Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin's disease

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.

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review

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.

Sternal osteomyelitis secondary to Aspergillus fumigatus after cardiothoracic surgery

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.

Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome

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.

Sternal osteomyelitis caused by Aspergillus fumigatus following cardiac surgery: Case and review

Postsurgical sternal wound infection is a serious post-operative complication of cardiac surgery. Aspergillus infection of the sternum is extremely rare. We describe a case of sternal infection due to Aspergillus in an immunocompetent patient following aortic valve replacement.

Primary sternal osteomyelitis in a 40 days old infant: a case report and review of the literature

Introduction

Primary sternal osteomyelitis is extremely rare in children and only very few cases have been reported in the international literature.

Case presentation

A 40 days old Caucasian infant was referred to our clinic with a 4 days history of fever and malaise, accompanying a painful swelling of four days duration involving the lower end of the sternum. Examination revealed a 2 cm swelling which was fixed to the underlying bone. A full blood count, erythrocyte sedimentation rate, and C-reactive protein were measured and x-rays (Anterior and Lateral views) and Ultrasound was performed. Blood cultures were also taken. The patient was commenced empirically to Vancomycin and Cefotaxime intravenously.

The values of White Blood Cell (16,720), erythrocyte sedimentation rate (132 mm) and C-reactive protein (108 mg/dl) were elevated, the X-rays showed bone destruction and dislocation of the 3^rd sternal nuclei and in the U/S performed appeared a soft tissue mass measuring 2,37/1,02 cm related to the periosteum. Surgical debridement was then performed and swab cultures were taken intraoperatively. The infant grew Streptococcus Pneumoniae and Enterococcus Species. The infant was discharged after 25 days from the hospital. He gradually improved over a period of 2 months, became pain free and repeated x-rays showed significant bone resolution.

Conclusion

Primary osteomyelitis in infants is a very rare condition that usually resolves with antibiotic therapy and surgical debridement.

Recommendations for managing Aspergillus osteomyelitis and joint infections based on a review of the literature

OBJECTIVES

To produce recommendations for the management of Aspergillus osteomyelitis and joint infections.

METHODS

Published literature was surveyed to identify both case reports of Aspergillus osteomyelitis and joint infections and anti-fungal pharmacology of anti-fungal agents. Included in the pharmacological review was an assessment of new and investigational anti-fungals to consider their potential role in the management of this infection.

RESULTS

Successful treatments, identified from the cases reviewed, were based on combination anti-fungal therapy with one agent having good bone penetration and one having reliable anti-Aspergillus activity.

CONCLUSIONS

For the management of serious Aspergillus osteomyleitis/joint infections amphotericin B in combination with flucytosine is recommended. A number of second line treatment combinations are identified. Monotherapy is appropriate with an azole in clinically stable patients.

Fungal arthritis and osteomyelitis

Fungal arthritis and osteomyelitis are uncommon diseases and generally present in an indolent fashion. The incidence of fungal bone and joint dis-ease is increasing with an increase in the prevalence of factors predisposing to invasive fungal disease, such as the use of central venous catheters, broad spectrum antibiotics, immunosuppression, and abdominal surgery. Definitive diagnosis relies on bone or synovial culture or biopsy. Successful management has traditionally consisted of amphotericin B in combination with surgical debridement. Given the rarity of this disease, treatment is not well defined, but reports of success with the use of azole antifungal agents, including itraconazole, fluconazole, voriconazole, and posaconazole, are promising.

Primary sternal osteomyelitis: a case series and review of the literature

PURPOSE

Primary sternal osteomyelitis is rare in the pediatric population.

METHODS

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

RESULT

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

CONCLUSION

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.

Sternal osteomyelitis complicating percutaneous coronary artery stenting

Hematogenous sternal osteomyelitis is a rare infection that has been associated with i.v drug abuse and blunt thoracic trauma, but iatrogenic infections have also been described following resuscitation and in conjunction with hemodialysis catheters. Staphylococcus aureus is the most common causative organism. Stenting is the preferred treatment for isolated stenosis of the coronary artery and is associated with a low complication rate and high patency rate. Such intravascular procedures are rarely complicated by infections. A 72-year-old man developed hematogenous sternal osteomyelitis following coronary artery stenting. Radiological diagnosis was made using CT scan and MRI, and blood cultures and aspiration fluid from the infected soft tissue were positive for S. aureus. Initial therapy consisted of i.v. second-generation cephalosporin followed by oral cephalexin and later linezolid. Prolonged antibiotic therapy without surgical intervention was successful in controlling this rare complication. The patient was well at the one-year follow up, with patent stent and no signs for recurrent osteomyelitis. Although transcutaneous stenting is a widely accepted strategy for treating stenosed arteries, this case highlights the possibility of hazardous infectious complications associated with such procedures.

New clinical presentations of invasive aspergillosis in non-conventional hosts

Infections by Aspergillus spp. are most typically associated with invasive pulmonary aspergillosis. However, an increasing number of reports deal with unusual manifestations of invasive aspergillosis. In the lung this may take the form of chronic invasive pulmonary aspergillosis, bronchocentric granulomatosis or tracehobronchitis. A number of extrapulmonary infections have been noted, sometimes in immunocompetent individuals. Examples include vertebral osteomyelitis, primary cutaneous aspergillosis (such as in premature neonates), prosthetic vascular graft infection and infective endocarditis. Early recognition of these entities, prompt initiation of new, highly active antifungal therapies and adjunctive surgical management may improve the prognosis of these conditions.