. Imaging can be helpful in making a clinical diagnosis prior to laboratory confirmation, as well as assist in characterizing disease extent and severity. In this review, we discuss the three major endemic fungal infections that occur in the U.S., including mycology, epidemiology, clinical presentations, and typical imaging features with an emphasis on the pediatric population.

Fungal arthritis: A challenging clinical entity

There has been an increasing incidence of fungal infections in recent years. Rarely joints are also affected by fungal infections. Mainly, these infections develop in prosthetic joints, but sometimes native joints are also involved. Candida infections are mostly reported, but patients may also develop infections secondary to non-Candida fungi, especially Aspergillus. Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy. Despite this, these infections are associated with high morbidity and mortality. This review described the clinical features, risk factors, and therapeutic interventions required to manage fungal 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.

Effects of immunocompromised status on diagnostic criteria in septic arthritis

Introduction

Septic arthritis is an orthopaedic emergency, with permanent cartilage damage possible within hours of the onset of symptoms. Diagnostic criteria for septic arthritis in immunocompetent patients are well established, however, there is a paucity of literature evaluating diagnostic criteria in immunocompromised patients. The purpose of this retrospective case-control study was to evaluate the laboratory and clinical information of immunocompromised patients with septic arthritis and compare them to immunocompetent patients with septic arthritis to enable physicians to diagnose septic arthritis more accurately in this population.

Methods

All patients at our institution, a level I trauma center, with a clinical diagnosis of septic arthritis between January 1, 2006 and November 1, 2021 were identified and reviewed retrospectively. Patients 18 years old or older were screened for immunocompromised status and those meeting criteria were included for review. The control cohort was matched by the joint affected and age. Data were analyzed using the Shapiro-Wilk test, Turkey's test, Mann-Whitney U test, independent sample t-test, and chi-square analysis. A p-value of <0.05 was considered significant.

Results

A total of 36 patients with positive joint aspirate cultures were compared (18 immunocompetent and 18 immunocompromised). The immunocompromised group had a significantly longer length of hospital stay than the immunocompetent group (p = 0.044). There was no significant difference in erythrocyte sedimentation rate (ESR) (p = 0.852), peripheral white blood cell count (pWBC) (p = 0.696), joint aspirate white blood cell count (aWBC) (p = 0.901), polymorphonuclear cell percentage (PMN%) (p = 0.325), or total operations performed per patient (p = 0.365).

Conclusion

At our institution, immunocompromised patients with septic arthritis did not have significantly different diagnostic laboratory values when compared to immunocompetent patients. This suggests that immunocompromised patients with suspicion of septic arthritis can be assessed with similar diagnostic criteria as immunocompetent individuals; however, a larger cohort study is needed to assess the difference more precisely in laboratory values.

Zygomaticomaxillary Osteomyelitis due to COVID-19 Associated Mucormycosis (CAM): A Case Series of 10 Patients

Aim

To highlight the incidence of osteomyelitis due to CAM and to elucidate the mode of spread of infection from maxilla to zygomatic bone, to highlight how that is distinct from other cases of zygomatic osteomyelitis due to other etiologies.

Methods

A standard protocol of treatment of the cases of CAM with zygomatic involvement based on our own outcomes was furnished. All 10 patients were treated with dual antifungal therapy and aggressive surgical resection via extraoral approach, in conjunction with functional endoscopic sinus surgery (FESS).

Results

Ten out of 116 patients of CAM reporting to our institute presented with zygomatic bone involvement with an incidence rate averaging at 8.6%, whereas in previous literature osteomyelitis of zygomatic bone was extremely rare with an incidence pattern of just 1.42%.

Conclusions

The treatment protocol followed by the authors gave good outcomes to all patients treated, with no mortalities.

A Rare Case of Candida parapsilosis Lumbar Discitis With Osteomyelitis

Fungal osteomyelitis is rare and usually seen in immunocompromised patients. We report a case of Candida parapsilosis osteomyelitis in an immunocompetent patient with no prior surgical history. He went for spinal laminectomy with debridement and drainage. Intraoperative culture grew C. parapsilosis, and the patient was treated with fluconazole.

Fungal Osteomyelitis due to Phaeoacremonium venezuelense: A Case Report

CASE

A 56-year-old immunosuppressed man presented with pain and swelling in the medial and anterior right foot with accompanied numbness in the second and third toes 1 month after a puncture wound by a Sylvester palm tree thorn. An intraoperative culture/biopsy returned positive for septic arthritis of the naviculocuneiform joint and fungal osteomyelitis of the navicular, medial, and intermediate cuneiforms due to Phaeoacremonium venezuelense.

CONCLUSION

Fungal osteomyelitis is extremely rare. Only 5 cases by Phaeoacremonium venezuelense have been reported previously in the literature. To the best of our knowledge, this is the first case of osteomyelitis by this strain.

Risk Factors, Clinical Characteristics, Management, and Outcomes of Musculoskeletal Fungal Infection at Thailand’s Largest National Tertiary Referral Center

To investigate the risk factors, clinical characteristics, management, and outcomes of musculoskeletal fungal infection in Thai patients, patients aged ≥18 years definitively diagnosed with musculoskeletal fungal infection by culture and/or histopathology at Siriraj Hospital (Bangkok, Thailand) during 2002–2020 were retrospectively enrolled. Twenty-eight patients (median age: 58.5 years [range: 22–81], 57.1% male) with fungal osteomyelitis (n = 22), septic arthritis (n = 1), or fungal osteomyelitis with septic arthritis (n = 5) were included. Immunocompromised status was common (82%). Most patients had de novo infection from hematogenous spreading that usually presented at a single, non-contiguous site. The median symptom duration prior to diagnosis was 2 months. The tibia and knee were the most common site of osteomyelitis (30%) and septic arthritis (72%), respectively. The most common pathogens were Talaromyces marneffei and Cryptococcus neoformans. Organism identification from tissues at the affected sites was required in all cases. Most patients (82%) required combination surgery and systemic antifungal therapy. Among those with complete follow-up (23/28), 61% and 39% had complete and partial responses, respectively. Musculoskeletal fungal infection is an uncommon disease with insidious onset and non-specific manifestations that requires pathogen identification via tissue cultures and histopathologic studies. Combination surgery and systemic antifungal therapy yielded generally favorable outcomes.

A Canker Barking at the Wrong Knee: Thyronectria austroamericana Septic Arthritis

The mold Thyronectria austroamericana is a plant pathogen that causes canker in honey locust trees. We describe the first case of this mold causing septic arthritis in humans.

Septic arthritis caused by Candida albicans: post intra-articular steroid injection in a native joint

Intra-articular steroid injections are widely prescribed for management of osteoarthritis when oral medication or physiotherapy treatment fails to relieve patient's pain. Septic arthritis is an uncommon side effect of steroid injection. Common causal micro-organisms are bacterial with Staphylococcus aureus being the most frequent. Fungal septic arthritis is rare and does not usually present beyond the neonatal period. We present a rare case of septic arthritis secondary to fungal infection.

Post-traumatic Curvularia sp. arthritis in an immunocompetent adult

A 44-year-old woman, victim of a road accident in Mali was diagnosed with left knee arthritis. Joint effusion aspiration and subcutaneous surgical biopsies were positive for a melanized asexual ascomycete. Using microscopy and molecular biology, the fungus was identified as Curvularia sp. In vitro antifungal susceptibility was determined by the EUCAST broth microdilution reference technique and by E-test. The patient was treated with liposomal amphotericin B before posaconazole relay. Mycological samples obtained 10 days after starting the antifungal therapy by liposomal amphotericin B were negative in culture. Curvularia spp. are environmental fungi which can under certain conditions be pathogenic for humans.

Management of osteoarticular fungal infections in the setting of immunodeficiency

Introduction: Osteoarticular fungal infections (OAFIs) complicate the clinical course of high-risk patients, including immunosuppressed individuals. Their management, however, despite being intricate, is governed by evidence arising from sub-optimal quality research, such as case series. Guidelines are scarce and when present result in recommendations based on low quality evidence. Furthermore, the differences between the management of immunocompromised and immunocompetent patients are not distinct. This is a narrative review after a literature search in PubMed, up to November 2019.Areas covered: The major fungal groups causing osteomyelitis and/or arthritis are Candida spp., Aspergillus spp., non-Aspergillus filamentous fungi, non-Candida yeasts and endemic dimorphic fungi. Their epidemiology is briefly analyzed with emphasis on immunodeficiency and other risk factors. Management of OAFIs includes appropriate antifungal drug therapy (liposomal amphotericin B, triazoles or echinocandins), local surgery and immunotherapy for primary immunodeficiencies. Cessation of immunosuppressive drugs is also mandated.Expert opinion: Management of OAFIs includes affordable and available options and approaches. However, research on therapeutic practices is urgently required to be further improved, due to the rarity of affected patients. Evolution is expected to translate into novel antifungal drugs, less invasive and precise surgical approaches and targeted enhancement of immunoregulatory pathways in defense of challenging fungal pathogens.

Persistent candida arthritis successfully treated with micafungin instillation and surgery. A case report

We report a rare case of C. krusei knee arthritis treated with instillation of micafungin and arthroscopy. A 49-year-old man hospitalized for treatment of Acute Myeloid Leukemia developed knee arthritis with C. krusei. He was treated with a combination of arthroscopic debridement, intravenous as well as intra-articular micafungin. Serum and intra-articular concentrations of micafungin were determined. After instillation of micafungin in the knee and arthroscopic debridement, the patient completely recovered.

[Synovial fluid cytodiagnosis]

Synovial fluid samples represent only a very small percentage of routine work in a cytology laboratory. However, its microscopic examination allows us to observe different types of cells, particles and structures that, due to their morphological characteristics, may provide relevant data for cytodiagnosis. We present certain aspects related to arthrocentesis, the relationship between the gross appearance of synovial fluid and certain pathological processes, as well as the different techniques for processing and staining the smears. Furthermore, we describe the main cytological findings in various pathological conditions of the synovial joints, such as infections (bacterial and fungal), non-infectious inflammatory type (osteoarthrosis, rheumatoid arthritis, connective tissue diseases) and tumoral, distinguishing between primary and metastatic, both solid and haematological neoplasms.

Mucormycotic Osteomyelitis Involving the Maxilla: A Rare Case Report and Review of the Literature

Osteomyelitis is an inflammatory process of bone and marrow contents. These changes in bone are primarily seen in soft tissue followed by calcified tissue. It is an opportunistic infection due to the complication of some other conditions rendering the host susceptible to disease. Consequences of this infection range from draining tract to malignant transformation. Various etiological factors are involved in origin of the disease; among them, fungal origin is rare. Specific feature in fungal osteomyelitis is the involvement of maxillary sinus with a complaint of sinusitis associated with diabetes mellitus. Here, we discuss a case of osteomyelitis with fungal infection involving the maxilla. The patient is under medication for the past five years due to diabetes.

Fungal Musculoskeletal Infections

Fungi are rare but important causes of osteoarticular infections, and can be caused by a wide array of yeasts and molds. Symptoms are often subacute and mimic those of other more common causes of osteoarticular infection, which can lead to substantial delays in treatment. A high index of suspicion is required to establish the diagnosis. The severity of infection depends on the inherent pathogenicity of the fungi, the immune status of the host, the anatomic location of the infection, and whether the infection involves a foreign body. Treatment often involves a combination of surgical debridement and prolonged antifungal therapy.

A rare case of Candida parapsilosis osteomyelitis: a literature review and proposed treatment algorithm

Background

Candida parapsilosis is a rare opportunistic pathogen that can be found in immunosuppressed patients. There are seldom-reported cases of fungal osteomyelitis surrounding orthopedic implants.

Case presentation

This is a case of chronic Candida parapsilosis osteomyelitis in an immunocompromised patient with a prior open reduction and internal fixation for a closed bimalleolar ankle fracture that went on to neglected wound complications. The patient underwent series of treatments including removal of hardware, serial irrigation and debridements, negative pressure wound therapy, and intravenous antifungal therapy. Our case illustrates the possibility of this rare pathogen involved in orthopedic surgery particularly in immunocompromised hosts.

Conclusion

Fungal and atypical pathogens should always be considered in such patients or if another diagnosis is not clear. Protracted time to culture specimens should be considered for at least four weeks in such situations. This article outlines a review of the literature and treatment algorithm to guide physicians when managing patients with this rare infection.

Statin use correlates with reduced risk of chronic osteomyelitis: a nationwide case-control study in Taiwan

BACKGROUND/OBJECTIVE

Potential association between prior statin use and chronic osteomyelitis is examined.

METHODS

A nationwide case-control study was conducted based on data taken from the Taiwan National Health Insurance program. The case group includes 2338 subjects aged 20-84 years newly diagnosed for chronic osteomyelitis from 2000 to 2013; the control group included 2338 randomly selected subjects without chronic osteomyelitis matched for sex, age, and index year. Statin use was respectively defined as "current", "recent" or "past" if the most recent statin prescription was filled <3 months, 3-6 months or ≥6 months prior to the chronic osteomyelitis diagnosis. Relative risk of chronic osteomyelitis associated with statin use was measured by the odds ratio (OR) with 95% confidence interval (CI) using the conditional logistic regression model.

RESULTS

After controlling for potential confounders, the adjusted ORs of chronic osteomyelitis were 0.57 for subjects with current statin use (95% CI 0.45, 0.72), 0.80 for subjects with recent statin use (95% CI 0.48, 1.33), and 1.00 for subjects with past statin use (95% CI 0.83, 1.20), compared patients with no prior statin use. In further analysis, the adjusted ORs of chronic osteomyelitis were 0.70 for subjects with cumulative statin use <12 months (95% CI 0.47, 1.07), and 0.56 for subjects with cumulative statins use ≥12 months (95% CI 0.41, 0.77), compared with those with no prior statin use.

CONCLUSIONS

Current statin use is associated with reduced concurrent diagnosis of chronic osteomyelitis, particularly for a cumulative statin use ≥12 months.

Lumbar Spinal Candida Glabrata Treated Without Surgical Intervention: A Case Report

Candida glabrata is a low virulent commensal fungal organism that, rarely, can cause osteomyelitis. Diagnosis of such an infection is often difficult as the case typically presents with an insidious onset of back pain and minimally elevated biomarkers of inflammation. Furthermore, it is difficult to eradicate and often resistant to common antifungals. 

A 61-year-old man presented with an eight-month history of persistent low back pain which had unsuccessfully been managed by his primary care physician. He had a past surgical history of gastric by-pass complicated by adhesions, ulceration, and perforation with an infection of Candida glabrata that had been treated with intravenous micafungin. Radiological examination showed degenerative changes with suspicion of osteomyelitis and a computerized tomography (CT)-guided biopsy provided tissue samples with subsequent positive cultures for Candida glabrata. The patient was admitted for fungal osteomyelitis with Candida glabrata, treated with intravenous micafungin, and his infection was resolved after six months. At two-year follow-up his back pain has been resolved and no infection was present. In a patient with osteoarticular pain and a previous history of candidal infection with possible candidemia, one should maintain suspicion for fungal osteomyelitis.

Lasiodiplodia species fungal osteomyelitis in a multiple myeloma patient

Lasiodiplodia species are environmental fungi that have been reported as a cause of infection in both immunocompetent and immunocompromised patients. We present a case of fungal osteomyelitis caused by Lasiodiplodia species in a patient with multiple myeloma after autologous stem cell transplant. The patient was successfully treated with a combination of surgery and oral voriconzole. To the best of our knowledge, this is the first reported case of fungal osteomyelitis caused by Lasiodiplodia species.

Management of Candida guilliermondii joint infection in a dog

Background

Candida spp. are dimorphic fungi in the family Cryptococcaceae. Infections with Candida spp. are usually rare conditions in dogs, but immunocompromised patients have a higher risk for developing invasive candidal infections.

Case presentation

A 5-year-old male Boxer, positive to Leishmania infantum, was referred to the Veterinary Teaching Hospital of the Department of Veterinary Medicine, University of Perugia, Italy for examination of a non-weight bearing left hind limb lameness of a duration of at least 3 months. During this period, treatment involved systemic anti-inflammatory medications and intra-articular corticosteroid administration. On presentation, clinical examination and radiographic findings were suggestive of cranial cruciate ligament deficiency. To support this diagnosis a stifle arthroscopy was performed: it confirmed a partial rupture of cranial cruciate ligament. Samples culture of synovial fluid and membrane was routinely collected as well, and revealed Candida guilliermondii joint infection. Treatment for the C. guilliermondii joint infection involved systemic anti-fungal therapy, joint lavage and intra-articular administration of antifungal drugs. Lameness improved markedly during this treatment, but lameness did not resolve completely, probably due to cranial cruciate ligament deficiency. Tibial tuberosity advancement (TTA) was chosen in order to treat stifle instability and was performed 4 weeks following cessation of treatment of the C. guilliermondii joint infection. Six month after TTA the dog showed a completely recovery with no lameness.

Conclusions

To the authors’ knowledge, this is the first case of Candida spp. joint infection reported in dogs. The cause of the progression of the joint C. guilliermondii infection remains unclear but it may be associated with leishmaniasis or intra-articular corticosteroid injections. Treatment with systemic and intra-articular anti-fungal therapies was successful. In the evaluation of hind limb lameness in a chronically immunocompromised dog, it would be advisable to consider also an intra-articular Candida spp. infection.

Rare case of Isolated Aspergillus Osteomyelitis of Toe: Presentation and Management

Introduction:

Fungal osteomyelitis is an uncommon diseases and generally present in an indolent fashion. Isolated bone affection due to fungi are rare and we present one such case with fungal osteomyelitis of terminal phalanx of second toe.

Case Report:

We present a rare case of fungal osteomyelitis of right second toe in a 30 year old Indian female who presented with swelling of 8 months duration. Diagnosis was based on the histo-pathological report and culture showing Aspergillus growth. The patient was treated with surgical debridement and amphotericin-B was given for 6 weeks after debridement. There was no recurrence one year post surgery.

Conclusion:

Isolated Aspergillus osteomyelitis of the bone are very rare and mostly seen in immunocompromised patients and larger bones like spine, femur and tibia. Treatment with wound debridement and subsequently followed up with a course of Amphotericin-B for 6 weeks provided good results. There was no recurrence noted at 1 year follow up. Fungi should be kept in mind for differential diagnosis of osteomyelitis and culture should be appropriately ordered.

Current concepts in pathogenesis of acute and chronic osteomyelitis

PURPOSE OF REVIEW

The term osteomyelitis covers a wide range of inflammatory bone disorders caused by microbial invasion or due to autoinflammatory processes, but furthermore osteomyelitis also occurs at different ages and at preferred localizations in the human skeleton. This article aims to give an overview of the current literature focussing on pathognomonic aspects of osteomyelitis because of microbial invasion.

RECENT FINDINGS

Outlining the chronological sequence of osteomyelitis originating from the invasion of microbes finally leading to destruction of bone tissue, the formation and proliferation of biofilm structures play a key role in the development of inflammatory bone disorders. The components of the biofilm on the one hand mediate an immune response leading to an increase of local cytokines and induction of osteoclastogenesis but on the other hand also directly interact with the osteoblasts. As a result, the bone-remodelling process is immensely diminished by induction of proapoptotic pathways, decreased proliferation and differentiation of osteoblasts and an additional promotion of osteoclastogenesis.

SUMMARY

Although microbial invasion is responsible to be the cause for inflammatory bone disorders, except for an autoinflammatory origin, the underlying and detailed mechanisms in the pathogenesis of osteomyelitis are not yet fully understood, but represent an absolute precondition for the development of effective causal treatment strategies in the future.

Fungal osteomyelitis of maxillofacial bones: Rare presentation

Osteomyelitis is defined as inflammation of the medullary cavities, haversian system and adjacent cortex of bone. Osteomyelitis involving maxilla is quite rare when compared to that of mandible. Fungal osteomyelitis is very rarely seen and documented in the maxillofacial area. It is devastating to patients if it is invasive in nature. A prospective study was undertaken from December 2011 to December 2013. Biopsied hard tissue bits were decalcified and sections were stained with H&E, periodic acid Schiff and Grocott methenamine silver. Culture sensitivity was carried out in all cases. Surgical intervention followed by antifungal therapy was advocated to treat the patients. The current series showed five cases of fungal osteomyelitis which included candidal osteomyelitis, aspergillosis and mucormycosis with slight predominance of maxilla over mandible. Osteomyelitis of facial bones needs to be investigated thoroughly as there is no difference in clinical presentation between bacterial and fungal osteomyelitis. The diagnostic workup with biopsy and culture sensitivity helps to identify the pathogen at the earliest. Appropriate antifungal treatment needs to be advocated for successful treatment.

Infections and arthritis

Bacteria, viruses, fungi, and parasites can all cause arthritis of either acute or chronic nature, which can be divided into infective/septic, reactive, or inflammatory. Considerable advances have occurred in diagnostic techniques in the recent decades resulting in better treatment outcomes in patients with infective arthritis. Detection of emerging arthritogenic viruses has changed the epidemiology of infection-related arthritis. The role of viruses in the pathogenesis of chronic inflammatory arthritides such as rheumatoid arthritis is increasingly being recognized. We discuss the various causative agents of infective arthritis and emphasize on the approach to each type of arthritis, highlighting the diagnostic tests, along with their statistical accuracy. Various investigations including newer methods such as nucleic acid amplification using polymerase chain reaction are discussed along with the pitfalls in interpreting the tests.

Fungal osteomyelitis and septic arthritis

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Trichophyton rubrum osteomyelitis after calcaneus external fixation pin stabilization of a pilon fracture

Fungal organisms are an uncommon cause of osteomyelitis, and no dermatophyte osteomyelitis infections have been reported in published studies. We present the case of Trichophyton rubrum osteomyelitis of the calcaneus. Our patient initially presented with a pilon fracture requiring temporary external fixation while awaiting definitive fixation. From our review of the published data, the present case is the first of this type of fungal osteomyelitis to be reported. The patient was evaluated for a left neck mass during his hospitalization that was later found to be consistent with salivary duct carcinoma of the tail of the parotid gland. A left neck dissection and superficial excision of the parotid gland was performed after fixation of his pilon fracture. Subsequently, he developed an increasing lucency in the calcaneus and symptoms of pain and erythema months after the calcaneus pin had been removed. The osteomyelitis was treated with surgical debridement and 3 months of itraconazole once cultures had definitively grown T. rubrum.

Drug Adverse Event Detection in Health Plan Data Using the Gamma Poisson Shrinker and Comparison to the Tree-based Scan Statistic

Background: Drug adverse event (AE) signal detection using the Gamma Poisson Shrinker (GPS) is commonly applied in spontaneous reporting. AE signal detection using large observational health plan databases can expand medication safety surveillance. Methods: Using data from nine health plans, we conducted a pilot study to evaluate the implementation and findings of the GPS approach for two antifungal drugs, terbinafine and itraconazole, and two diabetes drugs, pioglitazone and rosiglitazone. We evaluated 1676 diagnosis codes grouped into 183 different clinical concepts and four levels of granularity. Several signaling thresholds were assessed. GPS results were compared to findings from a companion study using the identical analytic dataset but an alternative statistical method—the tree-based scan statistic (TreeScan). Results: We identified 71 statistical signals across two signaling thresholds and two methods, including closely-related signals of overlapping diagnosis definitions. Initial review found that most signals represented known adverse drug reactions or confounding. About 31% of signals met the highest signaling threshold. Conclusions: The GPS method was successfully applied to observational health plan data in a distributed data environment as a drug safety data mining method. There was substantial concordance between the GPS and TreeScan approaches. Key method implementation decisions relate to defining exposures and outcomes and informed choice of signaling thresholds.

Coccidioidomycosis infection of a total knee arthroplasty in a nonendemic region

Fungal prosthetic joint infections are rare and difficult to treat. There is an ongoing discussion about the type and duration of antifungal treatment and the necessity of prosthesis removal. We report the first European case of an infected total knee arthroplasty with Coccidioides immitis. Treatment consisted of lifelong treatment with oral fluconazole at a dose of 400 mg/d, without total knee arthroplasty removal. After 6 months, the initial complaints of pain and swelling were completely resolved. This case report clearly states that a travel history and culturing for fungi are helpful in patients with persisting complaints after joint arthroplasty.

Primary Candida guilliermondii Infection of the Knee in a Patient without Predisposing Factors

Isolated primary candidal infection of joint is extremely rare, with only a few reported cases. It occurs as a result of accidental implantations of fungus during traumatic procedures, such as surgery, and is usually reported in patients with predisposing factors such as immunosuppression, malignancy, and drug abuse. If left untreated, irreversible deformity and pain with severe osteoarticular destruction occur. Thus, early diagnosis and treatment are important. This paper presents a case of 72-year-old man with primary C. guilliermondii infection of knee joint without predisposing factors and previous traumatic procedures, who was misdiagnosed with advanced degenerative osteoarthritis. Our case is the second case of primary C. guilliermondii arthritis of knee to be reported in the English-language literature and the first to be successfully treated with total knee arthroplasty following IV amphotericin B and oral fluconazole. Primary candidal infection of joint is generally asymptomatic or involves only mild pain and swelling in the affected knee. Thus, although the majority of knee joint infections are of a pyogenic or tuberculous origin, if a patient complains of mild pain and swelling in the knee and has mild signs of infection, the possibility of fungal infection should be considered.

Interactions of Bacteria and Fungi at the Surface

The increased life span of humans and the dynamic development of Biomaterials' industry have led to widespread use of implants in modern medicine. Microorganisms, mostly opportunistic flora,are able to adapt perfectly to the changing environment of their host. Bacteria, once regarded as non-pathogenic, successfully bind to artificial surfaces resulting in diseases that are difficult to treat. The Chapter discusses the process of microbial adhesion to the surfaces. It provides the brief description of the most important infections of humans, which result from the microbial colonization of implanted biomaterials. This adhesion is characterized in the context of physicochemical and biological interactions between microorganism and the surface. We describe the effects of environmental factors and the contribution of bacterial/fungal cell structures on microbial adhesion. Finally, the Chapter presents the most important aspects of interactions between bacteria and charged surfaces.

Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy

Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.

Candidal arthritis in revision knee arthroplasty successfully treated with sequential parenteral-oral fluconazole and amphotericin B-loaded cement spacer

We present a case of a patient with preoperative cutaneous candidiasis, who developed candidal infection during stage revision knee arthroplasty. The patient received intravenous fluconazole for 6 weeks and resection arthroplasty with an amphotericin B-loaded cement spacer and continuous oral fluconazole therapy for 9 weeks. Revision surgery was successful.