Aspergillus fumigatus septic arthritis complicating intra-articular corticosteroid injection

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.

Native Joint Infections by Aspergillus Species

Background: Septic arthritis due to Aspergillus spp. represents a rare, but severe disease. Nevertheless, clear guidelines regarding most effective medical treatment have not yet been established. The present study is a literature review of all reported cases of fungal septic arthritis due to Aspergillus spp, in order to clarify epidemiology, as well as the medical and operative management and their outcome. Methods: A meticulous review of all published septic arthritis infections due to Aspergillus has been conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical intervention, as well as the infection’s outcome were recorded and evaluated. Results: A total of 30 Aspergillus spp. strains from 29 hosts have been studied. The patients’ mean age was 45.8 years. The most commonly affected joint was the knee (45.7%), while the predominant symptom was joint pain (62%). Most patients were immunocompromised (72.4%). Diagnosis was established through cultures and/or histopathology. Aspergillus fumigatus was the most common responsible fungi (63.3%), followed by A. flavus (16.6%) and A. terreus (10%). Regarding AFT, the preferred agent proved to be Amphotericin B (14 cases; 48.3%), followed by voriconazole (11; 37.9%), while the mean AFT duration was 5.6 months. In most cases surgical treatment was also performed (in 4 cases no surgery was reported). Treatment was effective in 20 cases (69%). Conclusions: Septic arthritis caused by Aspergillus spp. represents a severe clinical entity. It seems that, with the available data, prolonged AFT along with surgical intervention is the preferred management of this infection, while identification of the responsible fungus is of utmost importance.

Aspergillus arthritis: analysis of clinical manifestations, diagnosis, and treatment of 31 reported cases

Aspergillus arthritis is a debilitating form of invasive aspergillosis. Little is known about its epidemiology, clinical manifestations, laboratory features, treatment, and prognosis. Cases of Aspergillus arthritis were reviewed in the English literature from 1967 through 2015 for variables of arthritis with Aspergillus spp. recovered from joint and/or adjacent bone, underlying conditions, symptoms, signs, inflammatory biomarkers, diagnostic imaging, management, and outcome. Among 31 evaluable cases, 87% were males and 13% pediatric. Median age was 50 y (range 1-83 y). Seventeen (55%) patients were immunosuppressed with such conditions as hematological malignancies (26%), corticosteroids (39%), and/or transplantation (26%). Approximately one-half (52%) of patients had hematogenous seeding of the joint, and more than 80% had de novo infection with no prior antifungal therapy. Oligoarticular infection (2-3 joints) occurred in 45% and contiguous osteomyelitis was present in 61%. Clinical manifestations included pain (87%), edema (26%), and limited function (23%), with knees (35%), intervertebral discs (26%), and hips (16%) being most commonly infected. Aspergillus fumigatus constituted 77% of cases followed by Aspergillus flavus in 13%, Aspergillus niger in 3%, and not specified in 7%. Median ESR was 90 mm/hr and median CRP was 3.6 mg/dl. Median synovial fluid WBC was 17,200/μL (7,300-128,000) with 72% PMNs (range 61-92). Osteolysis occurred in 35%, and soft-tissue extension 47%. Nineteen patients (61%) were managed with combined medical and surgical therapy, 10 (32%) with medical therapy only, and 2 (6%) surgery only. Amphotericin B and itraconazole were the most frequently used agents with median duration of therapy of 219 days (range 30-545). Surgical interventions included debridement in 61%, drainage 19%, and amputation 6%. Complete or partial response was achieved in 71% and relapse occurred in 16%. Medical therapy was reinstituted with successful outcome in these patients. Overall survival was 65%. Aspergillus arthritis mainly develops as a de novo infection involving knees and intervertebral disks in immunocompromised patients with localizing symptoms. Contiguous osteomyelitis is frequently observed. Diagnosis is established by synovial fluid culture. Aspergillus arthritis is therapeutically challenging with most patients undergoing surgery and protracted antifungal therapy.

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.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

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.

Aspergillus spondylodiscitis in solid organ transplant recipients

BACKGROUND

Transplantation practices have had a significant effect on the epidemiology of invasive Aspergillosis. Aspergillus spondylodiscitis is rare in transplant recipients. The optimal treatment has yet to be defined because of the rarity of such cases. This article reviews the available literature on Aspergillus spondylodiscitis in solid organ transplant recipients and provides recommendations on its management.

METHODS

We identified 15 cases of Aspergillus spondylodiscitis in transplant recipients. Most patients were heart transplant recipients. Back pain was the mode of presentation in all patients. Most cases were afebrile. The dominant location was the lumbar spine.

RESULTS

Aspergillus fumigatus was responsible for 84.62% of cases and A flavus for 15.38%. The overall recovery rate was 66.67%. Delay in diagnosis remained a major impediment to the successful treatment of spinal aspergillosis. Treatment included antifungal therapy alone or combined with surgery. Initial therapy with voriconazole could lead to better curative effects.

CONCLUSION

Combined medical and operative interventions are recommended for treatment.

Aspergillus fumigatus joint infection: a review

OBJECTIVES

To describe a case of joint infection by Aspergillus fumigatus in a unusual site (sacroiliac) and perform a systematic review of such cases described in the literature.

METHODS

We performed a Medline search of the cases of fungal joint of Aspergillus fumigatus in the period ranging from 1970 to 2009.

RESULTS

Following PRISMA Guidelines, 15 cases including ours were reported during this period. Stem cell and solid organ transplantation, hematologic malignancy, and intra-articular steroids injection were the medical conditions found in such patients. The knee followed by the shoulder were the joints more affected. In the cases where synovial fluid analyses were reported, elevated cell count numbers could be found with a predominance of polymorphonuclear neutrophils.

CONCLUSIONS

Fungal joint arthritis is a rare clinical disease most frequently present in immuno-incompetent patients. Rheumatologists should be aware of this condition, where early diagnosis can be associated with good prognosis.

Articular aspergillosis: case report and review of the literature

The incidence of invasive aspergillosis is increasing due to more frequent use of immunosuppressant agents in patients with autoimmune diseases, hematological malignancies, and solid organ and hematopoietic stem cell transplants. Invasive aspergillosis most commonly affects the lungs, sinuses, and brain. Aspergillosis affecting the musculoskeletal system is rare. We describe here a case of articular aspergillosis in a febrile neutropenic patient successfully treated with voriconazole and caspofungin, and briefly review the 10 cases of articular aspergillosis that have previously been described in the literature.

Aspergillose disséminée à point de départ articulaire après infiltrations

Bone and joint infections due to Aspergillus are rare and occur more commonly in immunosuppressed patients. We report the case of an 84-year-old woman who developed septic arthritis caused by Aspergillus fumigatus after corticosteroid infiltration. This patient had presented with arthritis of the left knee for several months but no microorganism had been found despite numerous arthrocenteses. This arthritis was resistant to treatment by numerous corticosteroid infiltrations. During an arthroscopy, analysis of the synovial fluid yielded A. fumigatus. Thereafter, other explorations showed disseminated aspergillosis with osteo-articular destruction, blood and urinary dissemination. A systemic treatment by voriconazole associated to intra-articular injections and surgical debridement was initiated but the patient died. Septic arthritis caused by A. fumigatus is very rare but must be considered as a differential diagnosis of septic arthritis after corticosteroid infiltration. Their complications can be very important and destructive.

Fungal osteomyelitis of the axial border of the proximal sesamoid bones in a horse

CASE DESCRIPTION

A 12-year-old Standardbred gelding was referred for swelling of the right metacarpophalangeal joint.

CLINICAL FINDINGS

Ultrasonography of the right metacarpal area revealed hypoechoic areas in the right digital sheath and metacarpophalangeal joint consistent with synovial effusion. Radiography of the right metacarpophalangeal joint revealed lysis of the axial border of the proximal sesamoid bones. Aspergillus fumigatus was detected on fungal culture of synovial fluid.

TREATMENT AND OUTCOME

Regional limb perfusion (150 mg of amikacin in 60 mL of saline [0.9% NaCl] solution perfused for 30 minutes) was performed 2 and 4 days after admission. Itraconazole (5 mg/kg [2.27 mg/lb], PO, q 24 h) was administered for approximately 9 weeks. Joint lavage with amikacin (500 mg) in 1 L of saline solution was performed 4 times. Three months after discharge, the owner reported that the horse was mildly lame during trotting but was moving freely and comfortably during all gaits and had gained a considerable amount of weight. Because the osteoarthritis was not expected to improve and because it was recommended that the horse not return to purposeful exercise, the owner decided to retire the horse from racing.

CLINICAL RELEVANCE

Various diagnostic imaging methods and fungal cultures are useful for diagnosing fungal osteomyelitis of the axial borders of the proximal sesamoid bones in horses. Fungal osteomyelitis of the sesamoid bones and erosive arthritis should be considered as a differential diagnosis for horses in which corticosteroids have been administered intra-articularly.

A murine model of invasive aspergillosis: variable benefit of interferon-gamma administration under in vitro and in vivo conditions

BACKGROUND

Interferon-gamma modulates host defense in a number of infectious diseases. Previous studies have shown that systemic administration of interferon-gamma (IFN-gamma) can enhance survival in experimental invasive aspergillosis (IA).

METHODS

Using a novel model of murine IA that is characterized by primary pulmonary infection, we investigated the role of IFN-gamma in the phagocytosis and killing of Aspergillus fumigatus by murine neutrophils and pulmonary alveolar macrophages in vitro and the impact of systemic and regional administration of IFN-gamma on the course of IA in glucocorticoid-treated mice.

RESULTS

In vitro, IFN-gamma significantly enhanced phagocytosis and killing function of both neutrophils and alveolar macrophages from normal animals, but not cortisone-treated animals. In vivo, intravenous administration of IFN-gamma did not improve phagocyte recruitment, in vivo killing, or mortality from IA. Regional (intranasal) administration of IFN-gamma to the lungs enhanced recruitment of phagocytic cells to the lungs and improved in vivo killing, but did not alter (and actually worsened) mortality from IA.

CONCLUSIONS

The in vitro and in vivo effects of IFN-gamma in IA are contingent on many variables, including the route of administration and the specific pathogenesis of infection.

Fungal arthritis and osteomyelitis

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