Case report 89

The detection of Cryptococcus in skeletal infection after tooth extraction in an acute myeloid leukemia patient

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Cryptococcus-related infection developed after tooth extraction.

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Cryptococcal infection of mandible is rare.

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Surgical treatment was performed under poor general conditions.

Cryptococcus is a mycosis founded in immunocompromised patients. Cryptococcus in the oral cavity is rare and skeletal infection is uncommon.

We report the case of a 31-year-old man in whom cellulitis developed due to infection after tooth extraction complicated by acute myeloid leukemia (AML). Cellulitis of the left mandible did not improve after conservative therapy, including antimicrobial therapy, because of AML and chemotherapy, and gas was generated in the left cervical and supraclavicular regions. We considered the infection symptoms to be life-threatening, and surgery was performed for the infection of the head and neck under poor general conditions. As histopathological examination of the removed tissue revealed cryptococcus, antifungal agents were administered for cryptococcal infection. The surgical site healed after the operation.

Surgical treatment, including debridement and drainage, should be avoided for patients with a poor general condition caused by AML and chemotherapy. However, the detection of Cryptococcus in the surgical site in such a condition is important.

Fungal Infections of the Spine

STUDY DESIGN

Review of the literature.

OBJECTIVE

To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease.

SUMMARY OF BACKGROUND DATA

Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series.

METHODS

MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database.

RESULTS

A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles.

CONCLUSION

Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections.

LEVEL OF EVIDENCE

3.

Skeletal cryptococcosis from 1977 to 2013

Skeletal cryptococcosis, an aspect of disseminated cryptococcal disease or isolated skeletal cryptococcal infection, is a rare but treatable disease. However, limited information is available regarding its clinical features, treatment, and prognosis. This systematic review examined all cases published between April 1977 and May 2013 with regard to the factors associated with this disease, including patient sex, age, and epidemiological history; affected sites; clinical symptoms; underlying diseases; laboratory tests; radiological manifestations; and delays in diagnosis, treatment, follow-up assessments, and outcomes. We found that immune abnormality is a risk factor but does not predict mortality; these observations are due to recent Cryptococcus neoformans var gattii (CNVG) outbreaks (Chaturvedi and Chaturvedi, 2011). Dissemination was irrespective of immune status and required combination therapy, and dissemination carried a worse prognosis. Therefore, a database of skeletal cryptococcosis cases should be created.

Skeletal cryptococcosis: Case report and review of the literature

A case of isolated cryptococcal skull infection is presented in a patient with unexplained CD4 lymphopenia and chronic hepatitis B. All cases of this disease reported in the English literature from 1956 to the present are reviewed. The literature suggests that skeletal cryptococcosis is manifested in only 5% to 10% of recognized cases of disseminated cryptococcosis and that isolated skeletal disease without evidence of other tissue involvement is even less common. When isolated bony disease does occur it tends to occur in immunocompromised hosts, particularly those with defects of cell mediated immunity. Any bony site can be involved, most commonly the vertebrae, with the presentation often being a soft tissue swelling and pain in the affected area. Systemic constitutional symptoms occur in a minority of patients. Radiographic investigations are nonspecific and the gold standard of diagnosis remains culture isolation from bone tissue. The most commonly employed therapy for isolated bone disease is amphotericin alone or combined with surgical debridement. The new azoles may have a role in future therapy.

Cryptococcus neoformans abscess and osteomyelitis in an immunocompetent patient with tuberculous lymphadenitis

Infection with Cryptococcus neoformans usually occurs in immunocompromised hosts and may occur in immunocompetent patients. Of all cryptococcal infections, 10-40% of patients have no apparent immune deficiency. Disseminated disease may occur in up to 62% of HIV-seronegative patients with cryptococcosis; however, cryptococcal osteomyelitis is rare. Here, we report an immunocompetent patient with cryptococcal vertebral osteomyelitis and concomitant tuberculous lymphadenitis. The patient received 12 weeks of fluconazole and a 1-year course of anti-tuberculous agents, with complete recovery.

What's new in mycotic bone and joint diseases?

Deep fungi exhibit different degrees of aggressiveness toward joints and bone, most likely depending on the individual make-up of the respective organism. Immunodepressed patients have a propensity to bone and joint involvement by sporotrichosis, cryptococcosis and candidiasis. African histoplasmosis, blastomycosis and coccidioidomycosis are the main mycoses to produce osteoarthritic complications. Arthralgias as part of primary mycotic infection are seen in histoplasmosis capsulati and in coccidioidomycosis. The recognition of the specific agent by morphologic, cultural and serologic methods changes potentially the prognosis and treatment of patients.