Isolated cryptococcal osteomyelitis in an immune-competent host: a case report

Cryptococcus neoformans osteomyelitis of the tibia: a case report and review of the literature

INTRODUCTION

Osteomyelitis is a bone inflammation that can be related to various infectious agents. As with any other type of inflammation, the prevailing symptoms and signs may include redness, swelling, pain, and heat. Fungal osteomyelitis is rare and usually found in immune-compromised patients.

CASE PRESENTATION

A non-human immunodeficiency virus immunocompromised Greek female patient, 82 years old, visited the emergency department due to a 3 day pain located mainly over the left tibia's anterior surface, accompanied by swelling and redness. There was also a subcutaneous lesion of her left breast. Medical history revealed that the patient had an unmasked close contact with pigeons, a main host of the disease. Initial x-ray imaging showed an osteolytic area in the upper third of the tibial diaphysis. The patient was admitted and underwent a computed tomography-guided biopsy. The specimen revealed a Cryptococcus neoformans infection of the bone and the breast. She was treated with 400 mg fluconazole twice a day for 3 weeks while in hospital and 200 mg twice a day upon discharge for 9 months. After that, she underwent surgical debridement because of lasting local irritation. She was closely monitored in our outpatient office, and in her last visit, 1 year after the initial admission, inflammatory signs had regressed vastly.

CONCLUSIONS

To our knowledge, this is the ninth cryptococcal osteomyelitis of the tibia to be recorded since 1974, and the most unusual finding was the bifocal nature of the infection, affecting both the tibia and the breast.

An unusual recurrent case of Cryptococcal sacroiliitis in an immunocompetent elderly female in Rajasthan, India

A 70-year-old female presented with left sided low back pain. There was no history of any co-morbidities or immunocompromised state. Skeletal cryptococcosis was confirmed bsaed on culture and histopathology, along with pulmonary involvement. After a month of oral antifungal therapy, the patient's symptoms resolved, but an abscess relapsed at the same site, which was treated with a combination of IV Amphotericin B and 5-flucytosine followed by oral fluconazole, with no recurrence or complaints reported in subsequent follow-up.

Fungal Infection Post Arthroscopic Meniscal Repair: A Rare Complication

Infections after arthroscopic procedures are rare. Infection due to fungal organisms is rarer and difficult to diagnose due to its insidious nature and chronic presentation but when neglected has devastating consequences. We present a 23-year-old immunocompetent adult post-arthroscopic meniscal repair with fungal surgical site infection. The patient underwent open debridement and was started on antifungals. His surgical wound healed and with physiotherapy he regained his full range of movement.

Fatal cryptococcal meningitis in a non-HIV patient

Cryptococcal infections (Cryptococcosis) are fatal fungal infections typically caused by Cryptococcus neoformans, a saprophyte frequently found in soil contaminated with  pigeon droppings and frequently seen in immunocompromised (specifically HIV Positive) individuals. Now a day’s awareness is emerging on cryptococcal disease among non-immunocompromised patients also. We present a case of Cryptococcus meningitis (CM) in a patient with cardiopulmonary arrest. A 55 year old male patient came with history of headache and fever with neck rigidity since last 3 months. The patient was admitted as a case of CM based on clinical findings and radiological features. Investigations were done to rule out other disorders of the immune system. He was treated with Amphotericine B (IV) and Fluconazole orally for 2 weeks. Culture of CSF was done which showed presence of Cryptococcus neoformans. It is concluded from the findings that Cryptococcus may also affect non-HIV patients regardless to their immune system.

Cryptococcal Osteomyelitis in an Immunocompetent Patient

Cryptococcal osteomyelitis is extremely rare. When cryptococcal infections occur, they are usually caused by Cryptococcus neoformans and involve the lungs or central nervous system in an immunocompromised individual. However, we report a case of osteomyelitis of the right ankle and right elbow due to C. neoformans in a 29-year-old immunocompetent male.

Cryptococcal infection presenting as soft tissue abscess and arthritis: Case report

RATIONALE

Cryptococcal infection has been documented in immunocompromised patients. AIDS and renal transplant recipients account for majority of the cases. Most cases present with central nervous system or disseminated disease, with only few presenting soft tissue, bone, and joint manifestations.

PATIENT CONCERNS

We present a case of soft tissue mass in a 66-year-old female renal transplant recipient and that of arthritis in a 64-year-old immunocompetent man who presented pseudogout arthropathy. Chest radiographies of both cases were negative. Biopsy revealed cryptococcal organisms. Blood culture or cerebrospinal fluid sampling indicated positive results for cryptococcal antigen.

DIAGNOSIS

Cryptococcus neoformans was recovered in the wound culture.

INTERVENTIONS

The patients received intravenous fluconazole and flucytosine, followed by oral fluconazole administration.

OUTCOMES

Symptomatic improvements were achieved and no subsequent relapses were observed.

LESSONS

The authors experienced 2 cases of cryptococcosis with very unusual clinical presentation. Early clinical suspicion and serum cryptococcal antigen testing can help in rapid appropriate diagnosis in immunocompetent as well as immunocompromised patients even in the absence of pulmonary involvement.

Cryptococcal Osteomyelitis of the Entire Humerus: A Case Report

CASE

We describe a case of cryptococcal osteomyelitis in a 70-year-old man who presented with left elbow and shoulder pain. Subsequent imaging indicated osteomyelitis of the entire humerus, and he underwent debridement of the elbow and shoulder. Pathological findings revealed Cryptococcus neoformans infection. Surgical management was followed by a prolonged course of antibiotics.

CONCLUSION

Although C. neoformans is rare as the etiology of infection of the entire humerus, orthopaedic surgeons should consider cryptococcosis as a potential cause of infection.

Cryptococcal osteomyelitis of the Zygomatic bone: a case report

Background

Disseminated cryptococcosis is a well-characterized complication in immunocompromised patients with cryptococcal pneumonia or meningitis; however, isolated cryptococcal osteomyelitis is a rare entity that occurs in approximately 5% of patients with cryptococcosis. Cryptococcal osteomyelitis in the head and neck region is extremely rare. To the best of our knowledge, no cases of cryptococcal osteomyelitis affecting only the zygomatic bone have been reported to date.

Case presentation

A 78-year-old man without other comorbidities presented with progressive swelling of the right cheek along with pain and trismus. Clinical examination revealed a tender swelling in the right zygomatic region; the maximal mandibular opening was about 2 cm. Laboratory data showed mildly elevated inflammatory indices (C-reactive protein: 0.45 mg/dL; erythrocyte sedimentation rate: 35 mm/h). Computed tomography showed a 30-mm-diameter lesion at the right zygomatic arch. A part of the lesion has extended to the subcutaneous area of the cheeks with signs of bone destruction and surrounding contrast effects. Histopathological examination of fine-needle aspirate and needle biopsy showed cryptococcus. Furthermore, culture of the aspirate showed growth of Cryptococcus neoformans. No evidence of any other site involvement was observed. Therefore, the patient was diagnosed with isolated cryptococcal osteomyelitis and was initiated on fluconazole therapy. The treatment was effective, and all symptoms were resolved in 4 weeks. Fluconazole therapy was stopped after 6 months. There are no signs of recurrence as of 15-month follow-up. The patient has no cosmetic abnormalities or sequelae.

Conclusions

Fine-needle aspiration cytology, needle biopsy, and fungal culture were useful for definitive diagnosis. Immunocompetent patients with isolated osteomyelitis may be cured with oral fluconazole alone.

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.

Disseminated Cryptococcal Osteomyelitis to the Hand in an Immunosuppressed Lymphoma Patient

Fungal osteomyelitis of the hand is rare with limited evidence-based literature to guide diagnosis and management. We report a case of disseminated cryptococcal osteomyelitis in the middle phalanx from a pulmonary fungal infection in a patient with a history of lymphoplasmacytic lymphoma. Although rare, cryptococcosis should be considered in the differential diagnosis of aggressive lytic lesions with bone pain and associated large soft tissue masses, especially in the immunosuppressed host.

Rapid Fatal Outcome of Cryptococcal Meningoencephalitis in a Non-HIV Immunocompromised Patient with a Low Fluconazole Susceptibility Isolate: A Case Report from Madagascar

Cryptococcal meningoencephalitis is considered rare in HIV-negative individuals. In Madagascar, the epidemiology of cryptococcosis has not yet been well described, neither in immunocompetent nor in immunocompromised patients. We report here the first Malagasy detailed case of cryptococcal meningoencephalitis in a non-HIV immunocompromised adult patient carrying a low fluconazole susceptibility isolate. We emphasize the importance of early and accurate diagnosis to meet the challenges of managing cryptococcosis in developing countries.

Cryptococcal osteomyelitis: a report of 5 cases and a review of the recent literature

Cryptococcus neoformans is a fungal pathogen associated with advanced HIV disease and other disorders associated with immune dysfunction. The pulmonary and the central nervous system are the most common manifestations of the disease. Localised osteomyelitis as the sole manifestation of extrapulmonary disease is rare. Herein, we present five cases of Cryptococcus osteomyelitis as the only manifestation of extrapulmonary disease. We also identified 84 additional cases of isolated cryptococcal osteomyelitis in the literature. Using these data, we have made some general recommendations regarding an approach to treatment of this uncommon clinical entity.

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.