Candida albicans arthritis in a healthy adult

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.

A rare primary Candida parapsilosis infection of the knee joint in a patient without predisposing factors: A case report

RATIONAL

Knee joint infection caused by isolated primary Candida is extremely rare, with only a few cases reported. It occurs most often in patients with predisposing factors (e.g., immunosuppression, malignancy, drug abuse) or fungal invasion during traumatic procedures, including surgery. We report an unusual case of Candida parapsilosis infection in the knee joint with no predisposing factors.

PATIENT CONCERNS

A 65-year-old man entered our hospital complaining of persistent pain and mild swelling of the right knee that seriously affected normal walking. There was no obvious cause for his distress.

DIAGNOSIS

The case was eventually diagnosed as a primary Candida parapsilosis infection which had many diagnostic particularities and difficulties.

INTERVENTIONS

Total knee arthroplasty (TKA) was ultimately performed followed by fluconazole coverage.

OUTCOMES

The patient showed good clinical performance at the 3- and 6-month follow-up visits and was very satisfied with the therapeutic effect.

LESSONS

If there were suspected symptoms of primary Candida infection cases, imaging and microscopic examinations, tissue cultures, and pathological examination of the puncture knee joint fluid were required.

Candida Arthritis: Analysis of 112 Pediatric and Adult Cases

Background. Candida arthritis is a debilitating form of deeply invasive candidiasis. However, its epidemiology, clinical manifestations, management, and outcome are not well understood.

Methods. Cases of Candida arthritis were reviewed from 1967 through 2014. Variables included Candida spp in joint and/or adjacent bone, underlying conditions, clinical manifestations, inflammatory biomarkers, diagnostic imaging, management, and outcome.

Results. Among 112 evaluable cases, 62% were males and 36% were pediatric. Median age was 40 years (range, <1–84 years). Most patients (65%) were not pharmacologically immunosuppressed. Polyarticular infection (≥3 joints) occurred in 31% of cases. Clinical manifestations included pain (82%), edema (71%), limited function (39%), and erythema (22%) with knees (75%) and hips (15%) most commonly infected. Median erythrocyte sedimentation rate was 62 mm/hr (10–141) and C reactive protein 26 mg/dL (0.5–95). Synovial fluid median white blood cell count was 27 500/µL (range, 100–220 000/µL) with 90% polymorphonuclear neutrophils (range, 24–98). Adjacent osteomyelitis was present in 30% of cases. Candida albicans constituted 63%, Candida tropicalis 14%, and Candida parapsilosis 11%. Most cases (66%) arose de novo, whereas 34% emerged during antifungal therapy. Osteolysis occurred in 42%, joint-effusion in 31%, and soft tissue extension in 21%. Amphotericin and fluconazole were the most commonly used agents. Surgical interventions included debridement in 25%, irrigation 10%, and drainage 12%. Complete or partial response was achieved in 96% and relapse in 16%.

Conclusion. Candida arthritis mainly emerges as a de novo infection in usually non-immunosuppressed patients with hips and knees being most commonly infected. Localizing symptoms are frequent, and the most common etiologic agents are C albicans, C tropicalis, and C parapsilosis. Management of Candida arthritis remains challenging with a clear risk of relapse, despite antifungal therapy.

Primary Candida guilliermondii Infection of the Knee in a Patient without Predisposing Factors

Isolated primary candidal infection of joint is extremely rare, with only a few reported cases. It occurs as a result of accidental implantations of fungus during traumatic procedures, such as surgery, and is usually reported in patients with predisposing factors such as immunosuppression, malignancy, and drug abuse. If left untreated, irreversible deformity and pain with severe osteoarticular destruction occur. Thus, early diagnosis and treatment are important. This paper presents a case of 72-year-old man with primary C. guilliermondii infection of knee joint without predisposing factors and previous traumatic procedures, who was misdiagnosed with advanced degenerative osteoarthritis. Our case is the second case of primary C. guilliermondii arthritis of knee to be reported in the English-language literature and the first to be successfully treated with total knee arthroplasty following IV amphotericin B and oral fluconazole. Primary candidal infection of joint is generally asymptomatic or involves only mild pain and swelling in the affected knee. Thus, although the majority of knee joint infections are of a pyogenic or tuberculous origin, if a patient complains of mild pain and swelling in the knee and has mild signs of infection, the possibility of fungal infection should be considered.

Rutin has therapeutic effect on septic arthritis caused by Candida albicans

As of late, numerous reports have demonstrated the multiple biological activities of polyphenolic flavonoids. Amongst these reports, some indicate that the flavonoids play an important role in inflammation therapy. In this present study, we investigated the effect of rutin, a polyphenolic flavonoid, on septic arthritis due to Candida albicans, a major etiological agent that causes fungal arthritis. To induce septic arthritis, an emulsified mixture of C. albicans cell wall and Complete Freund's Adjuvant (CACW/CFA) was injected into BALB/c mice via hind footpad route once a day, everyday, for three days. In order to determine the effect of rutin, twenty-four hours after the final injection, mice having the swollen footpad were given the flavonoid (1 mg/dose/mouse) intraperitoneally every other day for three times. The footpad-edema was measured for a period of 17 days. Results showed that the rutin treatment reduced app. 45% of the edema at the peak day (day 11) of septic arthritis (P<0.05). In addition, 6 days after the peak, there was an app. 35% additional reduction of the edema (P<0.05). We found that this anti-arthritic activity was mediated by rutin's ability to inhibit nitric oxide production from macrophages and T-cells proliferation. Furthermore, this flavonoid also inhibited the growth of C. albicans yeast cells (P<0.01) and resulted in no hemolysis. These data indicate that rutin, which has both anti-arthritic and antifungal effects, can safely be administered into the blood circulation for treatment of septic arthritis caused by C. albicans. Ultimately, it can be suggested that the dual effects of rutin, anti-arthritic and anti-candidal may be helpful as an all-in-one treatment for septic arthritis.

Ginkgo terpene component has an anti-inflammatory effect on Candida albicans-caused arthritic inflammation

The Ginkgo biloba extract, EGb 761, contains flavonoid glycosides and unique terpene lactones as major active components. In this study, we determined the anti-inflammatory effect of the water-soluble portion (GH415) of the EGb 761 on the inflammation caused by Candida albicans, a major ethiological agent that causes fungal arthritis. For inflammatory induction, an emulsified mixture of C. albicans cell wall and Complete Freund's Adjuvant (CACW/CFA) was injected into BALB/c mice by the hind footpad route once a day for 3 days. Twenty-four hours after the final injection, mice having the swollen footpad were given the GH415 (2 mg/dose) intraperitoneally to the mice once every 3 days for 15 days. The footpad-swelling of these mice was measured during the entire observation period. Results showed that the GH415 treatment reduced the swelling. In the same animal model, this effect was enhanced by treatment with the GH415 entrapped within liposome (Lipo-GH: 200 micro/dose). Further analysis revealed that terpene, not flavone portion, was responsible for such therapeutic anti-inflammatory effect. Treatment with the terpene (7.4 microg/dose) by liposomal delivery method had similar effects as the treatment with indomethacin at 30 microg/dose. Addition of the terpene to lipopolysaccharide-treated macrophages showed suppression of nitric oxide (NO) production. These results suggest that blockage of the NO production from the macrophages that infiltrated to the inflamed site may be a possible mechanism for the therapeutic anti-inflammatory effect.

Fungal arthritis. A review

Fungal arthritis (FA) due to a candida infection was reviewed in English literature and described in 45 cases. The increasing use of potent antibiotics, immunosuppressives, and especially the use of artificial joints, predisposed to the infection. Weightbearing joints, particularly the knees, were most frequently affected. Symptoms were described as a warm, tender and swollen joint, and the duration of symptoms prediagnosis was described as being up to 4 years. Amphotericin B was the treatment drug of choice, and in cases of no response, supplemented with either flucytosine or ketoconazole. Local FA healed in all cases. FA in an artificial joint resulted in all cases in removal of the prostheses. Mortality in systemic fungal infections including FA was 50%.

Candida albicans arthritis in a nonimmunocompromised patient. Complication of placebo intraarticular injections

A nonimmunocompromised 32-year-old man with arthrosis of the knee participated as a placebo control in a clinical trial of intraarticular injections of hyaluronan. After the fourth weekly injection of saline, he developed a warm and swollen knee, and synovial fluid cultures revealed growth of Candida albicans. Oral fluconazole treatment was instituted 2 weeks after onset of symptoms, but failed to eradicate the infection. The patient recovered after treatment with local and systemic amphotericin B, systemic 5-fluorocytosine and surgical synovectomy. Quantitation of joint cartilage proteoglycan fragments in synovial fluid indicated extensive breakdown of cartilage during the acute phase of arthritis but, parallel to clinical recovery, these levels returned to normal.