Cryptococcal rib osteomyelitis in a pediatric patient

Osteomyelitis of the Rib in a Child With Indolent Symptoms

We describe a case of osteomyelitis of the rib caused by methicillin-susceptible Staphylococcus aureus. The patient presented with a subtle, indolent course leading to a suspected 2-year delay in diagnosis. This case highlights that the diagnosis of rib osteomyelitis, which can readily mimic other diagnoses, such as costochondritis, intraabdominal infections, pneumonia, or malignancies warrants a high index of suspicion. Albeit rare, pediatricians should be aware of the possibility of rib osteomyelitis in healthy children to help ensure a prompt diagnosis and appropriate, timely management.

Cryptococcus neoformans osteomyelitis of the calcaneus: Case report and literature review

Cryptococcus neoformans is an encapsulated, yeast-like fungus that can cause a systemic mycosis, particularly in immunocompromised patients. Disseminated infections typically affect the central nervous system, and osseous lesions are infrequent. Only 5%–10% of disseminated cryptococcosis involves bones. A 69-year-old female presented pain, swelling, and a soft tissue mass in her right lateral hindfoot. Her medical history included a kidney transplant (10 years earlier) secondary to chronic disease due to IgA nephropathy. The patient underwent an excisional biopsy, surgical debridement, and secondarily negative pressure wound therapy to achieve skin closure. Biopsy revealed a rare Cryptococcus neoformans osteomyelitis of the calcaneus. The patient then received IV treatment with liposomal amphotericin B at 3 mg/kg/d for 25 days. In conclusion, we present a case of cryptococcal osteomyelitis which, although not a frequent disease, must be considered as one of the differential diagnoses of osteolytic osseous lesions in patients with chronic osteomyelitis. Cryptococcus neoformans may be a potential cause of below-knee infection, mainly in immunocompromised patients.

Metagenomic Next-Generation Sequencing Technique Helps Identify Cryptococcal Infection in the Rib: A Report of 2 Cases and Review of the Literature

CASE

Two patients presented with pathological lytic bone lesions in the rib and associated soft tissue mass believed initially to represent soft tissue neoplasm. However, further consideration of infectious etiologies led to the identification of cryptococcal osteomyelitis. In one case, the microbiological culture was negative, but Cryptococcus neoformans was identified with the help of the metagenomic next-generation sequencing (mNGS) technique. Both patients received oral fluconazole-only treatment, and the infections were successfully eradicated.

CONCLUSIONS

The mNGS technique helps identify cryptococcal infection in the rib.

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.

Cryptococcal osteomyelitis in an adolescent survivor of T-cell acute lymphoblastic leukemia

Cryptococcosis is infrequent in children, and isolated cryptococcal osteomyelitis is rarely encountered. Here, we describe a 14-year-old patient in remission from T-cell acute lymphoblastic leukemia with osteomyelitis because of Cryptococcus neoformans var. grubii. The patient was effectively treated with antifungal therapy.

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.

Rib osteomyelitis in a pediatric patient case report and literature review

Rib osteomyelitis is a very rare form of childhood osteomyelitis. We describe a case of a 9-year-old child with an osteomyelitis of the rib due to Staphylococcus aureus and review 57 cases reported in the literature. This case demonstrates that the diagnosis of this uncommon disease requires a high index of suspicion due to its rarity and nonspecific signs.

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.

Disseminated cryptococcosis including osteomyelitis in a horse

A 4-year-old Arab mare was diagnosed with disseminated cryptococcosis, including osteomyelitis of the proximal phalanx of the left hind limb, osteomyelitis with associated soft tissue granuloma of a rib and disseminated, large cryptococcal nodules in the lungs. The lesion in the dorsoproximal aspect of the proximal phalanx had a large area of cortical lysis with spiculated periosteal new bone and extensive soft tissue swelling. The affected rib had a pathological fracture. Cryptococcal osteomyelitis has not been previously reported in horses but should be considered as a differential diagnosis, particularly in endemic regions.

Cryptococcal osteomyelitis of the humeral head initially diagnosed as avascular necrosis

Cryptococcal skeletal infections can lead to significant morbidity and mortality and should be considered in the differential diagnosis of lytic osseous lesions. Clinical and radiological similarities to various disorders may lead to delay in initiation of antifungal treatment. This report describes a case of cryptococcal osteomyelitis of humeral bone in a 19-year-old female, emphasizing the clinical presentation, diagnostic approach and treatment options.

Osteomyelitis of the rib due to Streptococcus pneumoniae: a very rare condition in children

Rib osteomyelitis is a rare disease. We present a previously unreported case of Streptococcus pneumoniae osteomyelitis of the rib. A 4-month-old-infant presented with fever, irritability and abdominal tenderness. Pericostal collection was discovered incidentally on ultrasound; it was first drained by needle aspiration and appropriate antibiotic therapy was given, with resolution of fever in 24 h, but recurrence of symptoms 4 days later, with swelling over the affected rib. Surgical drainage with resection of the infected portion of the rib were done followed by a prolonged course of intravenous and then oral antibiotics, without any recurrence at 6 months follow-up. A review of the pertinent literature was made. This case demonstrates that the spectrum of pathogens potentially responsible for rib osteomyelitis may be broader than previously reported. The management and outcome are similar to rib osteomyelitis due to any other bacteria.

Muscular-skeletal cryptococcosis in a patient with idiopathic CD4+ lymphopenia

A healthy 27-year-old woman presented, four months after childbirth, ingravescent pain and claudication of the left lower limb. Magnetic Resonance Imaging of the lumbosacral and iliac regions showed widespread muscular-skeletal lesions. The patient underwent surgery; Cryptococcus neoformans was isolated from surgical samples. Liposomal amphotericin B, fluconazole and itraconazole were administered. Laboratory findings showed lymphocytopenia, with reduction of CD4+ lymphocytes (23 cells per cubic millimeter) in the absence of HIV infection and any other defined immunodeficiency. This is a rare case of muscular-skeletal cryptococcal infection isolated in a subject affected with idiopathic CD4+ lymphocytopenia.

[Clinical significance of the increased uptake of a solitary rib lesion in the bone scintigraphy. Based on an osteoblastoma]

A case of a bone tumor located in the right sixth rib detected by means of the bone scan as a solitary lesion is presented. Although the chest X-ray and CT were normal, a low signal intensity on T1 images and high-intensity on T2 images were seen in the MRI. The post-surgical histological diagnosis was osteoblastoma. A review of the clinical significance of solitary rib lesions which appear with increased uptake on bone scan was performed. When a differential diagnosis is made of a solitary rib lesion that appears on a bone scan, osteoblastoma should be considered.

Prevalence of Cryptococcus neoformans in clinical specimens

Cryptococcus neoformans isolated from various clinical materials in 14 cases, was identified by (1) cultivation on Sabouraud glucose agar and CHROMagar Candida, (2) microscopic examination of Indian-ink-stained preparations and (3) determination of biochemical properties (assimilation and fermentation of saccharides, assimilation of KNO3, production of urease and phenol monooxygenase). C. neoformans was determined in five specimens from paediatric patients in the intensive care unit and in nine specimens from adult patients, most frequently from liquor at meningitis (n = 3).