Coccidioidomycosis infection of a total knee arthroplasty in a nonendemic region

Fungal Prosthetic Joint Infection: A Case Series and Review of the Literature

INTRODUCTION

Fungal prosthetic joint infections comprise less than 1% of prosthetic joint infections. Thus, little is known regarding optimal management. This study aims to characterize the microbiology, surgical and medical management, and outcomes for these complex infections. The objectives of this study were to assess the impact of surgical approach, antifungal treatment, fungal species, and time to onset of infection from initial surgery on patient outcomes.

METHODS

A retrospective record review over 12 years was performed in two health systems that included patients with a deep culture positive for a fungal isolate and the presence of a prosthetic joint. A literature review was performed using the same inclusion criteria. A total of 289 cases were identified and analyzed.

RESULTS

Candida was the most common isolate, and a two-stage revision was the most commonly employed surgical modality. The type of surgical intervention had a statistically significant relationship with outcome (P = 0.022).

CONCLUSIONS

Two-stage revision with extended antifungal therapy is preferred in these infections due to higher rates of positive outcomes.

Diagnosis, Treatment, and Outcome of Coccidioidal Osseous Infections: A Systematic Review

Extrapulmonary infections by Coccidioides spp., though rare, can occur via dissemination, affecting singular or multiple sites, including the skin and musculoskeletal system. Skeletal involvement often manifests as osteomyelitis, particularly in the axial skeleton. The present systematic review evaluates all documented cases of skeletal coccidioidomycosis to assess the diagnostic and treatment strategies alongside the outcomes, drawing insights from an analysis of 163 verified cases. A systematic review following PRISMA guidelines identified all studies reporting skeletal infections by Coccidioides spp. up to 2023 from the PubMed and Scopus databases. Eligible studies evaluated osteoarticular infections from Coccidioides spp. Data extraction included demographics, microbiological data, diagnostic methods, and treatment outcomes. Of the 501 initially identified records, a total of 163 patients from 69 studies met the inclusion criteria. Most cases were from the USA, predominantly males, while the median age of the population was 36 years. Diabetes mellitus was the common comorbidity (14.7%). C. immitis was the most prevalent pathogen. The spine and hand were common sites of infection (17.5% and 15.1%, respectively). Osteomyelitis by Coccidioides spp. was diagnosed, in most cases, by positive cultures (n = 68; 41.7%), while, in 49 (30.9%), both the histological examination and cultures yielded the fungus. Surgical debridement was performed in 80.9% of cases. A total of 118 (72.3%) patients were treated with monotherapy, while combination therapy with two or more antifungal agents was reported in 45 (17.7%). Amphotericin B (either liposomal or deoxycholate) was the most commonly given agent as monotherapy in 51 (31.2%) patients, while 30 (18.4%) patients received itraconazole as monotherapy. The rate of infection's resolution was higher in patients undergoing surgical debridement (79.5%), compared to those treated only with antifungal agents (51.6%, p = 0.003). Treatment outcomes showed complete resolution in 74.2% of patients, with a mortality rate of 9.2%. Coccidioidal osseous infections present diagnostic and therapeutic challenges. Surgical intervention is often necessary, complementing antifungal therapy. Vigilance for Coccidioides spp. infections, especially in regions with endemicity, is crucial, particularly when bacterial cultures yield negative results.

Coccidioidomycosis in Joint Replacement: A Review of the Literature With Case Presentations

Coccidioidomycosis is a fungal infection endemic to certain regions of the Americas. In some cases, the organism may infect the musculoskeletal system, resulting in a prosthetic joint infection (PJI). Due to its difficulty in diagnosis, treatment of coccidioidomycosis in PJI is often delayed. Furthermore, with limited number of case reports, a standard of care in treatment has yet to be established. We present 2 cases of coccidioidomycosis PJI, the extensive evaluation that led to the diagnosis, and the treatment provided. This report highlights the natural progression of coccidioidomycosis in a prosthetic joint, the diagnostic features including histology, advanced imaging, and final treatment administered.

Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature

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.

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.

Disseminated coccidioidomycosis in immunocompetent patients in non-endemic areas: a case series and literature review

Coccidioidomycosis is caused by the dimorphic fungi Coccidioides species which is endemic in the Western hemisphere. Reports on the characteristics of travel-related disseminated coccidioidomycosis in immunocompetent patients are rare, especially in non-endemic regions. The multifaceted symptoms of this condition present a diagnostic challenge to clinicians. This study aimed to review immunocompetent patients diagnosed with disseminated coccidioidomycosis in a tertiary hospital in Eastern China and other non-endemic areas, and to emphasize the importance of combining travel history with clinical manifestations and proper diagnostic examinations. This study retrospectively reviewed a case series of disseminated coccidioidomycosis diagnosed in an academic hospital in Eastern China. We conducted a global literature review of disseminated coccidioidomycosis in immunocompetent patients with travel history. We identified six patients in our case series and reviewed 42 cases in the literature. Travel history included Mexico, Arizona, California, and regions of low endemicity. Extrapulmonary sites of infection, which presented with diverse signs and symptoms, involved the skin and soft tissue, musculoskeletal system, lymph nodes, and central nervous system. Misdiagnoses and diagnostic delays were common. Next-generation sequencing substantially promoted precise diagnosis in our series. The overall prognosis for immunocompetent individuals was positive, mainly benefited from long-term azole therapies. The patients that succumbed had either central nervous system involvement or multiorgan dissemination. Progressive pneumonia with varied symptoms and travel history should alert healthcare professionals in non-endemic areas to consider the possibility of Coccidioides species infection. We recommend detailed history-taking and hypothesis-free detection of pathogens for cases with diagnostic delay.

Fungal periprosthetic joint infection: Rare but challenging problem

Periprosthetic joint infection (PJI) is the most difficult complication following total joint arthroplasty. Most of the etiological strains, accounting for over 98% of PJI, are bacterial species, with Staphylococcusaureus and Coagulase-negative staphylococci present in between 50% and 60% of all PJIs. Fungi, though rare, can also cause PJI in 1%-2% of cases and can be challenging to manage. The management of this uncommon but complex condition is challenging due to the absence of a consistent algorithm. Diagnosis of fungal PJI is difficult as isolation of the organisms by traditional culture may take a long time, and some of the culture-negative PJI can be caused by fungal organisms. In recent years, the introduction of next-generation sequencing has provided opportunity for isolation of the infective organisms in culture-negative PJI cases. The suggested treatment is based on consensus and includes operative and non-operative measures. Two-stage revision surgery is the most reliable surgical option for chronic PJI caused by fungi. Pharmacological therapy with antifungal agents is required for a long period of time with antibiotics and included to cover superinfections with bacterial species. The aim of this review article is to report the most up-to-date information on the diagnosis and treatment of fungal PJI with the intention of providing clear guidance to clinicians, researchers and surgeons.

Reactivation of Coccidioides immitis in a Prosthetic Knee after Initiation of Chemotherapy

Coccidioides is an endemic fungus in the Southwestern United States and Central and South America. Coccidioidomycosis primary infections are typically of the lung with an asymptomatic or self-limiting course. Some infections disseminate to other parts of the body and a few can remain latent for many years. Reactivation of latent fungal disease can occur following an insult to the host immune system. Here, we describe a case of a 76-year-old Caucasian male patient who moved from California to Wisconsin with a history of coccidioidomycosis infection of the left knee that reactivated decades later in his prosthetic knee shortly after being initiated on ibrutinib (Imbruvica), a Bruton tyrosine kinase (BTK) inhibitor, for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). There have been some case reports regarding coccidioidomycosis infections after initiating ibrutinib therapy but none with a 50 year latency period before reactivation. Readers will learn the immunological effects of ibrutinib on the hosts' innate and adaptive immunity and its role in putting the host at risk for invasive fungal infections. We also review the literature and data on treatment regimens and recommendations based on current guidelines.

Non-Candida Fungal Prosthetic Joint Infections

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.

Coccidiomycosis immitis Resulting in a Prosthetic Joint Infection in an Immunocompetent Patient after a Total Hip Arthroplasty: A Case Report and Review of the Literature

Coccidiomycosis immitis is a fungal infection that is a rare cause of prosthetic joint infection (PJI) in patients. This case report describes an immunocompetent patient who had a right total hip arthroplasty (THA) complicated with Coccidiomycosis immitis. This patient is the 9th reported case of Coccidiomycosis immitis causing a PJI and only the second case to be reported in a THA. Once progressed, it can be difficult to treat, often reoccurring and requiring repeat sur-gical and prolonged therapy. We discuss the clinical presentation in this patient and review the literature on the current pub-lished cases.

Success Rate of Fungal Peri-Prosthetic Joint Infection Treated by 2-Stage Revision and Potential Risk Factors of Treatment Failure: A Retrospective Study

Background

The aim of this study was to investigate the success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and related factors of treatment failure to offer a better treatment protocol.

Material/Methods

We reviewed 18 joints (13 knees and 5 hips) of 17 patients (10 women and 7 men) diagnosed with fungal peri-prosthetic joint infection from January 2000 to June 2015 at our institute. The mean follow-up was 65.1 months (range, 25–129 months). All joints were treated with complete debridement, implantation of antifungal-loaded cement spacers, at least 6 weeks of parenteral antifungal agents, and delayed reimplantation.

Results

Notably, 15 joints were infected with Candida, and molds were isolated in 3 joints. The median duration of resection arthroplasty and reimplantation was 33.9 weeks (range, 12–132 weeks). Thirteen (10 knees and 3 hips, 72.2%) of the 18 joints (13 knees and 5 hips) had no recurrent or persistent infection, while the remaining 5 joints (3 knees and 2 hips, 27.8%) failed to control infection after reimplantation of prosthesis or spacer. The long interval between prosthesis resection and reimplantation (69 weeks vs. 23.1 weeks, p=0.240) and mixed bacterial infection (80% vs. 46.2%, p=0.314) were associated with higher failure rate.

Conclusions

Debridement with the retention of the prosthesis is not an ideal treatment protocol for fungal peri-prosthetic joint infection; thus, a two-stage revision could be valid. We suggest that 6 weeks of parenteral antifungal agents are necessary, and 6 subsequent weeks of oral antifungal treatment is also important. We do not recommend that the two-stage revision be performed on patients who have more than 2 host risk factors.

Reactivation of coccidioidomycosis: a prosthetic joint infection in Spain

A resident of Spain was found to have a prosthetic knee infection due to coccidioidomycosis. He had a history of having pneumonia which resolved while living in an area of California endemic for Coccidioides in 1957-1961. The patient left California in 1961 returned to Spain and never left Spain thereafter. In 2006, a total knee replacement was done. In 2013, a prosthetic knee infection was documented due to coccidioidomycosis. By molecular DNA analysis, Coccidioides immitis was identified from the knee tissue, a species most commonly found in California. This represents reactivation of a Coccidioides infection 56 years after leaving the endemic area.

Systemic inflammatory markers and aspiration cell count may not differentiate bacterial from fungal prosthetic infections

BACKGROUND

Fungal periprosthetic joint infections (PJIs) are rare. Fewer than 200 cases have been reported in the literature. The characteristics of systemic inflammatory markers and joint aspirate cell count analysis obtained in patients with fungal PJIs have not been fully assessed. The ability to diagnose involvement of fungal PJI preoperatively may optimize the surgical and medical management of these patients.

QUESTIONS/PURPOSES

We determined whether preoperative systemic inflammatory markers and total synovial fluid leukocyte count and neutrophil percentage were different between patients with fungal and bacterial PJI.

METHODS

We reviewed the medical records of 44 patients with culture-positive diagnosed fungal PJIs treated at our institution between January 1, 2002, and December 31, 2011, in this study. This represented 1.2% of the total 3822 PJIs treated at our institution during the study period. The mean values for C-reactive protein, erythrocyte sedimentation rate, leukocyte count, and neutrophil percentage of patients with purely fungal PJIs were compared to those of 59 patients with bacterial PJIs treated by one surgeon during the same time period.

RESULTS

The mean erythrocyte sedimentation rate values for fungal and bacterial PJIs were 40 mm/hour (95% CI: 30, 50 mm/hour) and 41 mm/hour (95% CI: 33, 49 mm/hour), respectively (p=0.61). The mean C-reactive protein values for fungal and bacterial PJIs were 42 mg/L (95% CI: 22, 62 mg/L) and 65 mg/L (95% CI: 43, 88 mg/L), respectively (p=0.42). The mean total nucleated leukocyte counts for fungal and bacterial PJIs were 11,928 (95% CI: 3906, 19,950) with 81% (95% CI: 75%, 88%) neutrophils and 36,901 (95% CI: 21,822, 51,921) with 73% (95% CI: 65%, 81%) neutrophils, respectively (leukocyte count: p=0.19; neutrophil percentage: p=0.55).

CONCLUSIONS

Early detection of fungal PJI is needed, but systemic inflammatory markers and synovial fluid cell count analyses from aspirations do not discriminate whether an infection may be of fungal origin.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Fungal osteomyelitis and septic arthritis

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Prosthetic joint infection

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.

First imported coccidioidomycosis in Turkey: A potential health risk for laboratory workers outside endemic areas

Coccidioidomycosis caused by Coccidioides immitis or Coccidioides posadasii is endemic in arid climate zones in America, travel-related cases have been reported. We report the first documented case of coccidioidomycosis in Turkey, overviewing reported cases in Europe and underlying difficulties of differential diagnosis outside endemic regions. The patient was an otherwise healthy 41-year-old man who travelled endemic areas. Laboratory diagnosis was based on direct microscopy of two subsequent subcutaneous biopsy specimens and culture and confirmed molecularly. Laboratory personnel should become aware that BioSafety Level-3 organisms may become more frequent and widespread.

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections

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.