Candida krusei Arthritis in a Patient with Hematologic Malignancy: Successful Treatment with Voriconazole

Candida parapsilosis-Caused Arthritis with Rice Body Formation: A Case Presentation and Literature Review

A 68-year-old male patient came to the orthopedics department because of swelling and pain in his left shoulder joint. He received more than 15 intraarticular steroid injections in the shoulder joint at a local private hospital. MRI showed that the synovial membrane of the joint capsule was thickened and swollen, and there were extensive "rice body-like" low T2 signal shadows filling. Arthroscopic removal of rice bodies and subtotal bursectomy were performed. The observation channel was placed through the posterior approach, and a large amount of rice bodies in yellow bursa fluid were observed to flow out. Rice bodies with a diameter of approximately 1-5 mm filled the joint cavity were seen in the observation channel. The histopathological examination of the rice body showed that it was mainly composed of fibrin without a clear tissue structure. Bacterial and fungal cultures of synovial fluid suggested Candida parapsilosis infection, so the patient received antifungal treatment. However, the shoulder swelled again after three weeks, MRI revealed that there was significant fluid accumulation in the subacromial-subdeltoid region with necrotic synovial tissue floating and ultrasound examination showed joint cavity effusion, synovial hyperplasia, and some synovium looked like "floating weeds". After 2 weeks, there were recurrent rice bodies in the articular cavity. Arthroscopic surgery was performed again to clean the joint and a catheter was placed for irrigation and drainage, and a large amount of necrotic synovial tissue floating as seen in ultrasound. Finally, patient received sensitive antifungal treatment and did not relapse within 6 months. During the recurrence in the current case, we recorded the process of rice body formation, which has for the first time been reported.

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.

Diagnosis and treatment for primary Candida parapsilosis infection of the native knee joint: A case report

Introduction and importance

Candida arthritis is a very rare disease and Candida parapsilosis infection of the native knee joint is extremely rare. It is challenging to diagnose and treat because the clinical manifestations, laboratory and radiologic findings are not specific and not well defined. We report the rare case of C. parapsilosis infection of the native knee joint.

Case presentation

A 67-year-old man visit outpatient clinic for persistent right knee pain and effusion. Inflammatory markers were elevated and the biochemical studies of joint fluid showed elevated WBC counts. Under assumption of septic arthritis, arthroscopic irrigation and debridement were performed. C. parapsilosis was isolated on intraoperative knee joint culture. Fluconazole was used under diagnosis of Candida arthritis. Once there were no relapse of infection, total knee arthroplasty was implemented.

Clinical discussion

As Candida arthritis can be lead to poor prognosis, Candida arthritis should be considered in patients with untreated knee infections. Blood and radiographic examination, and fungus culture from the knee joint should be accompanied for early diagnosis. Total knee arthroplasty may be considered after treatment of Candida infection with fluconazole. Prognosis was similar compared with patients who underwent total knee arthroplasty for primary knee osteoarthritis.

Conclusion

If patients complaint persistent knee pain with or without effusion, surgeons should consider the possibility of Candida infection. After diagnosis of Candida arthritis, proper antifungal agents should be used for treatment of infection. After the infection has cleared up, total knee arthroplasty can be planned.

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Candida infection of the native knee joint is rare but should not be excluded in the presence of knee pain and effusion.

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Early diagnosis and adequate treatment of Candida arthritis is important.

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Treatment should be started with fluconazole to address Candida parapsilosis infection.

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If there is no relapse of infection, total knee arthroplasty can be implemented as a treatment for secondary knee osteoarthritis.

Voriconazole efficacy against Candida glabrata and Candida krusei: preclinical data using a validated in vitro pharmacokinetic/pharmacodynamic model

BACKGROUND

Voriconazole exhibits in vitro activity against Candida glabrata and Candida krusei (EUCAST/CLSI epidemiological cut-off values 1/0.25 and 1/0.5 mg/L, respectively). Yet, EUCAST found insufficient evidence to set breakpoints for these species. We explored voriconazole pharmacodynamics (PD) in an in vitro dynamic model simulating human pharmacokinetics (PK).

METHODS

Four C. glabrata and three C. krusei isolates (voriconazole EUCAST and CLSI MICs of 0.03-2 mg/L) were tested in the PK/PD model simulating voriconazole exposures (t½ ∼6 h q12h dosing for 3 days). PK/PD breakpoints were determined calculating the PTA for exposure indices fAUC0-24/MIC associated with half-maximal activity (EI50) using Monte Carlo simulation analysis.

RESULTS

Fungal load increased from 3.60±0.35 to 8.41±0.24 log10 cfu/mL in the drug-free control, with a maximum effect of ∼1 log10 kill of C. glabrata and C. krusei isolates with MICs of 0.06 and 0.25 mg/L, respectively, at high drug exposures. The 72 h log10 cfu/mL change versus fAUC0-24/MIC relationship followed a sigmoid curve for C. glabrata (R2=0.85-0.87) and C. krusei (R2=0.56-0.76) with EI50 of 49 (32-76) and 52 (33-78) fAUC/MIC for EUCAST and 55 (31-96) and 80 (42-152) fAUC/MIC for CLSI, respectively. The PTAs for C. glabrata and C. krusei isolates with EUCAST/CLSI MICs ≤0.125/≤0.06 mg/L were >95%. Isolates with EUCAST/CLSI MICs of 0.25-1/0.125-0.5 would require trough levels 1-4 mg/L; isolates with higher MICs would not attain the corresponding PK/PD targets without reaching toxicity.

CONCLUSIONS

The in vitro PK/PD breakpoints for C. glabrata and C. krusei for EUCAST (0.125 mg/L) and CLSI (0.06 mg/L) bisected the WT populations. Trough levels of >4 mg/L, which are not clinically feasible, are necessary for efficacy against WT isolates.

Persistent candida arthritis successfully treated with micafungin instillation and surgery. A case report

We report a rare case of C. krusei knee arthritis treated with instillation of micafungin and arthroscopy. A 49-year-old man hospitalized for treatment of Acute Myeloid Leukemia developed knee arthritis with C. krusei. He was treated with a combination of arthroscopic debridement, intravenous as well as intra-articular micafungin. Serum and intra-articular concentrations of micafungin were determined. After instillation of micafungin in the knee and arthroscopic debridement, the patient completely recovered.

Candida glabrata-Induced Refractory Infectious Arthritis: A Case Report and Literature Review

The incidence of deep fungal infection due to non-albicans Candida species (especially Candida glabrata) has significantly increased in recent decades. Candida glabrata is an opportunistic pathogen of low virulence which mainly invades the gastrointestinal, genitourinary, and respiratory tracts, but has rarely been reported as complication of articular surgery in the literature. We present a case of knee fungal arthritis caused by C. glabrata after a minimally invasive arthroscopic surgery. In this case, the patient's knee got infected after arthroscopic treatment for a recurrent popliteal cyst, and she was unable to be cured by either debridement or antifungal drugs. Mycological and molecular identification of the necrotic tissues isolate revealed C. glabrata as etiologic agent. We originally planned to conduct a debridement once again, but it was found that the articular cartilage was extensively damaged during the operation. Besides, the magnetic resonance imaging of the affected knee also showed that the infection had invaded the subchondral bone. So we treated this case with a two-stage primary total knee arthroplasty with an antibiotic-laden cement spacer block. After a 10-month follow-up, the patient had completely recovered and has not experienced any recurrence to date. In addition, we review 21 cases of C. glabrata-induced infectious arthritis described to date in the literature.

[Strategies for antifungal treatment failure in intensive care units]

Recent epidemiologic studies reveal both an increasing incidence and an escalation in resistance of invasive fungal infections in intensive care units. Primary therapy fails in 70 % of cases, depending on the underlying pathogens and diseases. The purpose of this review is to raise awareness for the topic of antifungal therapy failure, describe the clinical conditions in which it occurs, and suggest a possible algorithm for handling the situation of suspected primary therapy failure.

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.

Consensus guidelines for the treatment of yeast infections in the haematology, oncology and intensive care setting, 2014

Pathogenic yeast forms are commonly associated with invasive fungal disease in the immunocompromised host, including patients with haematological malignancies and patients of haemopoietic stem cell transplants. Yeasts include the Candida spp., Cryptococcus spp., Pneumocystis jirovecii and some lesser-known pathogens. Candida species remain the most common cause of invasive yeast infections (and the most common human pathogenic fungi). These guidelines present evidence-based recommendations for the antifungal management of established, invasive yeast infections in adult and paediatric patients in the haematology/oncology setting. Consideration is also given to the critically ill patient in intensive care units, including the neonatal intensive care unit. Evidence for 'pre-emptive' or 'diagnostic-driven antifungal therapy' is also discussed. For the purposes of this paper, invasive yeast diseases are categorised under the headings of invasive candidiasis, cryptococcosis and uncommon yeast infections. Specific recommendations for the management of Pneumocystis jirovecii are presented in an accompanying article (see consensus guidelines by Cooley et al. appearing elsewhere in this supplement).

Candida krusei arthritis in an adolescent with acute myelogenous leukemia

We report a case of Candida krusei arthritis in an adolescent with secondary acute myelogenous leukemia, who underwent an allogeneic bone marrow transplant complicated by C. krusei fungemia 4 months before her presentation. The infection was successfully treated with voriconazole.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy

Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.

Lessons from animal studies for the treatment of invasive human infections due to uncommon fungi

Clinical experience in the management of opportunistic infections, especially those caused by less common fungi, is, due to their rarity, very scarce; therefore, the most effective treatments remain unknown. The ever-increasing numbers of fungal infections due to opportunistic fungi have repeatedly proven the limitations of the antifungal armamentarium. Moreover, some of these fungi, such as Fusarium spp. or Scedosporium spp., are innately resistant to almost all the available antifungal drugs, which makes the development of new and effective therapies a high priority. Since it is difficult to conduct randomized clinical trials in these uncommon mycoses, the use of animal models is a good alternative for evaluating new therapies. This is an extensive review of the numerous studies that have used animal models for this purpose against a significant number of less common fungi. A table describing the different studies performed on the efficacy of the different drugs tested is included for each fungal species. In addition, there is a summary table showing the conclusions that can be derived from the analysis of the studies and listing the drugs that showed the best results. Considering the wide variability in the response to the antifungals that the different strains of a given species can show, the table highlights the drugs that showed positive results using at least two parameters for evaluating efficacy against at least two different strains without showing any negative results. These data can be very useful for guiding the treatment of rare infections when there is very little experience or when controversial results exist, or when treatment fails.

Candida Arthritis after Arthroscopic Arthroplasty in a Patient without Predisposing Factors

Because candidiasis is usually associated with immunosuppression, candida arthritis in an immunocompetent patient is rare. The symptoms of candidiasis are similar to bacterial infections, tuberculosis, and autoimmune diseases. In our patient with no predisposing factors, candida arthritis was initially excluded because the probability of occurrence was low. The patient had no leukocytosis, the acid-fast bacteria (AFB) stain was negative, and the autoimmune antibody screen was negative. After Candida parapsilosis was cultured in the synovial fluid, the patient was treated with amphotericin B (0.7 mg/kg/day) and oral fluconazole (400 mg/day). The treatment was successful and there were no side effects of the medications.