Phaeohyphomycosis infection leading to flexor tendon rupture: a case report

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT) is a common closed-space infection of the flexor tendon sheaths of the hand, which remains one of the most challenging problems facing hand surgeons. PFT goes by several names including septic or suppurative flexor tenosynovitis. Adequate treatment requires timely diagnosis and often prompt surgical treatment. However, despite prompt treatment, and regardless of the protocol used, complication rates as high as 38% have been reported in the literature. Moreover, even with successful eradication of the infection, a significant proportion of patients will suffer from continuing pain, swelling, stiffness, loss of composite flexion, weakness, and recurrence potentially requiring amputation. This review will focus on current evidence-based antimicrobial and surgical treatment strategies to maximize treatment outcomes.

Phaeoacremonium Tenosynovitis of the Wrist

A 79-year-old man presented with a painless, soft, subcutaneous mass lesion of the right volar wrist that had been slowly growing for 3 years. A cloudy, yellow serous effusion was aspirated from the punctured mass, from which Phaeoacremonium spp., an extremely rare cause of tenosynovitis, was isolated in culture. Total synovectomy was performed without the use of antifungal agents. No recurrence or complications occurred as of 6 months after surgery. Fungal infection is rare but should be considered in the differentiation of chronic tenosynovitis.

Phaeohyphomycosis infection in the knee

Phaeohyphomycosis is caused by cutaneous fungi and rarely affects large joints. This is a case report on phaeohyphomycosis in the left knee of an elderly individual without immunosuppression. It was accompanied by pain and swelling the anterior knee. The case was first suspected to be suprapatellar bursitis, and was treated with nonsteroidal anti-inflammatory drugs, without remission of symptoms. Surgical treatment was performed, with resection of the suprapatellar bursa and anterior region of the quadriceps tendon. The material was sent for anatomopathological examination and culturing. The pathological examination showed phaeohyphomycosis. The treatment instituted consisted of itraconazole, 200 mg/day for six weeks, and complete remission of symptoms was achieved. The physical examination remained normal after one year of follow-up. This is the first published case of phaeohyphomycosis infection in the suprapatellar region of the knee. Although almost all the cases reported have been associated with immunosuppressed patients, this was an exception. It is important to suspect phaeohyphomycosis in cases of knee infection, in the area of the suprapatellar bursa, when the symptoms do not resolve after clinical treatment.

Management of a Dermocutaneous Black Mold Abscess of the Finger with Flexor Sheath Involvement

CASE

We present the case of a 76-year-old man with a black mold infection of the index finger. This granulomatous abscess uncharacteristically invaded the flexor sheath compartment, threatening proximal spread. Treatment consisted of excision of the abscess and drainage of the flexor sheath. The patient recovered unremarkably, maintaining digital function without recurrent infection.

CONCLUSION

The members of the fungal genus Exophiala are dark-pigmented mycoses commonly termed "black mold." Previously reported atraumatic black mold infections of the hand have been limited to subcutaneous involvement. To our knowledge, this is the first report of the successful treatment of a flexor sheath infection caused by the species E. jeanselmei.

Attritional extensor tendon rupture in a patient with Phialophora verrucosa tenosynovitis: case report

Deep tissue fungal infections of the hand are exceedingly uncommon. We present a case of fungal tenosynovitis caused by Phialophora verrucosa that led to extensor tendon rupture in a patient who was on chronic immunosuppressive therapy. Indolent fungal cysts can elude clinical diagnosis until excision is performed with definitive pathologic examination. In immunocompromised patients, antifungal therapy may be warranted after cyst excision even in the absence of acute infection to prevent subsequent progression to tenosynovitis.

Dual Invasive Infection with Phaeoacremonium parasiticum and Paraconiothyrium cyclothyrioides in a Renal Transplant Recipient: Case Report and Comprehensive Review of the Literature of Phaeoacremonium Phaeohyphomycosis

Despite increasing reports of human infection, data about the optimal care of Phaeoacremonium infections are missing. We report a case of an infection due to Phaeoacremonium parasiticum and Paraconiothyrium cyclothyrioides, initially localized to skin and soft tissue, in a kidney transplant patient. Despite surgical drainage and excision of the lesion and combination antifungal therapy with voriconazole and liposomal amphotericin B, a disseminated infection involving the lungs and brain developed and led to death. We performed a systematic literature review to assess the general features and outcome of human infections due to Phaeoacremonium species. Thirty-six articles were selected, and 42 patients, including ours, were reviewed. Thirty-one patients (74%) were immunocompromised because of organ or bone marrow transplantation (n = 17), diabetes or glucose intolerance (n = 10), rheumatoid arthritis or Still's disease (n = 4), chronic hematological diseases (n = 3), or chronic granulomatous disease (n = 3). Ten patients (24%) reported initial cutaneous trauma. Skin and soft tissue infections represented 57% of infections (n = 24), and disseminated infections, all occurring in immunocompromised patients, represented 14% of infections (n = 6). The main antifungal drugs used were azoles (n = 41) and amphotericin B (n = 16). Surgical excision or drainage was performed in 64% of cases (n = 27). The cure rate was 67% (n = 28). There were 10% cases of treatment failure or partial response (n = 4), 19% relapses (n = 8), and 7% losses to follow-up (n = 3). The death rate was 19% (n = 8). Management of Phaeoacremonium infections is complex because of slow laboratory identification and limited clinical data, and treatment relies on a combination of surgery and systemic antifungal therapy.

Closed flexor tendon ruptures

We review different causes, diagnoses, and treatment options of closed flexor tendon disruptions in the hand. A classification of closed tendon ruptures based on their mechanism includes traumatic tendon avulsion, spontaneous midsubstance rupture, attrition rupture, infiltrative tenosynovial rupture, and iatrogenic. Certain conditions result in tendon disruption inflicted by more than 1 of these etiologies. In rheumatoid arthritis, tendon rupture may result from attrition on an exposed rough surface, proliferative tenosynovial tendon infiltration, or steroid use.