Invasive aspergillosis complicated by subclavian artery occlusion and costal osteomyelitis after autologous bone marrow transplantation

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.

Disseminated Aspergillus flavus following septic arthritis in an immunocompetent patient: a case report

BACKGROUND

Aspergillosis is a rare cause of osteomyelitis and septic arthritis. Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. It is associated with a high incidence of morbidity and mortality. Infection with Aspergillus flavus species in the knee has been very rarely seen in the past.

CASE PRESENTATION

We present a case of septic arthritis of the knee in an Indian patient secondary to infection with Aspergillus flavus, which was earlier managed as a case of tuberculosis based on the endemicity of the condition, later leading to disseminated aspergillosis. There was no clinical feature or investigation suggesting immunocompromised state. Following knee arthrotomy, Aspergillus flavus was isolated and patient was subsequently managed with antifungals leading to recovery after three months.

CONCLUSIONS

Disseminated aspergillosis can mimic tuberculosis both clinically and radiologically. Though fungal infections affect joints rarely but they must always be ruled out to avoid later complications.

Osteomyelitis of the rib due to Streptococcus pneumoniae: a very rare condition in children

Rib osteomyelitis is a rare disease. We present a previously unreported case of Streptococcus pneumoniae osteomyelitis of the rib. A 4-month-old-infant presented with fever, irritability and abdominal tenderness. Pericostal collection was discovered incidentally on ultrasound; it was first drained by needle aspiration and appropriate antibiotic therapy was given, with resolution of fever in 24 h, but recurrence of symptoms 4 days later, with swelling over the affected rib. Surgical drainage with resection of the infected portion of the rib were done followed by a prolonged course of intravenous and then oral antibiotics, without any recurrence at 6 months follow-up. A review of the pertinent literature was made. This case demonstrates that the spectrum of pathogens potentially responsible for rib osteomyelitis may be broader than previously reported. The management and outcome are similar to rib osteomyelitis due to any other bacteria.

Aspergillus fumigatus empyema, arthritis, and calcaneal osteomyelitis in a lung transplant patient successfully treated with posaconazole

A 64-year-old male with Aspergillus fumigatus infection that had disseminated from the lung to the ankle and adjacent bone was treated successfully with posaconazole after therapy with itraconazole and amphotericin B lipid complex failed. Marked clinical improvement occurred within 6 weeks of initiation of posaconazole therapy; after 6 months, infection had resolved at all sites. The patient has had no recurrence of infection.

Floating aortic thrombus in systemic aspergillosis and detection by transesophageal echocardiography

After immunosuppressive treatment for a colitis ulcerosa, a 49-yr-old man developed signs of systemic aspergillosis with subsequent septic shock and encephalitis. For recurrent signs of thromboembolism, transesophageal echocardiography was performed and revealed a large floating thrombus of the aortic arch. Despite appropriate antibiotic treatment, the patient died a few days later suffering from adult respiratory distress syndrome. The appearance of aortic thrombi concomitant to systemic fungal infection rarely has been reported. The present case is the first report of in vivo detection of large vessel involvement in systemic aspergillosis by transesophageal echocardiography. In our opinion, transesophageal echocardiography is the method of choice for bedside diagnosis of this rare complication in critically ill patients.

Osteomyelitis of the ribs in the antibiotic era

A total of 106 cases of rib osteomyelitis were reviewed, including 2 cases described in detail. Mycobacterial and bacterial infections accounted for 47 cases each. Fungal rib osteomyelitis occurred in 11 cases and 1 case was caused by Entamoeba histolytica. Most cases occurred in children and young adults. The mean duration of symptoms before diagnosis was 16, 26 and 32 weeks for bacterial, mycobacterial and fungal rib osteomyelitis, respectively. Common clinical signs were fever (73%), soft tissue mass (64%) and chest pain (60%). Route of infection was defined in 85 cases: 62% from contiguous spread and 38% via haematogenous route of infection. Eighty-nine percent had a favourable outcome after antimicrobial therapy with or without surgery. In conclusion, rib osteomyelitis is a rare infection of various aetiologies. The majority of cases occur in children and young adults and its diagnosis is usually delayed for several weeks.

Phase II study of intensive chemotherapy with autologous bone marrow transplantation in patients in complete remission of disseminated breast cancer

BACKGROUND

This trial studied the disease-free survival after high-dose chemotherapy in patients in complete remission of metastatic breast cancer.

PATIENTS AND METHODS

Thirty women, mean age 42.2 years (range 33-55) with metastatic breast cancer, received high-dose chemotherapy in a phase II study. Patients were eligible if they were < or = 55 years of age, had achieved complete remission within 6 months of the initiation of chemotherapy, and had a WHO performance scale of 0 or 1. The high-dose regimen consisted of melphalan 180 mg/m2 and mitoxantrone 60 mg/m2 both divided over 3 days. On day 7 bone marrow and/or peripheral stem cells were infused. After bone marrow recovery, external beam radiation was administered to sites of previous metastatic disease in 15 patients.

RESULTS

Apart from leuko- and thrombocytopenia, mucositis was the major side effect. One patient died during the bone marrow transplant period due to an aspergillus infection. The median follow-up since high-dose chemotherapy is 25 months (range 13 to 56 months). The median disease-free survival since high-dose chemotherapy is 27 months and the disease free survival is still 43% with an overall survival of 53% at 3 years. In two patients tumor relapse occurred only in the brain; in one patient the only relapse sign was a meningeal carcinosis. At the moment 17 patients are disease-free (13(+)-56+) months after high-dose chemotherapy.

CONCLUSION

Until now this high-dose regimen in selected patients with complete remission after induction chemotherapy for metastatic breast cancer has a promising disease free survival.