Candida septic arthritis with rice body formation: a case report and review of literature

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.

Candida parapsilosis-Caused Arthritis with Rice Body Formation: A Case Presentation and Literature Review

A 68-year-old male patient came to the orthopedics department because of swelling and pain in his left shoulder joint. He received more than 15 intraarticular steroid injections in the shoulder joint at a local private hospital. MRI showed that the synovial membrane of the joint capsule was thickened and swollen, and there were extensive "rice body-like" low T2 signal shadows filling. Arthroscopic removal of rice bodies and subtotal bursectomy were performed. The observation channel was placed through the posterior approach, and a large amount of rice bodies in yellow bursa fluid were observed to flow out. Rice bodies with a diameter of approximately 1-5 mm filled the joint cavity were seen in the observation channel. The histopathological examination of the rice body showed that it was mainly composed of fibrin without a clear tissue structure. Bacterial and fungal cultures of synovial fluid suggested Candida parapsilosis infection, so the patient received antifungal treatment. However, the shoulder swelled again after three weeks, MRI revealed that there was significant fluid accumulation in the subacromial-subdeltoid region with necrotic synovial tissue floating and ultrasound examination showed joint cavity effusion, synovial hyperplasia, and some synovium looked like "floating weeds". After 2 weeks, there were recurrent rice bodies in the articular cavity. Arthroscopic surgery was performed again to clean the joint and a catheter was placed for irrigation and drainage, and a large amount of necrotic synovial tissue floating as seen in ultrasound. Finally, patient received sensitive antifungal treatment and did not relapse within 6 months. During the recurrence in the current case, we recorded the process of rice body formation, which has for the first time been reported.

Exuberant Rice Body Formation Associated with Adverse Local Tissue Reaction After Hip Resurfacing Arthroplasty: A Case Report and Review of the Literature

CASE

A 65-year-old man with osteoarthritis of the hip developed a soft-tissue mass of the inferior gluteal region 3 years after metal-on-metal resurfacing hip arthroplasty. Clinical and imaging findings suggested an adverse local tissue reaction. Intraoperatively, nearly 1 liter of intra-articular fibrinous loose bodies (rice bodies) was removed, and histology showed features of an adaptive immune response. The patient had no evidence of an autoimmune disease or mycobacterial infection.

CONCLUSION

To our knowledge, this is the first reported case of florid rice bodies associated with a metal-on-metal hip arthroplasty and adverse local tissue reaction.

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.

Metagenomic next-generation sequencing assists the diagnosis treatment of fungal osteoarticular infections

Background

Fungal osteoarticular infection (FOI) is not commonly seen in clinical practice but proposes a great challenge to orthopedic surgeons. In this study, we aimed to investigate the risk factors, the clinical features, and surgical outcomes of FOI in our institution. Specifically, we aimed to explore the role of metagenomic next-generation sequencing (mNGS) in the diagnosis and treatment of FOI.

Methods

All the patients who were diagnosed and managed with FOI in our institution from January 2007 to December 2020 were retrospectively reviewed, including primary fungal implant-related infection, primary fungal osteomyelitis or arthritis, and fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. The potential risk factors and the clinical and surgical features were analyzed. The pathogen data were compared between culture and the mNGS test.

Results

A total of 25 patients were included, namely, 12 primary implant-related infections, 7 primary fungal osteomyelitis or arthritis, and 6 fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. Most cases had undergone multiple surgeries or long-term antibiotic treatment. Diagnosis was mainly based on microbial culture and the mNGS test. Optimization of culture methods and the use of mNGS assisted the diagnosis. Specifically, mNGS was performed in 12 patients, 5 of whom were culture-negative. In the remaining seven cases, mNGS demonstrated the same results as culture. Management of FOI was complicated as most patients required multiple surgeries followed by long-term antifungal treatment. In selected cases, antifungal-impregnated cement spacer retention can be an optional choice. The overall success rate was 100% (25/25) for our cohort.

Conclusion

We concluded that patients with comorbidities and a history of multiple surgeries or long-term antibiotics are under higher risk for FOI. Use of mNGS assists the diagnosis and treatment of FOI. Surgery combined with long-term antifungal treatment achieved satisfactory outcomes. In selected cases, antifungal-impregnated cement spacer retention can be an optional treatment choice.

Idiopathic tenosynovitis of the wrist with multiple rice bodies: A case report and review of literature

BACKGROUND

Multiple rice bodies in the wrist is a rare disorder that requires surgery, and there are still many uncertainties regarding its diagnosis and treatment.

CASE SUMMARY

We described a rare case of chronic idiopathic tenosynovitis with rice bodies of the wrist in a 71-year-old man and reviewed similar topics in the literature. A total of 43 articles and 61 cases were included in the literature review. Our case had a usual presentation: it was similar to those in the literature. The affected population was mainly older adults, with an average age of 59.43 (range, 3 to 90) years. The male-to-female ratio was 1.54:1 (37/24).Most of them showed limited swelling and pain, only 23.0% had carpal tunnel symptoms, and the average disease duration was 18.03 (0.5-60) mo. Wrist flexor tendon sheath involvement was the most common (95.1%, 58/61), and only 3 cases had extensor tendon sheath involvement.The main causes were tuberculosis (34.4%, 21/61), non-tuberculous mycobacteria (24.6%, 15/61), idiopathic tenosynovitis (31.1%, 19/61), and others (9.84%, 6/61). There were 10 patients with recurrences; in 6 of them, were due to non-tuberculous mycobacterial infections.

CONCLUSION

We reported a case of wrist idiopathic tenosynovitis with rice body formation, and established a clinical management algorithm for wrist tenosynovitis with rice bodies, which can provide some reference for our clinical diagnosis and treatment. The symptoms of rice-body bursitis of the wrist are insidious, nonspecific, and difficult to identify. The aetiology is mainly idiopathic tenosynovitis and mycobacterial (tuberculosis or non-tuberculous) infections; the latter are difficult to treat and require long-duration systemic combination antibiotic therapies. Therefore, before a diagnosis of idiopathic tenosynovitis is made, we must exclude other causes, especially mycobacterial infections.

A Case of Rice Body Synovitis of the Knee Joint

Background

Rice body synovitis (RBS) is a rare disease. It is prone to be developed due to rheumatoid disorder or tuberculosis infection. Additional infectious arthritis (non‐tuberculous mycobacterial infection and fungal infection), juvenile arthritis, the onset of adult Still's disease, systemic lupus erythematosus (SLE), seronegative arthritis, and non‐specific arthritis. The clinical imaging, histopathological features, and surgical treatment process of a patient were documented combined with literature. Furthermore, differentiation was performed with additional synovitis diseases so that the cognition of synovitis could be enhanced for clinical reference.

Case Presentation

The present study reported a 50‐year‐old female patient who suffered from intermittent left knee pain with limited movement for 9  years. The conditions were aggravated after long‐term standing or walking and remitted after taking a rest, accompanied by noose and jamming. The specialist range of motion (ROM) examinations of the left knee revealed: 30° ‐ 0° ‐ 110° and left McMurray sign (+). Plain MRI scanning revealed that in the left knee cavity and the popliteal fossa area, a large number of low signals on free rice‐like bodies were visible inside and the lower femur and the upper tibia exhibited abnormally high signals of patchy lipography. Surgical exploration revealed numerous rice‐like free bodies in the suprapatellar bursa, the intercondylar fossa, and the posterior articular capsule. The patient presently has resolution of symptoms after surgical treatment.

Conclusions

The RBS of the knee joint is very rare in the clinic. As MRI examination can provide valuable information, clinicians should actively perform MRI examination. Once the disease is diagnosed by examination, surgery is the optimal treatment.

Some undesirable traps which can mislead the pathologist

In clinical laboratories, the diagnosis of parasite diseases can sometimes be challenging for non-expert microbiologists. Indeed, in spite of the advent of the molecular biology, macroscopic and microscopic examinations still remain essential. Nonetheless, it is usually not automated and requires great skills to complete the correct diagnosis. It is not infrequent that inert elements mislead to erroneous diagnoses. Through three different concrete examples, this article aims at underscoring the actual risk of parasite misidentification and at highlighting the systematic approach to be conducted in order to enable reliable diagnosis.

Non-tuberculosis Mycobacterium Tenosynovitis with Rice Bodies in a Patient with Systemic Lupus Erythematosus

Infectious disease with various presentations in systemic lupus erythematosus often resembles lupus flare. A 37-year-old woman presented with a swollen left index finger that had not resolved, despite 7 years of immunosuppressive treatment. MRI showed rice-body formation in the flexor tendon sheath and tenosynovectomy demonstrated chronic synovitis with epithelioid granuloma. A mycobacterial culture confirmed invasive mycobacterial tenosynovitis due to Mycobacterium chelonae. The patient was treated with moxifloxacin and clarithromycin and completely recovered.

Idiopathic tenosynovitis with rice bodies

PURPOSE

Idiopathic tenosynovitis with rice bodies is a rare disease and its non-association with rheumatic diseases, tuberculosis infection or trauma is reported only in few cases in literature.

PATIENTS, MATERIALS AND METHODS

Our study presents a series of five patients diagnosed with tenosynovitis with rice bodies at the flexor tendons of the upper limb. Medical history revealed no associated disease or trauma. Disease duration ranged between two months and four years, two patients presenting symptoms of acute carpal tunnel and three patients tumor mass. In one case, the tumor measured 210 mm in length and a tendon rupture was suspected. Laboratory and imaging investigations could not establish a specific associated pathology and a preoperative diagnosis. Surgical treatment consisting of synovectomy was performed in all patients.

RESULTS

In all five cases, intraoperative appearance could easily determine the presence of rice bodies. Histopathological examination revealed typical aspect for rice bodies and make the diagnosis possible without the need for other more laborious processing (immunohistochemistry). The amount of rice bodies was directly proportional to disease duration. In all cases, the recovery was complete. After a median 30.4-month follow-up, no recurrence was detected. Subsequently performed laboratory investigations and specific tests did not reveal tuberculosis infection, rheumatic disease, or other diseases.

CONCLUSIONS

This is the largest series of patients with idiopathic tenosynovitis with rice bodies and the bigger tumor mass reported to date. Synovectomy with removal of all rice bodies represents the optimal treatment. A longer disease course may be associated with a larger number of rice bodies, which may be associated with tendon rupture. The etiopathogenesis remains unclear, further studies being necessary to establish it.

Candida Parapsilosis associated rice bodies in the extensor compartment of the wrist--an emerging finding

Candida parapsilosis has been considered an emerging pathogen with increasing incidence reported in the literature. As a normal commensal of human skin, it is likely that Candida species could gain access to soft tissues of the hand and wrist by direct inoculation, resulting in an infectious tenosynovitis. With the increased prevalence of intravenous drug use (IVDU), users are at increasing risk for musculoskeletal infections including soft tissue abscesses, cellulitis, tenosynovitis, and septic arthritis. Chronic tenosynovitis, with rice body formation in particular, is a comparatively rare musculoskeletal infection. Knowledge of this entity, the related pathogens, imaging findings, and the treatment plan is important not only to the treating clinician, but also to radiologists as the physiological and anatomic consequences can be detrimental to patient recovery.

Non-tuberculous Mycobacterium or Fungus Induced Chronic Tenosynovitis with Rice Body of the Hand

BACKGROUND

Chronic tenosynovitis of the wrist and hand is commonly seen by orthopedists, especially hand surgeons. However, cases with rice body formation are comparatively rare. Thus, we retrospectively reviewed the cases of chronic tenosynovitis in our department and evaluated the necessity of antibiotic therapy in the early post-surgical stage.

METHODS

We analyzed the medical and surgical records of patients who had undergone surgery for chronic tenosynovitis with rice body formation in our department from 1997 to 2015. We evaluated the causes of chronic tenosynovitis, culture findings, pathological findings, and post-operative treatment courses.

RESULTS

Nineteen patients with 23 involved hands underwent surgery for chronic tenosynovitis, and 9 patients had rice body formation. The most common cause of chronic tenosynovitis was non-tuberculous mycobacteriosis, and other causes were fungal infection and infection of unknown origin. Recurrence was observed in 2 cases of mycobacteriosis and 1 case of fungal infection; 1 case of mycobacteriosis also had a re-recurrence.

CONCLUSIONS

In the diagnosis of chronic tenosynovitis with rice body formation, it is necessary to consider not only non-tuberculous mycobacteriosis, but also fungal infection as its origin. However, it is difficult to define the cause of synovitis, but in cases in which these infections are suspected, anti-bacterial therapy in the early post-surgical period could be effective.

Olecranon Bursitis Caused by Candida parapsilosis in a Patient with Rheumatoid Arthritis

Septic bursitis is usually caused by bacterial organisms. However, infectious bursitis caused by fungi is very rare. Herein, we present a 68-year-old woman with long-standing rheumatoid arthritis who developed pain, erythema, and swelling of the right olecranon bursa. Aspiration of the olecranon bursa showed a white blood cell count of 3.1 × 10(3)/μL (41% neutrophils, 30% lymphocytes, and 29% monocytes). Fluid culture was positive for Candida parapsilosis. She was treated with caspofungin 50 mg intravenously daily for 13 days followed by fluconazole 200 mg orally daily for one week. She responded well to this treatment but had recurrent swelling of the bursa. Bursectomy was recommended but she declined this option. This case, together with other reports, suggests that the awareness of uncommon pathogens, their presentation, and predisposing risk factors are important to establish an early diagnosis and prevent long-term complications.

Management of Candida guilliermondii joint infection in a dog

Background

Candida spp. are dimorphic fungi in the family Cryptococcaceae. Infections with Candida spp. are usually rare conditions in dogs, but immunocompromised patients have a higher risk for developing invasive candidal infections.

Case presentation

A 5-year-old male Boxer, positive to Leishmania infantum, was referred to the Veterinary Teaching Hospital of the Department of Veterinary Medicine, University of Perugia, Italy for examination of a non-weight bearing left hind limb lameness of a duration of at least 3 months. During this period, treatment involved systemic anti-inflammatory medications and intra-articular corticosteroid administration. On presentation, clinical examination and radiographic findings were suggestive of cranial cruciate ligament deficiency. To support this diagnosis a stifle arthroscopy was performed: it confirmed a partial rupture of cranial cruciate ligament. Samples culture of synovial fluid and membrane was routinely collected as well, and revealed Candida guilliermondii joint infection. Treatment for the C. guilliermondii joint infection involved systemic anti-fungal therapy, joint lavage and intra-articular administration of antifungal drugs. Lameness improved markedly during this treatment, but lameness did not resolve completely, probably due to cranial cruciate ligament deficiency. Tibial tuberosity advancement (TTA) was chosen in order to treat stifle instability and was performed 4 weeks following cessation of treatment of the C. guilliermondii joint infection. Six month after TTA the dog showed a completely recovery with no lameness.

Conclusions

To the authors’ knowledge, this is the first case of Candida spp. joint infection reported in dogs. The cause of the progression of the joint C. guilliermondii infection remains unclear but it may be associated with leishmaniasis or intra-articular corticosteroid injections. Treatment with systemic and intra-articular anti-fungal therapies was successful. In the evaluation of hind limb lameness in a chronically immunocompromised dog, it would be advisable to consider also an intra-articular Candida spp. infection.

Candida parapsilosis Tenosynovitis in an Immunocompetent Patient: Case Report and Review of Literature

We describe a case of fungal tenosynovitis with Candida parapsilosis, which is an uncommonly reported agent causing tenosynovitis. It occurred in an immunocompetent individual, and the patient underwent an extensive noninfectious work-up for ongoing swelling and stiffness before being correctly diagnosed and treated. We emphasize the importance of considering atypical infections in the differential diagnoses in a patient presenting with indolent symptoms of tenosynovitis.

[Presence of riziform bodies in a patient with juvenile idiopathic arthritis: case report and literature review.]

Riziform bodies are structures formed by fibrin and cells that can be found in the synovial fluid or attached to the synovium, and have this denomination due to its rice grain-like appearance. They have already been described in several diseases such as tuberculous arthritis, rheumatoid arthritis, and rarely in juvenile idiopathic arthritis (JIA). This is the case of a boy with a 4-month course of chronic monoarthritis of the left knee, with family history of sarcoidosis in which diagnostic investigation showed the presence of these riziform bodies in the synovial biopsy. Diagnostic investigation ruled out sarcoidosis, tuberculosis and malignancies, establishing the diagnosis of JIA. Our objective was to describe what we believe is the 9th case reported on the presence of riziform bodies in JIA, which are probably underdiagnosed, and should be considered mainly in cases of severe arthritis of difficult medical treatment.