Sternal osteomyelitis due to Aspergillus fumigatus after cardiac surgery

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 fumigatus sternal osteomyelitis following cardiac surgery: Case report and literature review

BACKGROUND

Sternal osteomyelitis caused by Aspergillus spp is uncommon in cardiac surgery patients requiring sternotomy.

CASE PRESENTATION

We report a 77-year-old male with a history of poorly controlled diabetes who was diagnosed with Aspergillus sternal osteomyelitis, three months following an uneventful coronary artery bypass surgery. He underwent multiple debridement surgeries and was treated with voriconazole. Despite a complicated post-operative course, the patient responded well to voriconazole with clinical and biochemical evidence of remission. Unfortunately, he died of an unrelated cause due to decompensated heart failure.

DISCUSSION

Though uncommon, Aspergillus sternal osteomyelitis should be considered in the differential diagnosis of immunocompetent patients with post-operative sternal wound infections and negative bacterial tissue cultures. Management should include a combination of medical and surgical 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.

Osteomyelitis caused by Aspergillus species: a review of 310 reported cases

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%.

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.

An investigation of Aspergillus cardiac surgical site infections in 3 pediatric patients

BACKGROUND

Within a 3-month period, 3 pediatric patients at our hospital developed Aspergillus surgical site infections after undergoing cardiac surgery.

METHODS

A multidisciplinary team conducted an epidemiologic review of the 3 patients and their infections, operative and postoperative patient care delivery, and routine maintenance of hospital equipment and air-filtration systems and investigated potential environmental exposures within the hospital that may have contributed to the development of these infections.

RESULTS

Review of the patients and their infections, operative and postoperative patient care delivery, and routine maintenance did not reveal a source for infection. Inspection of operating room (OR) facilities identified several areas in need of repair. Of the 58 samples of air and equipment exhaust in the ORs and patient care areas, 11 revealed 2 to 4 colony-forming units of various Aspergillus species per cubic meter of air, and the remaining 47 samples were negative for Aspergillus. Eighty-three samples of surfaces and equipment water reservoirs were obtained from the OR and patient care areas. One culture of a soiled liquid nitrogen tank housed between the 2 cardiac ORs revealed 13 colony-forming units of Aspergillus.

CONCLUSION

No definitive source was identified, although a soiled liquid nitrogen tank contaminated with Aspergillus and kept near the OR was found and could have been a possible source.

Post-operative aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.

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.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

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.

Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

Diagnosis and treatment of Aspergillus flavus sternal wound infections after cardiac surgery

We report the clinical data for 9 patients affected during an outbreak of Aspergillus flavus sternal wound infections after cardiac surgery. In 7 patients, the infection had a locally invasive character, with 3 of these patients having multiple relapses; 2 patients had fulminant mediastinitis and died. Most patients received combined surgical and medical treatment.

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

This report details the case of a 67 year old woman with sternal osteomyelitis caused by Aspergillus fumigatus. She was diagnosed with Hodgkin's disease in 1975 and was successfully treated with chemotherapy. A lobectomy for recurrence localised to the left lung was complicated nine years later by severe bronchiectasis, for which she required a total left sided pneumonectomy. At surgery, a non-invasive aspergillus was found. She presented eight years later with symptoms that were initially attributed to recurrence of Hodgkins's disease, but on investigation were found to be caused by fungal sternal osteomyelitis. Treatment with itraconazole suspension at a dose of 400 mg daily was successful.