Paracoccidioidomycosis of bones and joints. A clinical, radiologic, and pathologic study of 9 cases

Fungal Musculoskeletal Infections: Comprehensive Approach to Proper Diagnosis

Fungal musculoskeletal infections often have subacute or indolent manifestations, making it difficult to distinguish them from other diseases and infections, given that they are relatively uncommon. Fungal infections occur by hematogenous spread, direct inoculation, or contiguous extension and may be related to different risk factors, including immunosuppression and occupational activity. The infection can manifest in isolation in the musculoskeletal system or as part of a systemic process. The fungi may be endemic to certain regions or may be found throughout the world, and this can help to narrow the diagnosis of the etiologic agent. Infections such as candidiasis, cryptococcosis, aspergillosis, and mucormycosis are often related to immunosuppression. On the other hand, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and blastomycosis can occur in healthy patients in geographic areas where these infections are endemic. Furthermore, infections can be classified on the basis of the site of infection in the body. Some subcutaneous infections that can have osteoarticular involvement include mycetoma, sporotrichosis, and phaeohyphomycosis. Different fungi affect specific bones and joints with greater prevalence. Imaging has a critical role in the evaluation of these diseases. Imaging findings include nonspecific features such as osteomyelitis and arthritis, with bone destruction, osseous erosion, mixed lytic and sclerotic lesions, and joint space narrowing. Multifocal osteomyelitis and chronic arthritis with joint effusion and synovial thickening may also occur. Although imaging findings are often nonspecific, some fungal infections may show findings that aid in narrowing the differential diagnosis, especially when they are associated with the patient's clinical condition and history, the site of osteoarticular involvement, and the geographic location. ©RSNA, 2024.

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.

Examining variation in skeletal tuberculosis in a late pre-contact population from the eastern mountains of Peru

OBJECTIVE AND MATERIALS

This research evaluates the presence and chronology of tuberculosis (TB) in the northeastern highlands of Peru (CE 800-1535) through the analysis of osseous lesions from Pre-Contact Kuelap, Chachapoyas.

METHODS

We examined macroscopic lesion morphology and distribution from the skeletal series (MNI = 207).

RESULTS

We determined that skeletal evidence was highly consistent with advanced multifocal and spinal tuberculosis in 13 individuals. Destructive lesions of the lower thoracic and/or lumbar vertebra bodies and sacroiliac joints are evident in most cases, but we also observed lesions within the manubriosternal, hip, and knee joints. Both adult males (n = 7) and females (n = 6) present skeletal lesions from young adult to older adults, but there is only one late adolescent. Only three individuals demonstrate similar lesion distributions.

CONCLUSIONS

Variation in lesion distribution in this population-based study shows the importance of identifying extra-vertebral tuberculosis and suggests that the disease may have manifested differently than at other coastal sites. These cases confirm the presence of tuberculosis both before and after Inca occupation across this central Andean highlands region.

SIGNIFICANCE

This evidence for the likely endemic presence of TB in the New World prior to European Contact furthers our understanding of the distribution of this infectious disease across the region as well as elucidating lesion distribution.

LIMITATIONS

The diagnosis of tuberculosis is based on skeletal lesions and it should be confirmed by molecular analysis.

FUTURE RESEARCH

Additional examination of vertebral bodies (including juvenile remains) for evidence of earlier manifestations of infection.

Acute-subacute paracoccidioidomycosis: A paediatric cohort of 141 patients, exploring clinical characteristics, laboratorial analysis and developing a non-survival predictor

The acute-subacute form of paracoccidioidomycosis (PCM) is a severe systemic mycosis that affects children and adolescents from endemic regions, leading to generalised lymphadenopathy, fever, weight loss, anaemia, eosinophilia, hypoalbuminemia and hypergammaglobulinemia. The objective of this study is to describe the clinical and laboratorial characteristics of acute-subacute PCM, to determine a mortality risk factor and to propose a test for non-survival hazard related to the disease. Children and adolescents diagnosed with PCM, under 15 years were included in the study. Their epidemiological, clinical and laboratorial data were obtained from the hospital records. Descriptive analysis, comparison of means, univariate logistic regression, multivariate logistic regression and a ROC curve were performed in order to identify significant information (P < .05). Through a period of 38 years, 141 children and adolescents were diagnosed with acute-subacute PCM. The main antifungal agent used for the treatment was sulfamethoxazole-trimethoprim (SMX-TMP). The complication rate was 17%, the relapse rate was 7.8% and the mortality rate was 5.7%. A low albumin dosage was identified as a predictor factor for mortality. The cut-off for serum albumin was 2.18 g/dL, above which, the survival rate is 99.1%. Thus, simple clinical and laboratorial examinations may lead to the diagnosis of acute-subacute PCM, and the beginning of the treatment is encouraged even before the isolation of the fungus in biological samples, preventing unfavourable outcomes. Patients with an albumin dosage ≤ 2.18g/dL must receive special attention, preferably hospitalised, during the first four weeks of treatment for presenting an elevated mortality hazard.

Imaging paracoccidioidomycosis: A pictorial review from head to toe

Paracoccidioidomycosis is an infectious disease characterized primarily by pulmonary involvement and potential dissemination to other organs, mainly mucosa and skin; however, it can affect any organ in the body. Although difficult to diagnose purely based on imaging, imaging is important for diagnosis, follow-up, and assessment of disease-related complications. We provide a comprehensive review of the most notable imaging findings of paracoccidioidomycosis.

Magnetic resonance imaging findings of paracoccidioidomycosis in the musculoskeletal system

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in musculoskeletal paracoccidioidomycosis (PCM).

METHODS

Retrospective case series study after IRB approval. Two musculoskeletal radiologists reviewed in consensus the MRI findings of 11 patients with microbiologically and/or pathologically proven osteoarticular PCM. The MRI evaluation included discrimination of abnormalities in joints, bones and soft tissues.

RESULTS

Mean age of patients was 29 years (10-55 years), eight men and three women. Musculoskeletal involvement was the only or the primary presentation of the disease in seven patients (63%). Osteomyelitis was the most common presentation, with seven cases (63%). Primary arthritis was found in one patient (9%). Isolated extra-articular soft tissue PCM was found in three patients: myositis (2) and subcutaneous infection (1). All cases showed regions with signal intensity higher than or similar to the signal of muscle on T1-weighted images. Penumbra sign was present in five cases (45%). T2-weighted images showed reactive soft tissue oedema in eight cases (72%). Post-gadolinium images showed peripheral (8/9) or heterogeneous (1/9) enhancement. Synovial enhancement was present in all cases of joint involvement (6/6). Lipomatosis arborescens was documented in one case of chronic knee involvement.

CONCLUSION

To our knowledge, this is the first case series describing MRI findings of musculoskeletal PCM. Musculoskeletal involvement was the primary presentation of the disease in most cases, and therefore, neoplasms were initially in the differential diagnosis. Osteomyelitis was the most common presentation, often with secondary involvement of joint and or soft tissue.

Computed tomography findings of paracoccidiodomycosis in musculoskeletal system

Objective

To evaluate musculoskeletal involvement in paracoccidioidomycosis at computed tomography.

Materials and Methods

Development of a retrospective study based on a review of radiologic and pathologic reports in the institution database. Patients with histopathologically confirmed musculoskeletal paracoccidioidomycosis and submitted to computed tomography were included in the present study. The imaging findings were consensually described by two radiologists. In order to avoid bias in the analysis, one patient with uncountable bone lesions was excluded from the study.

Results

A total of seven patients were included in the present study. A total of 18 bone lesions were counted. The study group consisted of 7 patients. A total number of 18 bone lesions were counted. Osteoarticular lesions were the first manifestation of the disease in four patients (57.14%). Bone lesions were multiple in 42.85% of patients. Appendicular and axial skeleton were affected in 85.71% and 42.85% of cases, respectively. Bone involvement was characterized by well-demarcated osteolytic lesions. Marginal osteosclerosis was identified in 72.22% of the lesions, while lamellar periosteal reaction and soft tissue component were present in 5.55% of them. One patient showed multiple small lesions with bone sequestra.

Conclusion

Paracoccidioidomycosis can be included in the differential diagnosis of either single or multiple osteolytic lesions in young patients even in the absence of a previous diagnosis of pulmonary or visceral paracoccidioidomycosis

Extra-pulmonary manifestations of paracoccidioidomycosis associated with acquired immunodeficiency syndrome: a case report

We present a patient with Paracoccidioidomycosis/HIV coinfection which has been investigated because of chronic monoarthritis and mucocutaneous lesions. A biopsy of the synovial membrane and skin revealed structures consistent with Paracoccidioides brasiliensis. At diagnosis, the count of CD4 + T cells was 44 cells/mm³. We emphasize the importance of clinical suspicion of Paracoccidioidomycosis in patients with HIV/AIDS who live in or are from risk areas.

Overinfection by Paracoccidioides brasiliensis in Gouty Crystal Arthritis

Paracoccidioidomycosis is an endemic South American systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis (P. brasiliensis). The main clinical form of disease is pulmonary, but all organs may be involved. We report a case of overinfection by P. brasiliensis in chronic gouty arthritis affecting the proximal phalanx of the right hallux. The patient required proximal amputation and long-term antifungal therapy.

Osteomyelitis and pyoarthritis resulting from local paracoccidioidomycosis in an immunocompetent patient: a case report

INTRODUCTION

Paracoccidioidomycosis is a type of mycosis that is endemic to Brazil and is triggered by the fungus Paracoccidioides brasiliensis. Isolated bone involvement in this disease is very rare, especially in children. To the best of our knowledge this report documents the first case of an immunocompetent pediatric patient in which paracoccidioidomycosis of the hip articulation was the sole manifestation of the disease (that is, there were no pulmonary or skin lesions).

CASE PRESENTATION

An 11-year-old Brazilian Caucasian boy from a rural area was examined in the orthopedic ward of our emergency department. Our patient reported a three-month history of pain in the right hip with intermittent claudication and also complained of recurring episodes of intense pain and an inability to walk, which he had been experiencing for the previous five days. He additionally presented with a fever that had persisted for two days. Our patient's medical history did not include any clinical respiratory manifestations, skin lesions, history of trauma or immunosuppression risk factors.

CONCLUSIONS

This is one of the very few reported cases of isolated articular involvement in osteomyelitis in a pediatric immunocompetent patient. Paracoccidioidomycosis should be considered among the differential diagnoses in such cases, especially in cases of patients who reside in rural areas where the condition is considered to be endemic, in order to administer the proper course of treatment in a timely fashion and improve the chances of a favorable prognosis.

Radiologic findings of osteoarticular infection in paracoccidioidomycosis

OBJECTIVE

To report the radiological abnormalities of osteoarticular involvement in paracoccidioidomycosis (PCM).

MATERIALS AND METHODS

After institutional board approval, the medical records and conventional radiology findings of 19 patients with osseous PCM were retrospectively reviewed. Number, distribution, and lesion characteristics were evaluated in consensus by two experienced musculoskeletal radiologists.

RESULTS

The mean age of patients was 16.1 years (range 4-49 years), 11 male and eight female. MSK involvement was the only or the primary presentation of the disease in eight of 19 patients (42.1%). In total, 51 focal bone lesions were detected, being 41 in long bones. In long bones lesions, 19 of 41 (46.4%) were metaphyseal, 12 of 41 (29.3%) meta-epiphyseal, and 12 of 41 (29.3%) diaphyseal. The most common presentation was a geographic osteolytic bone lesion (62.7%), without marginal sclerosis (82.4%) and without periosteal reaction (90.2%). Articular involvement was present in six of 19 patients (31.6%), being two cases of primary arthritis.

CONCLUSIONS

All encountered bone lesions were osteolytic. Metaphyseal or meta-epiphyseal osteomyelitis of a long bone was the most prevalent osteoarticular manifestation of paracoccidioidomycosis. PCM osteoarticular involvement could be solitary or multifocal, occurs almost exclusively in the acute/subacute clinical form, and it is more common in children and in juvenile patients. Axial skeleton involvement, arthritis, or a disseminated osseous pattern of infection may occasionally occur in this fungal disease.

Fungal infection by Paracoccidioides brasiliensis mimicking bone tumor

Paracoccidioides brasiliensis infection causes a systemic mycosis originally described in Latin America but with current reports of worldwide distribution. The clinical presentation of paracoccidiodomycosis as an isolated long-bone lesion in children is quite unusual. This article describes a 10-year-old male with a lytic femoral bone lesion caused by P. brasiliensis infection that was first suspected of being of neoplasic etiology. The text also emphasizes the importance of including endemic fungal infections in the differential diagnosis of bone lesions.

Infiltrative myelopathy by paracoccidioidomycosis. A review and report of nine cases with emphasis on bone marrow morphology

AIMS

To report nine additional well-defined cases with infiltrative myelopathy by paracoccidioidomycosis (PCM), to describe the specific lesions and infection-related stromal abnormalities, to review the literature on this type of involvement and to introduce a new cause of granulomatous lesions of bone marrow.

METHODS AND RESULTS

Different bone marrow specimens were studied (aspirated smears, aspirated clots, biopsy imprints and biopsies) from nine patients with acute or subacute forms of PCM known to have PCM infiltrative myelopathy.

CONCLUSIONS

The biopsy specimens were the best for demonstrating bone marrow involvement by PCM. The lesions varied from compact and focal granulomas with few fungal cells to numerous disseminated fungal cells within a loose granulomatous inflammatory reaction, with a continuum between these extremes suggesting a spectrum of immune response to the fungi. Other findings such as bone marrow fibrosis, parenchymal coagulative necrosis and bone necrosis were also observed in the affected areas.

Resultado tardio da infecção isolada no quadril por Paracoccidioides brasiliensis

Infecções causadas pelo Paracoccidioides brasiliensis são sempre um desafio diagnostico mesmo em áreas endêmicas, devidas as suas múltiplas apresentações clinicas e órgãos envolvidos. Este artigo descreve a evolução do único caso descrito na literatura no qual a doença acometeu apenas um quadril.