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Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature. Microorganisms 2022; 11:microorganisms11010084. [PMID: 36677376 PMCID: PMC9864285 DOI: 10.3390/microorganisms11010084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/15/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022] Open
Abstract
Fungal prosthetic joint infection (fPJI) is a rare complication; nonetheless, it represents a significant diagnostic and therapeutic challenge. There are no official guidelines on the most effective approach to identify and treat fPJIs. This systematic review aims to review the current literature on fPJI management and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Studies eligible for this systematic review were identified through an electronic systematic search of PubMed, Scopus, and Web of Science until 30 September 2022. Further references were obtained by cross-referencing. Sixty-three studies met the inclusion criteria, reporting on 372 cases of fPJI; such cases were described mostly in case reports and small case series with only a few larger cohort studies. Diagnosis of fPJI is challenging because of its chronic and indolent clinical course; it is further complicated by the technical difficulty of harvesting fungal cultures. A two-stage revision was the primary procedure in 239 (64.2%) patients whereas DAIR and one-stage approaches were reported in 30 (8.0%) and 18 (4.8 %) cases. In conclusion, our study highlights the heterogeneity of the reported treatments of fPJI, particularly in terms of medical management. With concern to a surgical approach, a two-stage revision arthroplasty is generally suggested, considering fPJI a delayed or late infection. The need for multicenter, prospective studies to provide standardized protocols and improve the treatment of fungal PJI clearly emerges.
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Koutserimpas C, Chamakioti I, Zervakis S, Raptis K, Alpantaki K, Kofteridis DP, Vrioni G, Samonis G. Non- Candida Fungal Prosthetic Joint Infections. Diagnostics (Basel) 2021; 11:diagnostics11081410. [PMID: 34441344 PMCID: PMC8391504 DOI: 10.3390/diagnostics11081410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Fungal prosthetic joint infections (PJIs) are rare, especially those caused by non-Candida species. Treatment has not been fully elucidated, since a plethora of antifungal and surgical interventions have been proposed. Τhis study represents an effort to clarify the optimal management of non-Candida fungal PJIs, by reviewing all relevant published cases. Methods: A thorough review of all existing non-Candida fungal PJIs in the literature was conducted. Data regarding demographics, responsible organisms, antifungal treatment (AFT), surgical intervention, time between initial arthroplasty and onset of symptoms, and time between onset of symptoms and firm diagnosis, as well as the infection’s outcome, were evaluated. Results: Forty-two PJIs, in patients with mean age of 66.2 years, were found and reviewed. Aspergillus spp. were isolated in most cases (10; 23.8%), followed by Coccidioides spp. (7; 16.7%) and Pichiaanomala (5; 11.9%). Fluconazole was the preferred antifungal regimen (20 cases; 47.6%), followed by amphotericin B (18 cases; 42.9%), while the mean AFT duration was 9.4 months (SD = 7.06). Two-stage revision arthroplasty (TSRA) was performed in 22 cases (52.4%), with the mean time between stages being 5.2 months (SD = 2.9). The mean time between initial joint implantation and onset of symptoms was 42.1 months (SD = 50.7), while the mean time between onset of symptoms and diagnosis was 5.8 months (SD = 14.3). Conclusions: Non-Candida fungal PJIs pose a clinical challenge, demanding a multidisciplinary approach. The present review has shown that combination of TSRA separated by a 3–6-month interval and prolonged AFT has been the standard of care in the studied cases.
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Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Ifigeneia Chamakioti
- Emergency Department, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Stylianos Zervakis
- Department of Cardiology, University Hospital of Heraklion, 714 09 Heraklion, Greece
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, "Venizeleion" General Hospital of Heraklion, 714 09 Heraklion, Greece
| | - Diamantis P Kofteridis
- Department of Internal Medicine, University Hospital of Heraklion, 715 00 Heraklion, Greece
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, 715 00 Heraklion, Greece
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Karczewski D, Khakzad T, Kriechling P, Akgün D. Aspergillus PJI - A systematic analysis of all known cases and report of a new one. J Mycol Med 2021; 31:101141. [PMID: 34274683 DOI: 10.1016/j.mycmed.2021.101141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 10/20/2022]
Abstract
Fungi resemble less than one percent of all periprosthetic joint infections (PJI). While Candida PJI is well described, Aspergillus PJI has only been reported in a few cases without any systematic analysis present at this point. This review aims to systematically summarize and describe all cases of Aspergillus PJI. The systematic review used PubMed and Cochrane Library to identify case reports and studies eligible for inclusion. One additional case was reported by the authors. T-, Mann-Whitney U- and Fisher-exact tests were used for calculations. Overall, 11 cases of Aspergillus PJI were identified, and ten could be included for a detailed analysis (four hip, four knee, one elbow, one PIP-arthroplasty infection). A. fumigatus was identified in four, A. terreus in three, and A. niger in two cases. The average patient age at time of Aspergillus spp. diagnosis was 64.1 years (32-83) and the mean time from primary implantation to Aspergillus PJI 5.2 years (1-16). The calculated CCI was 2.7 (0-6). Surgery included one-, two-, three-stage-, and spacer-exchange, debridement and resection arthroplasty. Four patients were treated with a triazole for an average of three months, three with amphotericin (mean eight weeks), one with both amphotericin (six weeks) and triazole (seven months). In one patient, reinfection with Coagulase Negative Staphylococci following Aspergillus PJI treatment was noted after four years. A. terreus (p = .048) was associated with failed prosthesis reimplantation (n = 4). To give a resume, Aspergillus PJI is a rare, yet severe complication, with heterogeneous clinical presentation. Complete prosthesis removal is the treatment of choice.
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Affiliation(s)
- Daniel Karczewski
- Charitè University Medicine Berlin, Center for Musculoskeletal Surgery, Chariteplatz 1, 10117, Berlin, Germany.
| | - Thilo Khakzad
- Charitè University Medicine Berlin, Center for Musculoskeletal Surgery, Chariteplatz 1, 10117, Berlin, Germany
| | - Philipp Kriechling
- Balgrist University Hospital, Department of Orthopaedics, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Doruk Akgün
- Charitè University Medicine Berlin, Center for Musculoskeletal Surgery, Chariteplatz 1, 10117, Berlin, Germany
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Kobayashi T, Lawler E, Samra H, Ford B, Sekar P. Prosthetic Finger Joint Infection Due to Aspergillus terreus. Open Forum Infect Dis 2020; 8:ofaa614. [PMID: 33511236 PMCID: PMC7813175 DOI: 10.1093/ofid/ofaa614] [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: 11/02/2020] [Accepted: 12/09/2020] [Indexed: 12/02/2022] Open
Abstract
Fungal periprosthetic joint infections (PJIs) are rare but associated with significant mortality. We report a case of a finger PJI secondary to Aspergillus terreus in an immunocompetent patient with soil exposure, successfully treated with surgical debridement and voriconazole. Identification of A terreus is important because of intrinsic amphotericin B resistance.
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Affiliation(s)
- Takaaki Kobayashi
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ericka Lawler
- Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hasan Samra
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bradley Ford
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Poorani Sekar
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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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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Belden K, Cao L, Chen J, Deng T, Fu J, Guan H, Jia C, Kong X, Kuo FC, Li R, Repetto I, Riccio G, Tarabichi M. Hip and Knee Section, Fungal Periprosthetic Joint Infection, Diagnosis and Treatment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S387-S391. [PMID: 30343967 DOI: 10.1016/j.arth.2018.09.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Anemüller R, Belden K, Brause B, Citak M, Del Pozo JL, Frommelt L, Gehrke T, Hewlett A, Higuera CA, Hughes H, Kheir M, Kim KI, Konan S, Lausmann C, Marculescu C, Morata L, Ramirez I, Rossmann M, Silibovsky R, Soriano A, Suh GA, Vogely C, Volpin A, Yombi J, Zahar A, Zimmerli W. Hip and Knee Section, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S463-S475. [PMID: 30348582 DOI: 10.1016/j.arth.2018.09.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Kim JK, Lee DY, Kang DW, Ro DH, Lee MC, Han HS. Efficacy of antifungal-impregnated cement spacer against chronic fungal periprosthetic joint infections after total knee arthroplasty. Knee 2018; 25:631-637. [PMID: 29778657 DOI: 10.1016/j.knee.2018.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/25/2018] [Accepted: 04/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although two-stage exchange arthroplasty is considered a treatment of choice for chronic features of fungal PJI (periprosthetic joint infection), there is no consensus for local use of antifungal agent. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer (AICS). METHODS Nine patients who were diagnosed and treated for chronic fungal PJI after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, AICS was inserted for all patients. Systemic antifungal medication was used during the interval between the two stage operations. RESULTS The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, five to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by open debridement tissue culture in three cases (33%). The average number of operations before final exchange arthroplasty was 2.7 times (range, one to five times). Average duration of antifungal agent use confirmed by sensitivity test was seven months (range, four to 15 months). Mean interval between the two stage operations was six months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months). CONCLUSION Two-stage exchange arthroplasty with AICS is a very effective strategy with excellent outcomes. LEVEL OF EVIDENCE Case series, IV.
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Affiliation(s)
- Jong-Keun Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Do-Yoon Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Wan Kang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Du-Hyun Ro
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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9
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de Faucal S, Wirth G, Dutronc H, Gabriel F, Accoceberry I, Dupon M. [Aspergillus fumigatus prosthetic bone and joint infections]. Med Mal Infect 2018; 48:148-150. [PMID: 29292067 DOI: 10.1016/j.medmal.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/04/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Affiliation(s)
- S de Faucal
- Service de maladies infectieuses et tropicales, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - G Wirth
- Service de maladies infectieuses et tropicales, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - H Dutronc
- Service de maladies infectieuses et tropicales, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - F Gabriel
- Laboratoire de parasitologie et mycologie, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - I Accoceberry
- Laboratoire de parasitologie et mycologie, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - M Dupon
- Service de maladies infectieuses et tropicales, CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
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10
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Single-Stage Revision for Chronic Fungal Periprosthetic Joint Infection: An Average of 5 Years of Follow-Up. J Arthroplasty 2017; 32:2523-2530. [PMID: 28478188 DOI: 10.1016/j.arth.2017.03.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/25/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Periprosthetic infections caused by fungal pathogens are a rare entity, and there exist no definite guidelines according to which these infections can be successfully managed. In these situations, we wondered whether patients could be treated successfully for their fungal infections with single-stage revision. METHODS A retrospective analysis between January 2004 and October 2014 included 11 patients (4 hips and 7 knees) with chronic fungal periprosthetic joint infection who underwent single-stage revision, including aggressive soft-tissue debridement, thorough removal of infected components and cement, pouring powdered vancomycin into the medullary cavity and direct intra-articular injection of fungus-sensitive antibiotics, and a reasonable combination of antifungal agents and antibacterial medications. Recurrence of infection and clinical outcomes were evaluated. The average follow-up was 5 years (range, 2-10 years). RESULTS There were 3 failures during the study period; 1 patient died during the perioperative period because of acute heart failure on the eighth postoperative day. Of the 11 patients, 7 patients had satisfactory outcomes and required no additional surgical or medical treatment for recurrence of infection. The mean postoperative Harris hip score and Hospital for Special Surgery knee score was 77 points (67-88 points; P < .05) and 78 points (73-84 points; P < .05), respectively, at the most recent assessment. CONCLUSION Treatment of chronic fungal periprosthetic joint infection with single-stage revision can be fairly effective for achieving acceptable functional outcomes, which indicated that this may be a feasible alternative strategy in selected patients.
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11
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Bartash R, Guo Y, Pope JB, Levi MH, Szymczak W, Saraiya N, Nori P. Periprosthetic hip joint infection with Aspergillus terreus: A clinical case and a review of the literature. Med Mycol Case Rep 2017; 18:24-27. [PMID: 28808616 PMCID: PMC5544492 DOI: 10.1016/j.mmcr.2017.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
Fungal periprosthetic joint infections due to Aspergillus species are rare but are associated with significant cost and morbidity. We present a case of Asperigillus terreus prosthetic joint infection of the hip. The patient was successfully treated with a prolonged course of systemic antifungals along with surgical management.
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Affiliation(s)
- Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
- Corresponding author.
| | - Yi Guo
- Department of Pharmacy, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - John B. Pope
- Department of Orthopedic Surgery, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - Michael H. Levi
- Microbiology Laboratory, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - Wendy Szymczak
- Microbiology Laboratory, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - Nidhi Saraiya
- Department of Pharmacy, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - Priya Nori
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
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12
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What’s New in the Diagnosis and Treatment of Orthopedic Prostheses-Related Infections. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2017. [DOI: 10.1007/s40506-017-0116-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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13
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Kwong CA, Puloski SKT, Hildebrand KA. Fungal periprosthetic joint infection following total elbow arthroplasty: a case report and review of the literature. J Med Case Rep 2017; 11:20. [PMID: 28109195 PMCID: PMC5251295 DOI: 10.1186/s13256-016-1176-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/11/2016] [Indexed: 01/23/2023] Open
Abstract
Background With improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections. Case presentation We present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus, is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty. Conclusions Arthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.
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Affiliation(s)
- Cory A Kwong
- Orthopaedic Surgery Resident PGY-3, Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Shannon K T Puloski
- Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Kevin A Hildebrand
- Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
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14
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Geng L, Xu M, Yu L, Li J, Zhou Y, Wang Y, Chen J. Risk factors and the clinical and surgical features of fungal prosthetic joint infections: A retrospective analysis of eight cases. Exp Ther Med 2016; 12:991-999. [PMID: 27446310 PMCID: PMC4950886 DOI: 10.3892/etm.2016.3353] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/01/2016] [Indexed: 12/16/2022] Open
Abstract
Fungal prosthetic joint infections (PJI) and reports of their clinical investigation are rare. In addition, there has been little evidence regarding the outcome of the two-stage exchange protocol for the treatment of fungal PJI. In order to investigate the risk factors and clinical, microbiological and pathological features of fungal PJIs, as well as the effects of the two-stage exchange protocol on their outcome, the present study analyzed eight retrospective fungal PJI cases, involving four cases affecting the hips and four affecting the knees, between May 2000 and March 2012. In all cases, a cemented spacer saturated with antimicrobials was used during the two-stage exchange protocol, and systematic antifungal agents were administrated during the interim period. The average follow-up duration was 4.4 years. Of the eight cases, six had undergone additional surgery on the infected joint prior to infection with the fungus. Following histological analyses, it was determined that the average number of polymorphonuclear cells in the three patients infected with a fungus was only <5/high power field (HPF; magnification, ×400), and that of the five patients with a hybrid infection was >5/HPF. The average Harris Hip scores or Hospital for Special Surgery knee scores were 43.6 preoperatively and 86 at the last follow-up. The two-stage exchange protocol was performed eight times in seven cases, with a failure rate of 12.5%. The remaining case was successfully treated by resection arthroplasty. The average duration of antifungal agent administration during the interim period in five of the eight cases was 1.5 months. For three of the patients, the duration of antifungal agent administration was prolonged until the c-reactive protein levels were decreased to normal. The average duration of spacer implantation into the joint was 4.3 months. The results of the present study suggested that undergoing surgery on a prosthetic joint may be a potential risk factor for the development of fungal PJI. In addition, infiltration of polymorphonuclear leukocytes into the site of the infection may not occur at the same rate as bacterial PJI. Therefore, a two-stage exchange protocol with implantation of a cement spacer saturated with antimicrobials may be considered an effective therapeutic strategy for the treatment of fungal PJI.
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Affiliation(s)
- Lei Geng
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Meng Xu
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Ligang Yu
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Jie Li
- Department of Pathology, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Yonggang Zhou
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Yan Wang
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Jiying Chen
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
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15
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Abstract
Yeasts and filamentous fungi both exist as single cells and hyphal forms, two morphologies used by most fungal organisms to create a complex multilayered biofilm structure. In this chapter we describe the most widely used assays for the determination of biofilm production and assessment of susceptibility of biofilms to antifungal agents or host phagocytes as various methods, the most frequent of which are staining, confocal laser scanning microscopy, quantification of extracellular DNA and protein associated with extracellular matrix and XTT metabolic reduction assay. Pathway-focused biofilm gene expression profiling is assessed by real-time reverse transcriptase polymerase chain reaction.
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Affiliation(s)
- Maria Simitsopoulou
- Laboratory of Infectious Diseases, 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Konstantinoupoleos 49, 546 42, Thessaloniki, Greece
| | - Athanasios Chatzimoschou
- Laboratory of Infectious Diseases, 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Konstantinoupoleos 49, 546 42, Thessaloniki, Greece
| | - Emmanuel Roilides
- Laboratory of Infectious Diseases, 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Konstantinoupoleos 49, 546 42, Thessaloniki, Greece.
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16
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Jakobs O, Schoof B, Klatte TO, Schmidl S, Fensky F, Guenther D, Frommelt L, Gehrke T, Gebauer M. Fungal periprosthetic joint infection in total knee arthroplasty: a systematic review. Orthop Rev (Pavia) 2015; 7:5623. [PMID: 25874061 PMCID: PMC4387362 DOI: 10.4081/or.2015.5623] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/07/2014] [Indexed: 12/30/2022] Open
Abstract
Fungal periprosthetic joint infection (PJI) is a rare but devastating complication following total knee arthroplasty (TKA). A standardized procedure regarding an accurate treatment of this serious complication of knee arthroplasty is lacking. In this systematic review, we collected data from 36 studies with a total of 45 reported cases of a TKA complicated by a fungal PJI. Subsequently, an analysis focusing on diagnostic, medicaments and surgical procedures in the pre-, intra- and postoperative period was performed. Candida spp. accounts for about 80% (36 out of 45 cases) of fungal PJIs and is therefore the most frequently reported pathogen. A systemic antifungal therapy was administered in all but one patient whereas a local antifungal therapy, e.g. the use of an impregnated spacer, is of inferior relevance. Resection arthroplasty with delayed re-implantation (two-stage revision) was the surgical treatment of choice. However, in 50% of all reported cases the surgical therapy was heterogeneous. The outcome under a combined therapy was moderate with recurrent fungal PJI in 11 patients and subsequent bacterial PJI as a main complication in 5 patients. In summary, this systematic review integrates data from up to date 45 reported cases of a fungal PJI of a TKA. On the basis of the current literature strategies for the treatment of this devastating complication after TKA are discussed.
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Affiliation(s)
- Oliver Jakobs
- Department of Orthopedic Surgery, Helios Endo-Klinik Hamburg , Hamburg, Germany
| | - Benjamin Schoof
- Department of Orthopedic Surgery, Helios Endo-Klinik Hamburg , Hamburg, Germany
| | - Till Orla Klatte
- Department of Trauma-, Hand- and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf , Hamburg, Germany
| | - Stefan Schmidl
- Department of Orthopedic Surgery, Helios Endo-Klinik Hamburg , Hamburg, Germany
| | - Florian Fensky
- Department of Trauma-, Hand- and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf , Hamburg, Germany
| | - Daniel Guenther
- Department of Trauma, Hannover Medical School , Hamburg, Germany
| | - Lars Frommelt
- Institute for Clinical Microbiology, Infectiology and Infection Control, Helios Endo-Klinik Hamburg , Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, Helios Endo-Klinik Hamburg , Hamburg, Germany
| | - Matthias Gebauer
- Department of Orthopedic Surgery, Helios Endo-Klinik Hamburg , Hamburg, Germany ; Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf , Hamburg, Germany
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17
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Zuo Q, Dong L, Mu W, Zhou L, Hu T, Zhang H. Trichosporon asahii infection after total knee arthroplasty: A case report and review of the literature. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2015; 26:47-51. [PMID: 25798156 PMCID: PMC4353271 DOI: 10.1155/2015/458670] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reports of fungal infection after total knee arthroplasty are extremely rare. In most reports, the infecting organism is a Candida species. The present report describes a case involving a 73-year-old immunocompetent woman who underwent total knee arthroplasty and presented one month later with signs of prosthetic infection. She underwent joint debridement and the fluid was sent for culture and sensitivity testing. The culture showed growth of Trichosporon asahii. The patient was administered intravenous and intra-articular injections of amphotericin B, followed by antifungal treatment with voriconazole for one year. At 26 months of follow-up, there was no evidence of infection and the patient was ambulating with a walker. To the authors' knowledge, the present case is the first report of T asahii infection following knee replacement. Early detection, prompt institution of the appropriate antibiotics and regular follow-up are recommended.
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Affiliation(s)
- Qiang Zuo
- Department of Orthopedics, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
- Department of Orthopedics, the First Affiliated Hospital of Baotou Medical College, Baotou, Inner Mongolia
| | - Lele Dong
- Department of Orthopedics, the First Affiliated Hospital of Baotou Medical College, Baotou, Inner Mongolia
| | - Weidong Mu
- Department of Orthopedics, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
- Correspondence: Dr Weidong Mu, Department of Orthopedics, Provincial Hospital Affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong Province, People’s Republic of China. Telephone 86-151-6886-3989, fax 86-180-4721-1365, e-mail
| | - Lingyun Zhou
- International Education College, Jiang Xi University of Traditional Chinese Medicine, Nanchang, Jiangxi Province
| | - Tongping Hu
- Clinical Laboratory, the First Affiliated Hospital of Baotou Medical College
| | - Hua Zhang
- Department of Oncology, the Third Affiliated Hospital of Inner Mongolia Medical College, Baotou, Inner Mongolia, People’s Republic of China
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18
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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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Abstract
Prosthetic joint infection (PJI) is a serious and potentially devastating complication of arthroplasty. Prior arthroplasty, immunosuppression, severe comorbid conditions, and prolonged surgical duration are important risk factors for PJI. More than half of the cases of PJI are caused by Staphylococcus aureus and coagulase-negative staphylococci. The biofilm plays a central role in its pathogenesis. The diagnosis of PJI requires the presence of purulence, sinus tract, evidence of inflammation on histopathology, or positive microbiologic cultures. The use of diagnostic imaging techniques is generally limited but may be helpful in selected cases. The most effective way to prevent PJI is to optimize the health of patients, using antibiotic prophylaxis in a proper and timely fashion. Management of PJI frequently requires removal of all hardware and administration of intravenous antibiotics. This review summarizes and analyzes the results of previous reports of PJI and assesses the prevention and management of this important entity.
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Abstract
Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.
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Affiliation(s)
- Aaron J. Tande
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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21
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Gebauer M, Frommelt L, Achan P, Board TN, Conway J, Griffin W, Heidari N, Kerr G, McLaren A, Nelson SB, Nijhof M, Zahar A. Management of fungal or atypical periprosthetic joint infections. J Arthroplasty 2014; 29:112-4. [PMID: 24360494 DOI: 10.1016/j.arth.2013.09.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Koehler P, Tacke D, Cornely OA. Aspergillosis of bones and joints - a review from 2002 until today. Mycoses 2014; 57:323-35. [DOI: 10.1111/myc.12165] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Philipp Koehler
- 1st Department of Internal Medicine; University Hospital of Cologne; Zentrum für Klinische Studien (BMBF 01KN1106); CECAD - Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases; Cologne Germany
| | - Daniela Tacke
- 1st Department of Internal Medicine; University Hospital of Cologne; Zentrum für Klinische Studien (BMBF 01KN1106); CECAD - Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases; Cologne Germany
| | - Oliver A. Cornely
- 1st Department of Internal Medicine; University Hospital of Cologne; Zentrum für Klinische Studien (BMBF 01KN1106); CECAD - Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases; Cologne Germany
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23
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Gebauer M, Frommelt L, Achan P, Board TN, Conway J, Griffin W, Heidari N, Kerr G, McLaren A, Nelson SB, Nijhof M, Zahar A. Management of fungal or atypical periprosthetic joint infections. J Orthop Res 2014; 32 Suppl 1:S147-51. [PMID: 24464889 DOI: 10.1002/jor.22559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Kuiper JWP, van den Bekerom MPJ, van der Stappen J, Nolte PA, Colen S. 2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections. Acta Orthop 2013; 84:517-23. [PMID: 24171675 PMCID: PMC3851663 DOI: 10.3109/17453674.2013.859422] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations. PATIENTS AND METHODS After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions. RESULTS Most patients presented with pain (78%) and swelling (65%). In 68% of the patients, 1 or more risk factors for fungal PJI were found. In 51% of the patients, radiographs showed signs of loosening of the arthroplasty. Candida species were cultured from most patients (88%). In 21% of all patients, fungal culture results were first considered to be contamination. There was co-infection with bacteria in 33% of the patients. For outcome analysis, 119 patients had an adequate follow-up of at least 2 years. Staged revision was the treatment performed most often, with the highest success rate (85%). INTERPRETATION Fungal PJI resembles chronic bacterial PJI. For diagnosis, multiple samples and prolonged culturing are essential. Fungal species should be considered to be pathogens. Co-infection with bacteria should be treated with additional antibacterial agents. We found no evidence that 1-stage revision, debridement, antibiotics, irrigation, and retention (DAIR) or antifungal therapy without surgical treatment adequately controls fungal PJI. Thus, staged revision should be the standard treatment for fungal PJI. After resection of the prosthesis, we recommend systemic antifungal treatment for at least 6 weeks-and until there are no clinical signs of infection and blood infection markers have normalized. Then reimplantation can be performed.
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Affiliation(s)
- Jesse WP Kuiper
- Department of Orthopedic Surgery, Center for Orthopaedic Research Alkmaar (CORAL), Alkmaar Medical Center, Alkmaar; the Netherlands
| | | | | | - Peter A Nolte
- Department of Orthopedic Surgery, Spaarne Hospital, Hoofddorp, the Netherlands.
| | - Sascha Colen
- Department of Orthopedic Surgery, University Hospitals Leuven, Pellenberg Site, Belgium
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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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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e31827525d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chakrabarti A, Singh R. The emerging epidemiology of mould infections in developing countries. Curr Opin Infect Dis 2012; 24:521-6. [PMID: 21799406 DOI: 10.1097/qco.0b013e32834ab21e] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review describes the emerging trends of mould infections in developing countries, and highlights the major epidemiological differences from the developed countries. RECENT FINDINGS The limited data available from developing countries suggest an alarming increase in invasive mould infections, especially aspergillosis and mucormycosis, and also a difference in risk factors and causative agents between the developed and developing world. Sino-orbital, cerebral and ophthalmic infections due to Aspergillus flavus are the major clinical types in aspergillosis, after pulmonary aspergillosis. Aspergillus and Fusarium spp. are frequent causes of trauma-associated keratitis in agricultural workers. Rhino-orbito-cerebral presentation associated with uncontrolled diabetes is the predominant mucormycosis. Isolated renal mucormycosis has emerged as a new clinical entity. Apophysomyces elegans and Mucor irregularis are emerging species in these regions and uncommon agents such as Rhizopus homothallicus have also been reported. Many pathogens are geographically restricted, with Pythium insidionum, Rhinocladiella mackenziei and M. irregularis being described almost exclusively from Thailand, Middle East and China, respectively. SUMMARY Despite limited studies, certain peculiarities have been observed in invasive mould infections in developing countries, including a high incidence of ophthalmic lesions, mucormycosis and aspergillosis; few different clinical presentations; and a varied spectrum of pathogens involved in such lesions.
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Affiliation(s)
- Arunaloke Chakrabarti
- Division of Mycology, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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