Osteomyelitis caused by Paracoccidioides brasiliensis in a child from the metropolitan area of Rio de Janeiro

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.

Magnetic resonance imaging findings of paracoccidioidomycosis in the musculoskeletal system

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in musculoskeletal paracoccidioidomycosis (PCM).

METHODS

Retrospective case series study after IRB approval. Two musculoskeletal radiologists reviewed in consensus the MRI findings of 11 patients with microbiologically and/or pathologically proven osteoarticular PCM. The MRI evaluation included discrimination of abnormalities in joints, bones and soft tissues.

RESULTS

Mean age of patients was 29 years (10-55 years), eight men and three women. Musculoskeletal involvement was the only or the primary presentation of the disease in seven patients (63%). Osteomyelitis was the most common presentation, with seven cases (63%). Primary arthritis was found in one patient (9%). Isolated extra-articular soft tissue PCM was found in three patients: myositis (2) and subcutaneous infection (1). All cases showed regions with signal intensity higher than or similar to the signal of muscle on T1-weighted images. Penumbra sign was present in five cases (45%). T2-weighted images showed reactive soft tissue oedema in eight cases (72%). Post-gadolinium images showed peripheral (8/9) or heterogeneous (1/9) enhancement. Synovial enhancement was present in all cases of joint involvement (6/6). Lipomatosis arborescens was documented in one case of chronic knee involvement.

CONCLUSION

To our knowledge, this is the first case series describing MRI findings of musculoskeletal PCM. Musculoskeletal involvement was the primary presentation of the disease in most cases, and therefore, neoplasms were initially in the differential diagnosis. Osteomyelitis was the most common presentation, often with secondary involvement of joint and or soft tissue.

Osteomyelitis and pyoarthritis resulting from local paracoccidioidomycosis in an immunocompetent patient: a case report

INTRODUCTION

Paracoccidioidomycosis is a type of mycosis that is endemic to Brazil and is triggered by the fungus Paracoccidioides brasiliensis. Isolated bone involvement in this disease is very rare, especially in children. To the best of our knowledge this report documents the first case of an immunocompetent pediatric patient in which paracoccidioidomycosis of the hip articulation was the sole manifestation of the disease (that is, there were no pulmonary or skin lesions).

CASE PRESENTATION

An 11-year-old Brazilian Caucasian boy from a rural area was examined in the orthopedic ward of our emergency department. Our patient reported a three-month history of pain in the right hip with intermittent claudication and also complained of recurring episodes of intense pain and an inability to walk, which he had been experiencing for the previous five days. He additionally presented with a fever that had persisted for two days. Our patient's medical history did not include any clinical respiratory manifestations, skin lesions, history of trauma or immunosuppression risk factors.

CONCLUSIONS

This is one of the very few reported cases of isolated articular involvement in osteomyelitis in a pediatric immunocompetent patient. Paracoccidioidomycosis should be considered among the differential diagnoses in such cases, especially in cases of patients who reside in rural areas where the condition is considered to be endemic, in order to administer the proper course of treatment in a timely fashion and improve the chances of a favorable prognosis.

Osteomielite de punho em paciente com paracoccidioidomicose disseminada: uma rara apresentação

Paracoccidioidomicose é a micose sistêmica endêmica mais frequente no Brasil. No início, o paciente não desenvolve sintomas. Com a progressão da doença, o indivíduo pode apresentar envolvimento disseminado, sendo que o acometimento ósseo é extremamente raro. O objetivo deste artigo é avaliar as alterações ósseas encontradas em estudos de imagem em um paciente com osteomielite de punho decorrente de paracoccidioidomicose disseminada.

Thoracic paracoccidioidomycosis: radiographic and CT findings

Paracoccidioidomycosis (PCM) is the most common systemic mycosis in Latin America. Although most cases occur in developing countries, recent immigration patterns and an increase in travel have led to a growing number of PCM cases in the United States and Europe. PCM is caused by the dimorphic fungus Paracoccidioides brasiliensis, and the chronic form may progress to severe pulmonary involvement. Several radiologic patterns have been described for pulmonary PCM, including linear and reticular opacities, variable-sized nodules, patchy ill-defined opacities, airspace consolidation, and cavitary lesions. Fibrosis and paracicatricial emphysema are common associated findings. Chest computed tomography (CT) is the method of choice for evaluating pulmonary PCM, with the most common CT findings being ground-glass attenuation, consolidation, small or large nodules, masses, cavitations, interlobular septal thickening, emphysema, and fibrotic lesions. PCM is also an important cause of the "reversed halo" sign at high-resolution CT and should be considered in the differential diagnosis. Awareness of the multiple radiologic manifestations of PCM as well as its epidemiologic and clinical characteristics may permit early diagnosis and initiation of specific treatment, thereby reducing associated morbidity and mortality.

Unifocal bone paracoccidioidomycosis, Brazil

We report a 47 year-old man from the State of Mato Grosso do Sul, Brazil, with unifocal tibial paracoccidioidomycosis. A radiograph showed an osteolytic lesion on the tibial middle third diaphysis. The diagnosis was confirmed by histopathologic analysis, and treatment with sulfamethoxazole and trimethoprim was started. After three months, the patient showed significant clinical improvement. Ten months after treatment, the patient showed lesion bone healing. This case describes the rare occurrence of an osteolytic lesion caused by endemic Paracoccidioides brasiliensis in Latin America.

Radiologic findings of osteoarticular infection in paracoccidioidomycosis

OBJECTIVE

To report the radiological abnormalities of osteoarticular involvement in paracoccidioidomycosis (PCM).

MATERIALS AND METHODS

After institutional board approval, the medical records and conventional radiology findings of 19 patients with osseous PCM were retrospectively reviewed. Number, distribution, and lesion characteristics were evaluated in consensus by two experienced musculoskeletal radiologists.

RESULTS

The mean age of patients was 16.1 years (range 4-49 years), 11 male and eight female. MSK involvement was the only or the primary presentation of the disease in eight of 19 patients (42.1%). In total, 51 focal bone lesions were detected, being 41 in long bones. In long bones lesions, 19 of 41 (46.4%) were metaphyseal, 12 of 41 (29.3%) meta-epiphyseal, and 12 of 41 (29.3%) diaphyseal. The most common presentation was a geographic osteolytic bone lesion (62.7%), without marginal sclerosis (82.4%) and without periosteal reaction (90.2%). Articular involvement was present in six of 19 patients (31.6%), being two cases of primary arthritis.

CONCLUSIONS

All encountered bone lesions were osteolytic. Metaphyseal or meta-epiphyseal osteomyelitis of a long bone was the most prevalent osteoarticular manifestation of paracoccidioidomycosis. PCM osteoarticular involvement could be solitary or multifocal, occurs almost exclusively in the acute/subacute clinical form, and it is more common in children and in juvenile patients. Axial skeleton involvement, arthritis, or a disseminated osseous pattern of infection may occasionally occur in this fungal disease.

Fungal infection by Paracoccidioides brasiliensis mimicking bone tumor

Paracoccidioides brasiliensis infection causes a systemic mycosis originally described in Latin America but with current reports of worldwide distribution. The clinical presentation of paracoccidiodomycosis as an isolated long-bone lesion in children is quite unusual. This article describes a 10-year-old male with a lytic femoral bone lesion caused by P. brasiliensis infection that was first suspected of being of neoplasic etiology. The text also emphasizes the importance of including endemic fungal infections in the differential diagnosis of bone lesions.

Resultado tardio da infecção isolada no quadril por Paracoccidioides brasiliensis

Infecções causadas pelo Paracoccidioides brasiliensis são sempre um desafio diagnostico mesmo em áreas endêmicas, devidas as suas múltiplas apresentações clinicas e órgãos envolvidos. Este artigo descreve a evolução do único caso descrito na literatura no qual a doença acometeu apenas um quadril.

Paracoccidioidomicose: atualização epidemiológica, clínica e terapêutica

São apresentados dados de atualização epidemiológica, clínica, diagnóstica e terapêutica relativos à paracoccidioidomicose. Discute-se a importância epidemiológica resultante do isolamento do Paracoccidioides brasiliensis a partir do tatu (Dasypus novemcinctus) em regiões do Brasil e Colômbia, assim como dos resultados de inquéritos soroepidemiológicos em cães e do surgimento do primeiro caso de paracoccidioidomicose doença em cão. As dificuldades de isolamento do fungo a partir do solo são correlacionadas com novos informes de investigação epidemiológica. São apresentados aspectos clínicos das manifestações da forma aguda da doença, assim como das manifestações da neuroparacoccidioidomicose e da enfermidade associada à infecção pelo HIV. Discute-se o papel da sorologia e da técnica da PCR no diagnóstico e dos possíveis avanços no tratamento da paracoccidioidomicose com os novos derivados triazólicos.