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Gamaletsou MN, Rammaert B, Brause B, Bueno MA, Dadwal SS, Henry MW, Katragkou A, Kontoyiannis DP, McCarthy MW, Miller AO, Moriyama B, Pana ZD, Petraitiene R, Petraitis V, Roilides E, Sarkis JP, Simitsopoulou M, Sipsas NV, Taj-Aldeen SJ, Zeller V, Lortholary O, Walsh TJ. Osteoarticular Mycoses. Clin Microbiol Rev 2022; 35:e0008619. [PMID: 36448782 PMCID: PMC9769674 DOI: 10.1128/cmr.00086-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Maria N. Gamaletsou
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Blandine Rammaert
- Université de Poitiers, Faculté de médecine, CHU de Poitiers, INSERM U1070, Poitiers, France
| | - Barry Brause
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Marimelle A. Bueno
- Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Manilla, Philippines
| | | | - Michael W. Henry
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aspasia Katragkou
- Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Ohio State University School of Medicine, Columbus, Ohio, USA
| | | | - Matthew W. McCarthy
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
| | - Andy O. Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Zoi Dorothea Pana
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Ruta Petraitiene
- Weill Cornell Medicine of Cornell University, New York, New York, USA
| | | | - Emmanuel Roilides
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Maria Simitsopoulou
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos V. Sipsas
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Valérie Zeller
- Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Olivier Lortholary
- Université de Paris, Faculté de Médecine, APHP, Hôpital Necker-Enfants Malades, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR 2000, Paris, France
| | - Thomas J. Walsh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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Mertens B, Van Daele R, Depypere M, Lagrou K, Debaveye Y, Wauters J, Nijs S, Metsemakers WJ, Spriet I. Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review. Antibiotics (Basel) 2022; 11:antibiotics11030344. [PMID: 35326807 PMCID: PMC8944859 DOI: 10.3390/antibiotics11030344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.
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Affiliation(s)
- Beatrijs Mertens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-16-34-69-57
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Melissa Depypere
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
| | - Katrien Lagrou
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Belgian National Reference Center for Mycosis, University Hospitals Leuven, B-3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, B-3000 Leuven, Belgium
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium;
- Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Joost Wauters
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Medical Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
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3
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Radhakrishnan S, Mujeeb H, Radhakrishnan C. Central skull base osteomyelitis secondary to invasive aspergillus sphenoid sinusitis presenting with isolated 12th nerve palsy. IDCases 2020; 22:e00930. [PMID: 32923366 PMCID: PMC7475189 DOI: 10.1016/j.idcr.2020.e00930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/21/2022] Open
Abstract
Skull base osteomyelitis is a potentially life-threatening infection, usually seen in elderly immunocompromised patients secondary to malignant otitis externa (MOE) caused by Pseudomonas. Central or atypical skull base osteomyelitis often poses a diagnostic challenge as they present as head-ache with or without cranial nerve palsy often without any obvious source of infection. Although the incidence of fungal skull base osteomyelitis is increasing central skull base osteomyelitis due to invasive fungal sinusitis presenting with isolated hypoglossal nerve palsy has not been reported in the literature, to our knowledge. We report a case of a 59-year-old diabetic patient on regular treatment including steroid for acetylcholine receptor binding antibody positive myasthenia gravis with thymoma who presented with persistent head-ache and on evaluation, was found to have 12th cranial nerve palsy on the right side. She was diagnosed to have invasive fungal sphenoid sinusitis and central skull base osteomyelitis involving the clivus and was successfully treated with endoscopic transnasal transsphenoidal debridement followed by antifungal therapy.
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Affiliation(s)
| | - Hiba Mujeeb
- Govt. Medical College, Manjeri, Malappuram, Kerala, India
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Papachristou SG, Iosifidis E, Sipsas NV, Gamaletsou MN, Walsh TJ, Roilides E. Management of osteoarticular fungal infections in the setting of immunodeficiency. Expert Rev Anti Infect Ther 2020; 18:461-474. [PMID: 32213145 DOI: 10.1080/14787210.2020.1748499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Savvas G Papachristou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences and Hippokration General Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences and Hippokration General Hospital, Thessaloniki, Greece
| | - Nikolaos V Sipsas
- Infectious Diseases Unit, Pathophysiology Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria N Gamaletsou
- Infectious Diseases Unit, Pathophysiology Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY, USA
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences and Hippokration General Hospital, Thessaloniki, Greece
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Sternal osteomyelitis secondary to Aspergillus fumigatus after cardiothoracic surgery. Med Mycol Case Rep 2020; 28:16-19. [PMID: 32274324 PMCID: PMC7132061 DOI: 10.1016/j.mmcr.2020.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 11/21/2022] Open
Abstract
Sternal Osteomyelitis from Aspergillus fumigatus in immunocompetent patients is extremely rare with limited number of cases reported so far. Here we discuss the case of a 65-year-old female with osteomyelitis of the sternum caused by Aspergillus fumigatus after undergoing coronary artery bypass graft surgery. Patient was treated with surgical debridement and prolonged antifungal therapy; however, the course was complicated due to poor adherence to antifungal therapy.
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1611] [Impact Index Per Article: 201.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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Vergara GE, Roura N, Del Castillo M, Mora A, Alcorta SC, Mormandi R, Cervio A, Salvat J. [Cervical aspergillosis with dissemination to the central nervous system: Case reports and review of the literature]. Surg Neurol Int 2015; 6:S524-9. [PMID: 26600985 PMCID: PMC4623611 DOI: 10.4103/2152-7806.167203] [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: 03/13/2015] [Accepted: 03/19/2015] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) of the central nervous system (CNS) is an uncommon condition that usually occurs in immunocompromised patients. This illness can manifest as meningitis, or as a micotic aneurism, stroke or abscess. The infection affects the CNS either primarily or, more often, secondarily via blood dissemination from a distant focus, and has a poor prognosis. We present a patient with IA primarily affecting the cervical bones, with later spread into the brain. CASE DESCRIPTION A 25-year old male was receiving chemotherapy for acute lymphocytic leukemia when he developed pneumonitis secondary to methotrexate and was started on corticosteroids. He subsequently developed cervicalgia, prompting a needle biopsy of the fourth vertebrae, after which a diagnosis of osteomyelitis was made. Even though the biopsy culture was negative, empirical antibiotics were initiated. A parietal lobe lesion was treated surgically months later after the patient presented with three episodes of transient aphasia. After A. fumigatus grew in culture, the patient's antibiotic regimen was changed to treat the specific agent with a good response. CONCLUSION IA must be considered a possibility whenever an immunocompromised patient presents with a new brain lesion. These lesions require surgical evacuation, a procedure that allows for diagnostic confirmation and enhances prognosis. Appropriate anti-fungal therapy must be started as soon as the diagnosis is confirmed. In addition, the patient's neurological exam must be repeated and images obtained periodically to monitor treatment and detect possible recurrences.
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Affiliation(s)
| | - Natalia Roura
- Traumatólogos (Neurortopedistas) del Departamento de Neurocirugía de FLENI, Buenos Aires, Argentina
| | | | - Andrea Mora
- Infectólogos del Departamento de Infectología de FLENI, Buenos Aires, Argentina
| | | | - Rubén Mormandi
- Neurocirujanos del Departamento de Neurocirugía de FLENI, Buenos Aires, Argentina
| | - Andrés Cervio
- Neurocirujanos del Departamento de Neurocirugía de FLENI, Buenos Aires, Argentina
| | - Jorge Salvat
- Neurocirujanos del Departamento de Neurocirugía de FLENI, Buenos Aires, Argentina
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Abstract
STUDY DESIGN Review of the literature. OBJECTIVE To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease. SUMMARY OF BACKGROUND DATA Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series. METHODS MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database. RESULTS A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles. CONCLUSION Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections. LEVEL OF EVIDENCE 3.
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Reischies F, Hoenigl M. The role of surgical debridement in different clinical manifestations of invasive aspergillosis. Mycoses 2014; 57 Suppl 2:1-14. [PMID: 25186615 DOI: 10.1111/myc.12224] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 11/30/2022]
Abstract
Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.
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Affiliation(s)
- Frederike Reischies
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
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10
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Al-Abdely HM, Alothman AF, Salman JA, Al-Musawi T, Almaslamani M, Butt AA, Al Thaqafi AO, Raghubir N, Morsi WE, Yared NA. Clinical practice guidelines for the treatment of invasive Aspergillus infections in adults in the Middle East region: Expert panel recommendations. J Infect Public Health 2014; 7:20-31. [DOI: 10.1016/j.jiph.2013.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/05/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022] Open
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Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome. J Infect 2013; 68:478-93. [PMID: 24378282 DOI: 10.1016/j.jinf.2013.12.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/16/2013] [Accepted: 12/18/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood. METHODS Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome. RESULTS Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006). CONCLUSIONS Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.
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Gabrielli E, Fothergill AW, Brescini L, Sutton DA, Marchionni E, Orsetti E, Staffolani S, Castelli P, Gesuita R, Barchiesi F. Osteomyelitis caused by Aspergillus species: a review of 310 reported cases. Clin Microbiol Infect 2013; 20:559-65. [PMID: 24303995 DOI: 10.1111/1469-0691.12389] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 08/31/2013] [Accepted: 08/31/2013] [Indexed: 11/30/2022]
Abstract
Aspergillus osteomyelitis is a rare infection. We reviewed 310 individual cases reported in the literature from 1936 to 2013. The median age of patients was 43 years (range, 0-86 years), and 59% were males. Comorbidities associated with this infection included chronic granulomatous disease (19%), haematological malignancies (11%), transplantation (11%), diabetes (6%), pulmonary disease (4%), steroid therapy (4%), and human immunodeficiency virus infection (4%). Sites of infection included the spine (49%), base of the skull, paranasal sinuses and jaw (18%), ribs (9%), long bones (9%), sternum (5%), and chest wall (4%). The most common infecting species were Aspergillus fumigatus (55%), Aspergillus flavus (12%), and Aspergillus nidulans (7%). Sixty-two per cent of the individual cases were treated with a combination of an antifungal regimen and surgery. Amphotericin B was the antifungal drug most commonly used, followed by itraconazole and voriconazole. Several combination or sequential therapies were also used experimentally. The overall crude mortality rate was 25%.
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Affiliation(s)
- E Gabrielli
- Clinica Malattie Infettive, Università Politecnica delle Marche, Ancona, Italy
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Neofytos D, Huprikar S, Reboli A, Schuster M, Azie N, Franks B, Horn D. Treatment and outcomes of Candida osteomyelitis: review of 53 cases from the PATH Alliance® registry. Eur J Clin Microbiol Infect Dis 2013; 33:135-41. [DOI: 10.1007/s10096-013-1939-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/22/2013] [Indexed: 11/30/2022]
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14
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Chronic granulomatous Aspergillus synovitis: a case report. Mediterr J Hematol Infect Dis 2013; 5:e2013043. [PMID: 23795281 PMCID: PMC3684320 DOI: 10.4084/mjhid.2013.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/02/2013] [Indexed: 11/26/2022] Open
Abstract
Aspergillus can cause invasive disease of various organs especially in patients with weakened immune systems. Aspergillus synovitis and arthritis are uncommon types of involvement due to this infection. Approaches to fungal osteoarticular infections are based on only case reports. This paper presents a rare case of chronic granulomatous Aspergillus synovitis in an immunocompromised 5-year old girl who was treated for acute lymphoblastic leukemia.
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Cryptococcose osseuse chez une patiente porteuse d’une leucémie lymphocytique traitée par fludarabine-cyclophosphamide-rituximab. J Mycol Med 2013; 23:57-63. [DOI: 10.1016/j.mycmed.2012.12.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 12/11/2012] [Accepted: 12/18/2012] [Indexed: 12/27/2022]
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Hall GL, Villanueva-Siles E, Borzykowski RM, Gruson KI, Dorfman HD, Geller DS. Aspergillus osteomyelitis of the proximal humerus: a case report. Skeletal Radiol 2012; 41:1021-5. [PMID: 22467007 DOI: 10.1007/s00256-012-1401-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 02/22/2012] [Accepted: 03/12/2012] [Indexed: 02/02/2023]
Abstract
Aspergillus osteomyelitis is an extremely rare manifestation of invasive aspergillosis. Generally, patients in states of significant immune deficiency are very susceptible to invasive aspergillosis. We report a case of Aspergillus osteomyelitis of the proximal humerus in an immunocompetent patient that required aggressive oral antifungal therapy, surgical debridement, and placement of an antifungal-impregnated cement spacer. Subsequently, her shoulder was reconstructed using a reverse total shoulder prosthesis The clinical course, radiographic findings, histology, and management rationale are presented.
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17
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Figuères ML, Cantarovich D, Tattevin P, Le Pogamp P, Polard JL, Stock N, Blancho G. Aspergillus arthritis and organ transplantation. Clin Kidney J 2012; 5:237-9. [PMID: 26069774 PMCID: PMC4400502 DOI: 10.1093/ckj/sfs024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 02/16/2012] [Indexed: 11/30/2022] Open
Abstract
We report a case of a kidney and pancreas transplanted patient, hospitalized for septic hip arthritis. The whole diagnostic work-up including synovial and bone biopsies remained negative. After inefficient empirical anti-bacterial antibiotic treatment, femoral head resection was performed and tissue analysis revealed Aspergillus fumigatus hyphae. Treatment with voriconazole along with hip replacement led to complete recovery. However, drug interaction between immunosuppressive and anti-fungal drugs was complicated by cellular acute graft rejection. Aspergillus fumigatus arthritis is an uncommon and serious infection that should be evoked especially in the case of resistance to anti-microbial antibiotics and/or an atypical clinical picture.
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Affiliation(s)
- Marie-Lucile Figuères
- Institut of Transplantation - Urology - Nephrology (ITUN), Hôtel Dieu. CHU de Nantes, France
| | - Diego Cantarovich
- Institut of Transplantation - Urology - Nephrology (ITUN), Hôtel Dieu. CHU de Nantes, France
- UMR INSERM 1024. Nantes, France
| | - Pierre Tattevin
- Service de Maladies Infectieuses, Hôpital Pontchaillou. CHU de Rennes, France
| | | | - Jean-Louis Polard
- Service de Chirurgie Orthopédique, Hôpital Pontchaillou. CHU de Rennes, France
| | - Nathalie Stock
- Service d'Anatomopathologie, Hôpital Pontchaillou. CHU de Rennes, France
| | - Gilles Blancho
- Institut of Transplantation - Urology - Nephrology (ITUN), Hôtel Dieu. CHU de Nantes, France
- UMR INSERM 1024. Nantes, France
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18
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Zhu LP, Chen XS, Wu JQ, Yang FF, Weng XH. Aspergillus vertebral osteomyelitis and ureteral obstruction after liver transplantation. Transpl Infect Dis 2011; 13:192-9. [DOI: 10.1111/j.1399-3062.2011.00599.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Studemeister A, Stevens DA. Aspergillus Vertebral Osteomyelitis in Immunocompetent Hosts: Role of Triazole Antifungal Therapy. Clin Infect Dis 2011; 52:e1-6. [DOI: 10.1093/cid/ciq039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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20
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Eltoukhy NS, Crank CW. Antifungal Distribution Into Cerebrospinal Fluid, Vitreous Humor, Bone, and Other Difficult Sites. CURRENT FUNGAL INFECTION REPORTS 2010. [DOI: 10.1007/s12281-010-0016-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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21
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Yu OHY, Keet AWW, Sheppard DC, Brewer T. Articular aspergillosis: case report and review of the literature. Int J Infect Dis 2009; 14:e433-5. [PMID: 19656708 DOI: 10.1016/j.ijid.2009.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 05/01/2009] [Accepted: 05/24/2009] [Indexed: 11/25/2022] Open
Abstract
The incidence of invasive aspergillosis is increasing due to more frequent use of immunosuppressant agents in patients with autoimmune diseases, hematological malignancies, and solid organ and hematopoietic stem cell transplants. Invasive aspergillosis most commonly affects the lungs, sinuses, and brain. Aspergillosis affecting the musculoskeletal system is rare. We describe here a case of articular aspergillosis in a febrile neutropenic patient successfully treated with voriconazole and caspofungin, and briefly review the 10 cases of articular aspergillosis that have previously been described in the literature.
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Affiliation(s)
- Oriana Hoi Yun Yu
- Department of Internal Medicine, Jewish General Hospital, McGill University, 3755 Cote St. Catherine Road, Montreal, Quebec, Canada H3T 1E2.
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22
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Garazzino S, Maiello A, DE Rosa FG, Aprato A, Di Perri G. Post-traumatic osteomyelitis due to Aspergillus flavus successfully treated with voriconazole: a case report. J Chemother 2008; 20:524-6. [PMID: 18676238 DOI: 10.1179/joc.2008.20.4.524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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23
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In vitro activities at pH 5.0 and pH 7.0 and in vivo efficacy of flucytosine against Aspergillus fumigatus. Antimicrob Agents Chemother 2008; 52:4483-5. [PMID: 18794382 DOI: 10.1128/aac.00491-08] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The antifungal agent flucytosine was found to be active in vitro against Aspergillus fumigatus isolates when the MIC was determined at pH 5.0 instead of pH 7.0. The in vitro MIC at pH 5.0 corresponded to the in vivo efficacy of flucytosine monotherapy in a murine model of invasive aspergillosis.
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24
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Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Segal BH, Steinbach WJ, Stevens DA, van Burik JA, Wingard JR, Patterson TF. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:327-60. [PMID: 18177225 DOI: 10.1086/525258] [Citation(s) in RCA: 1839] [Impact Index Per Article: 114.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Thomas J Walsh
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
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25
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Walsh T, Anaissie E, Denning D, Herbrecht R, Kontoyiannis D, Marr K, Morrison V, Segal B, Steinbach W, Stevens D, van Burik J, Wingard J, Patterson Y. Tratamiento de la Aspergilosis: Guías para la práctica clínica de la Sociedad de Enfermedades Infecciosas de los Estados Unidos de América (IDSA). Clin Infect Dis 2008. [DOI: 10.1086/590225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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26
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Ersoy A, Akdag I, Akalin H, Sarisozen B, Ener B. Aspergillosis osteomyelitis and joint infection in a renal transplant recipient. Transplant Proc 2007; 39:1662-3. [PMID: 17580212 DOI: 10.1016/j.transproceed.2006.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 11/16/2006] [Indexed: 12/12/2022]
Abstract
Invasive Aspergillosis occurs in almost every human organ, most commonly in the lungs. Bone involvement classically has been considered exceedingly rare for both immunocompromised and immunocompetent hosts, however, there are limited data in transplant recipients. We report an unusual case of osteomyelitis and joint infection of the ankle caused by Aspergillus fumigatus in a renal transplant recipient.
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Affiliation(s)
- A Ersoy
- Department of Nephrology, Uludag University Medical Faculty, Gorukle, Bursa 16059, Turkey.
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