Native Joint Infections by Aspergillus Species

Comparative reinfection rate of one-stage versus two-stage revision in the management of periprosthetic joint infection following total hip arthroplasty: a meta-analysis

BACKGROUND

Debates persist on the optimal surgical approach for treating Periprosthetic joint infection (PJI) following total hip arthroplasty (THA). This meta-analysis aimed to compare the reinfection rate of one-stage revision versus two-stage revision for PJI after THA.

METHODS

A comprehensive search was performed in four databases (PubMed, Embase, Web of Science, and Cochrane Library) to locate articles that assessed the reinfection rate of one-stage revision compared to two-stage revision. Meta-analyses of reinfection rate were performed.

RESULTS

A total of 14 articles including of 1429 patients were chosen for inclusion in this meta-analysis, with 561 patients in the one-stage group and 868 patients in the two-stage group. The meta-analysis of the 14 trials revealed that there was no statistically significant disparity in the reinfection rate between the two groups(OR = 1.34, 95% CI 0.92 ~ 1.93, P = 0.12, I2 = 0). A subgroup analysis was conducted based on the presence of a well-defined algorithm for decision making in either a one-stage or two-stage revision. There was no statistically significant difference in reinfection rate between one-stage and two-stage revision if there was a decision algorithm(OR = 0.83, 95% CI 0.44 ~ 1.54, P = 0.55, I2 = 0). If not, the reinfection rate of one-stage revision was significantly higher than that of two-stage revision(OR = 1.79, 95% CI 1.11 ~ 2.88, P = 0.02, I2 = 0). Postoperative hip function score was significantly better in the one-stage revision group than that of the two-stage revision group(SMD = 0.54, 95% CI 0.31 ~ 0.78, P<0.05, I2 = 79%).

CONCLUSIONS

A strategy that is clearly defined and can be used for decision making in one-stage or two-stage revision is necessary for the treatment of PJI after THA. When there is significant damage to the soft tissue and/or the presence of strong microorganisms, a two-stage revision is recommended in order to decrease the reinfection rate. One-stage revision is recommended for patients with low-toxic infections and intact soft tissue.

TRIAL REGISTRATION

PROSPERO (CRD42023450842, 17 August 2023) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023450842 .

Fungal Shoulder Periprosthetic Infections: A Systematic Review

Background: Data regarding fungal PJIs of the shoulder are scarce. The present systematic review aims to identify and evaluate all published shoulder fungal PJIs in an effort to better understand the diagnostic and therapeutic approach to these infections. Methods: A systematic review according to the PRISMA guidelines was conducted, locating all shoulder fungal PJIs. The initial search located 1435 articles. Data were collected on demographics, the causative fungus, antifungal treatment (AFT), surgical interventions, and infection outcomes. Results: After screening and implementation of the inclusion criteria, a total of 10 articles, including 10 cases, were eligible. The sample's mean age was 62.44 years. Diabetes mellitus was the most common comorbidity (30%), while 70% were immunocompromised. Candida spp. was the most common causative fungus (nine cases; 90%), while all cases were confirmed with cultures. In three cases (30%), there was bacterial co-infection. The mean duration of antifungal treatment (AFT) was 8.4 weeks, while the preferred agent was fluconazole (60% of cases), followed by amphotericin B (30%). Most cases (50%) underwent resection arthroplasty as part of the treatment, while two-stage revision arthroplasty was performed in 30%. Infection's eradication was reported in 90% of the studied cases. Conclusions: The diagnosis and management of fungal periprosthetic shoulder infections are particularly challenging and require a multidisciplinary approach. The combination of antifungal therapy and tailored surgical strategies is crucial, but further research is needed to refine treatment protocols and address the unique considerations in shoulder PJIs.

Aspergillus niger as a rare cause of postarthroscopy knee septic arthritis in a healthy patient

This case report outlines the diagnostic and therapeutic challenges encountered in a man in his 70s suffering from knee septic arthritis caused by Aspergillus niger It is the second published case in the literature with osteoarticular infection from A. niger and the first one in the last 40 years. Following knee arthroscopy, the patient experienced persistent pain, swelling and discomfort, prompting further investigation. Postoperative knee cultures were negative for infection, but symptoms were not ameliorated. Therefore, an arthroscopic debridement was performed that revealed severe joint inflammation and degeneration. Cultures from the synovial fluid and tissue samples identified infection from A. niger sp. Antimicrobial treatment with voriconazole finally led to significant clinical improvement and eradication of infection. This case highlights the intricacies involved in diagnosing and managing fungal osteoarticular infections in healthy patients without concomitant medical diseases or comorbidities.

Spinal Infections Caused by Coccidioides Species

Introduction: Spinal Coccidioidomycosis, although rare, represents the most frequent osseous presentation of Coccidioides spp infection. The present review aims to describe the anatomical distribution, the epidemiological characteristics, and the diagnostic and therapeutic approach of this severe infection. Methods:A meticulous review of all published spinal Coccidioidomycosis cases was carried out. The studied population's demographics and the anatomical distribution of the infection were recorded. Furthermore, the medical and operative management as well as the disease outcome were studied. Results:Seventy-six cases (of which 78.9% males) with a mean age of 35.5 years were located. Regarding the anatomical distribution of the infection, the thoracic area was the most commonly affected spine region (26.3%). Among the studied patients, 14 (18.4%) were immunocompromised. Pain was the most commonly reported symptom (21.1%). Regarding the diagnostic approach of this infection, plain x-ray or CT scan indicated the disease in the majority of cases (44.7%). Pathology (48.7%), serology (42.1%) and microbiological examinations (35.5%) further established the firm diagnosis, with Coccidioides immitis being the most frequently isolated fungus. Medical management included mainly amphotericin B (in 57.9% of cases), followed by fluconazole (in 38.2% of cases). The disease required surgical intervention in the majority of cases (76.3%), while the infection had a successful outcome in 80.3% of cases. Conclusion:Spinal Coccidioidomycosis seems to require prolonged medical treatment, including proper antifungal therapy and, in most cases, operative management. Multidisciplinary approach, including infectious disease specialists, orthopaedic and/or spine surgeons, microbiologists and radiologists seems to be of utmost important for yielding favorable outcomes.

Fungal arthritis: A challenging clinical entity

There has been an increasing incidence of fungal infections in recent years. Rarely joints are also affected by fungal infections. Mainly, these infections develop in prosthetic joints, but sometimes native joints are also involved. Candida infections are mostly reported, but patients may also develop infections secondary to non-Candida fungi, especially Aspergillus. Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy. Despite this, these infections are associated with high morbidity and mortality. This review described the clinical features, risk factors, and therapeutic interventions required to manage fungal arthritis.

Knee Septic Arthritis Caused by Pantoea agglomerans

INTRODUCTION

Septic arthritis usually affects native joints and represents an invasion of the joint space by a wide variety of microorganisms, most commonly bacteria, such as Staphylococci, Streptococci, and Gram-negative rods. An extremely rare case of septic knee arthritis caused by Pantoea agglomerans in a 67-year-old male is presented.

CASE REPORT

The patient was initially treated with arthroscopic debridement, but due to persistent symptomatology open surgical debridement 3 days after initial surgery was also performed. Cultures yielded P. agglomerans and Streptococcus agalactiae. He was commenced on causative antimicrobial treatment including intravenous linezolid, ciprofloxacin, and clindamycin. He was discharged 10 days later, on oral linezolid and ciprofloxacin for 3 months.

CONCLUSION

Delayed diagnosis in septic arthritis cases and inadequate control of the infection may lead to insufficient treatment and devastating consequences for the patient. The treatment includes surgical debridement and proper antimicrobial agents. Cultures dictate the proper treatment; hence, microbiological examination is of utmost importance, since it may reveal unusual organisms for which empirical treatment may prove insufficient.

Prosthetic Knee Joint Infection Due to Candida lusitaniae: A Diagnostic and Therapeutic Odyssey: A Case Study

Prosthetic joint infections (PJIs) caused by fungi, although relatively rare, represent a major surgery-related complication. An extremely rare fungal PJI, following revised total knee replacement (TKR) caused by Candida lusitaniae, is reported, and a meticulous review of similar cases is provided. A 74-year-old female, who underwent primary total knee arthroplasty 10 years ago and a revision surgery three weeks ago, presented with signs and symptoms of PJI. C. lusitaniae was eventually isolated from the periprosthetic tissue using the MALDI-TOF VitekMS-bioMérieux technique. Multiple strategies for managing this fungal PJI were performed, and finally, the patient was treated successfully with an intramedullary arthrodesis system and proper antifungal treatment, including fluconazole. A multidisciplinary approach is essential for the diagnosis and treatment of such severe infections. In persistent cases and in cases where revision surgery is extremely difficult to perform, arthrodesis seems to be an effective solution for the elimination of the infection. The efficacy of the therapeutic management of fungal PJIs remains unclear. Therefore, more research should be reported, focusing on proper treatment so that the optimal strategy in treating these severe infections may be established.

Necrotizing Skin and Soft Tissue Infection Due to Syncephalastrum Species and Fusarium solani Species Complex Following Open Tibia Fracture

Fungal necrotizing skin and soft tissue infection (NSSTI) represents a rare clinical entity. An extremely rare case of NSSTI, following an open tibia fracture in a 36-year-old male caused by both Syncephalastrum spp. and Fusarium solani species complex (SC) is presented. The infection was diagnosed through direct microscopy, cultures and histology. The disease had a long course. The patient underwent a total of seven consecutive surgical debridements, while proper and timely antifungal treatment was initiated and included liposomal amphotericin B and voriconazole. He gradually recovered and 4 years later he is completely functioning and healthy. Invasive fungal infections are well-documented causes of high morbidity and mortality in immunocompromised individuals, whereas in immunocompetent hosts, trauma-related fungal infections have also been reported. It is of note that Syncephalastrum spp. has very rarely been identified to cause infection in immunocompromised or immunocompetent hosts, whereas Fusarium spp. has rarely been involved in skin necrotic lesions in non-immunocompromised individuals. A high suspicion index, especially in necrotic lesions in trauma patients, is pivotal for early diagnosis, which may lead to lower mortality as well as lower amputation rates. Definite diagnosis through microscopy, histology and/or cultures are of paramount importance, whereas PCR testing may also be extremely useful.

Skeletal Infections Caused by Coccidioides Species

Background: Coccidioidomycosis represents an endemic and challenging disease, with rare extrapulmonary manifestations. The present review of all published cases of core and extremities osseous coccidioidomycosis aims to describe epidemiology, patients’ characteristics, symptoms as well as medical and surgical treatment options and their effectiveness. Methods: A thorough review of all published skeletal core and extremity infections due to Coccidioides species was conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical management as well as the infection outcome was recorded. Results: A total of 92 cases of Coccidioides spp. skeletal infections were recorded in 87 patients. The patients’ mean age was 35.3 years. The most common site of infection was the spine (82.6%), followed by the foot (6.5%), while the predominant symptom upon presentation was pain (29.9%). Immunosuppressive conditions and/or medications were observed in 21 patients (24.1%). Regarding imaging methods, indicating diagnosis, plain X-rays or CT scans were performed in most patients (50.6%), followed by magnetic resonance imaging (MRI) (47.1%). Most cases were diagnosed through histopathology (62; 71.3%), followed by serology testing (36; 42.4%) and by cultures (35; 40.2%). In 32 cases (36.8%), Coccidioides immitis was cultured, while in the remaining 55 cases (63.2%) the fungus was not further characterized. Regarding AFT, amphotericin B was the preferred agent (52.9%), followed by fluconazole (43.3%). In most cases (78.2%) surgical treatment was also performed. Treatment was successful in 80.5% of cases. Conclusions: Skeletal core and extremity infections due to Coccidioides spp. represent a severe disease. With the available data, the combination of prolonged proper AFT with surgical intervention seems to be the optimal current therapeutic approach.