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Ditsios K, Katsimentzas T, Pitsilos C, Koukourikos I, Christidis P, Ditsios T, Konstantinou P, Varitimidis S. Deep Fungal Infections of the Upper Extremity - A Review. Orthop Rev (Pavia) 2024; 16:94570. [PMID: 38469579 PMCID: PMC10927313 DOI: 10.52965/001c.94570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024] Open
Abstract
Deep fungal infections are rare in the upper extremity. Vessel and nerve infection, synovitis, tenosynovitis, myofasciitis, arthritis and osteomyelitis have been discovered in literature. Treatment in most cases includes surgical procedure and antifungal agent use. Amputation is the final, most devastating for patient's functionality, solution. Intravenous antifungal drugs, frequently followed by oral administration, are important ancillary agents both for the initial treatment and the prevention of recurrence. We therefore performed a review of the current literature, in order to assemble the dispersed results of different studies and clarify the various aspects of upper extremity fungal infections.
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Affiliation(s)
- Konstantinos Ditsios
- 2nd Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Triantafyllos Katsimentzas
- 2nd Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Charalampos Pitsilos
- 2nd Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Ilias Koukourikos
- 2nd Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | | | | | - Panagiotis Konstantinou
- 2nd Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Sokrates Varitimidis
- Academic Department of Orthopaedic Surgery School of Medicine, Faculty of Health Sciences, University of Thessaly, Larisa, Greece
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Gamaletsou MN, Rammaert B, Brause B, Bueno MA, Dadwal SS, Henry MW, Katragkou A, Kontoyiannis DP, McCarthy MW, Miller AO, Moriyama B, Pana ZD, Petraitiene R, Petraitis V, Roilides E, Sarkis JP, Simitsopoulou M, Sipsas NV, Taj-Aldeen SJ, Zeller V, Lortholary O, Walsh TJ. Osteoarticular Mycoses. Clin Microbiol Rev 2022; 35:e0008619. [PMID: 36448782 PMCID: PMC9769674 DOI: 10.1128/cmr.00086-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Maria N. Gamaletsou
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Blandine Rammaert
- Université de Poitiers, Faculté de médecine, CHU de Poitiers, INSERM U1070, Poitiers, France
| | - Barry Brause
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Marimelle A. Bueno
- Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Manilla, Philippines
| | | | - Michael W. Henry
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aspasia Katragkou
- Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Ohio State University School of Medicine, Columbus, Ohio, USA
| | | | - Matthew W. McCarthy
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
| | - Andy O. Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Zoi Dorothea Pana
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Ruta Petraitiene
- Weill Cornell Medicine of Cornell University, New York, New York, USA
| | | | - Emmanuel Roilides
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Maria Simitsopoulou
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos V. Sipsas
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Valérie Zeller
- Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Olivier Lortholary
- Université de Paris, Faculté de Médecine, APHP, Hôpital Necker-Enfants Malades, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR 2000, Paris, France
| | - Thomas J. Walsh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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3
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Tsantes AG, Papadopoulos DV, Markou E, Zarokostas K, Sokou R, Trikoupis I, Mavrogenis AF, Houhoula D, Piovani D, Bonovas S, Tsantes AE, Tsakris A, Vrioni G. Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases. Med Mycol 2022; 60:myac052. [PMID: 35867975 PMCID: PMC9849853 DOI: 10.1093/mmy/myac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/22/2023] Open
Abstract
Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment. LAY SUMMARY Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.
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Affiliation(s)
- Andreas G Tsantes
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
- Department of Microbiology, ‘Saint Savvas’ Oncology Hospital, 11522 Athens, Greece
| | | | - Eleftheria Markou
- Department of Microbiology, University Hospital of Ioannina, Ioannina 45500, Greece
| | | | - Rozeta Sokou
- Neonatal Intensive Care Unit, “Agios Panteleimon” General Hospital of Nikea, Piraeus 18454, Greece
| | - Ioannis Trikoupis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens 15772, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens 15772, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 15772, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve MI, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano 20089 MI, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve MI, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano 20089 MI, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 15772, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
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Koutserimpas C, Chamakioti I, Naoum S, Raptis K, Alpantaki K, Samonis G. Native Joint Infections by Aspergillus Species. Diagnostics (Basel) 2021; 11:diagnostics11122335. [PMID: 34943572 PMCID: PMC8700121 DOI: 10.3390/diagnostics11122335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Septic arthritis due to Aspergillus spp. represents a rare, but severe disease. Nevertheless, clear guidelines regarding most effective medical treatment have not yet been established. The present study is a literature review of all reported cases of fungal septic arthritis due to Aspergillus spp, in order to clarify epidemiology, as well as the medical and operative management and their outcome. Methods: A meticulous review of all published septic arthritis infections due to Aspergillus has been conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical intervention, as well as the infection’s outcome were recorded and evaluated. Results: A total of 30 Aspergillus spp. strains from 29 hosts have been studied. The patients’ mean age was 45.8 years. The most commonly affected joint was the knee (45.7%), while the predominant symptom was joint pain (62%). Most patients were immunocompromised (72.4%). Diagnosis was established through cultures and/or histopathology. Aspergillus fumigatus was the most common responsible fungi (63.3%), followed by A. flavus (16.6%) and A. terreus (10%). Regarding AFT, the preferred agent proved to be Amphotericin B (14 cases; 48.3%), followed by voriconazole (11; 37.9%), while the mean AFT duration was 5.6 months. In most cases surgical treatment was also performed (in 4 cases no surgery was reported). Treatment was effective in 20 cases (69%). Conclusions: Septic arthritis caused by Aspergillus spp. represents a severe clinical entity. It seems that, with the available data, prolonged AFT along with surgical intervention is the preferred management of this infection, while identification of the responsible fungus is of utmost importance.
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Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (S.N.); (K.R.)
| | - Ifigeneia Chamakioti
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (S.N.); (K.R.)
| | - Symeon Naoum
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (S.N.); (K.R.)
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece; (C.K.); (I.C.); (S.N.); (K.R.)
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, “Venizeleion” General Hospital of Heraklion, 71409 Heraklion, Greece;
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, Voutes, 71500 Heraklion, Greece
- Correspondence: ; Tel.: +30-6948712130
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Gamaletsou MN, Rammaert B, Bueno MA, Sipsas NV, Moriyama B, Kontoyiannis DP, Roilides E, Zeller V, Taj-Aldeen SJ, Henry M, Petraitis V, Denning DW, Lortholary O, Walsh TJ. Aspergillus arthritis: analysis of clinical manifestations, diagnosis, and treatment of 31 reported cases. Med Mycol 2017; 55:246-254. [PMID: 27609563 PMCID: PMC6251616 DOI: 10.1093/mmy/myw077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/15/2016] [Accepted: 04/24/2016] [Indexed: 11/14/2022] Open
Abstract
Aspergillus arthritis is a debilitating form of invasive aspergillosis. Little is known about its epidemiology, clinical manifestations, laboratory features, treatment, and prognosis. Cases of Aspergillus arthritis were reviewed in the English literature from 1967 through 2015 for variables of arthritis with Aspergillus spp. recovered from joint and/or adjacent bone, underlying conditions, symptoms, signs, inflammatory biomarkers, diagnostic imaging, management, and outcome. Among 31 evaluable cases, 87% were males and 13% pediatric. Median age was 50 y (range 1-83 y). Seventeen (55%) patients were immunosuppressed with such conditions as hematological malignancies (26%), corticosteroids (39%), and/or transplantation (26%). Approximately one-half (52%) of patients had hematogenous seeding of the joint, and more than 80% had de novo infection with no prior antifungal therapy. Oligoarticular infection (2-3 joints) occurred in 45% and contiguous osteomyelitis was present in 61%. Clinical manifestations included pain (87%), edema (26%), and limited function (23%), with knees (35%), intervertebral discs (26%), and hips (16%) being most commonly infected. Aspergillus fumigatus constituted 77% of cases followed by Aspergillus flavus in 13%, Aspergillus niger in 3%, and not specified in 7%. Median ESR was 90 mm/hr and median CRP was 3.6 mg/dl. Median synovial fluid WBC was 17,200/μL (7,300-128,000) with 72% PMNs (range 61-92). Osteolysis occurred in 35%, and soft-tissue extension 47%. Nineteen patients (61%) were managed with combined medical and surgical therapy, 10 (32%) with medical therapy only, and 2 (6%) surgery only. Amphotericin B and itraconazole were the most frequently used agents with median duration of therapy of 219 days (range 30-545). Surgical interventions included debridement in 61%, drainage 19%, and amputation 6%. Complete or partial response was achieved in 71% and relapse occurred in 16%. Medical therapy was reinstituted with successful outcome in these patients. Overall survival was 65%. Aspergillus arthritis mainly develops as a de novo infection involving knees and intervertebral disks in immunocompromised patients with localizing symptoms. Contiguous osteomyelitis is frequently observed. Diagnosis is established by synovial fluid culture. Aspergillus arthritis is therapeutically challenging with most patients undergoing surgery and protracted antifungal therapy.
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Affiliation(s)
- Maria N. Gamaletsou
- Weill Cornell Medicine of Cornell University, New York, NY, USA
- Pathophysiology Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
- National Aspergillosis Centre, University of South Manchester, Manchester, UK
| | - Blandine Rammaert
- Université Paris-Descartes, Sorbonne Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d’Infectiologie Necker-Pasteur, Institut Imagine, Paris
- Unité de Mycologie Moléculaire, Institut Pasteur, Paris, France
| | | | - Nikolaos V. Sipsas
- Pathophysiology Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
| | - Brad Moriyama
- Department of Pharmacy, NIH Clinical Center, Bethesda, MD, USA
| | | | - Emmanuel Roilides
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | - Valerie Zeller
- Osteoarticular Reference Center, Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Saad J. Taj-Aldeen
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar
| | - Michael Henry
- Weill Cornell Medicine of Cornell University, New York, NY, USA
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
- Hospital for Special Surgery, New York, NY, USA
| | - Vidmantas Petraitis
- Weill Cornell Medicine of Cornell University, New York, NY, USA
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
| | - David W. Denning
- The National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and the Manchester Academic Health Science Centre, Manchester, UK
| | - Olivier Lortholary
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
- Institut Pasteur, Unité de mycologie moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France
- Université Paris Descartes, APHP, Hopital Necker Enfants Malades, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Paris, France
| | - Thomas J. Walsh
- Weill Cornell Medicine of Cornell University, New York, NY, USA
- Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA
- Hospital for Special Surgery, New York, NY, USA
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Reischies F, Hoenigl M. The role of surgical debridement in different clinical manifestations of invasive aspergillosis. Mycoses 2014; 57 Suppl 2:1-14. [PMID: 25186615 DOI: 10.1111/myc.12224] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 11/30/2022]
Abstract
Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.
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Affiliation(s)
- Frederike Reischies
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
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Durox H, Boumediene A, Genet C, Lo Ré P, Rogez JP, Weinbreck P, Denes E. Aspergillose disséminée à point de départ articulaire après infiltrations. Med Mal Infect 2007; 37:609-12. [PMID: 17336017 DOI: 10.1016/j.medmal.2006.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 12/26/2006] [Indexed: 10/23/2022]
Abstract
Bone and joint infections due to Aspergillus are rare and occur more commonly in immunosuppressed patients. We report the case of an 84-year-old woman who developed septic arthritis caused by Aspergillus fumigatus after corticosteroid infiltration. This patient had presented with arthritis of the left knee for several months but no microorganism had been found despite numerous arthrocenteses. This arthritis was resistant to treatment by numerous corticosteroid infiltrations. During an arthroscopy, analysis of the synovial fluid yielded A. fumigatus. Thereafter, other explorations showed disseminated aspergillosis with osteo-articular destruction, blood and urinary dissemination. A systemic treatment by voriconazole associated to intra-articular injections and surgical debridement was initiated but the patient died. Septic arthritis caused by A. fumigatus is very rare but must be considered as a differential diagnosis of septic arthritis after corticosteroid infiltration. Their complications can be very important and destructive.
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Affiliation(s)
- H Durox
- Service des maladies infectieuses et tropicales, CHU Dupuytren, Limoges, France.
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