Candida Arthritis: Analysis of 112 Pediatric and Adult Cases

Abstract

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.

Recognition and Clinical Presentation of Invasive Fungal Disease in Neonates and Children

“…The humerus, vertebrae, and ribs are other potential sites of infection. Local symptoms are usually present and include pain, tenderness, overlying erythema and edema, and limitation of movement; a majority of patients are febrile at presentation [ 54 , 55 ]. Infective endocarditis secondary to Candida sp infection can affect children with an underlying hematological malignancy, particularly during periods of immunosuppression, but is seen more commonly in children with preexisting heart disease.…”

Fungal arthritis with adjacent osteomyelitis caused by Candida pelliculosa: a case report

“…With recent advances in medical technology, the incidence of Candida sp. osteoarticular infection has been steadily increasing over the last two decades [8][9][10]. Candida sp.…”

“…Risk factors for Candida sp. osteoarticular infection include abdominal or orthopedic surgery, alcohol abuse, central venous catheters, diabetes mellitus, hemodialysis, hyperalimentation, immunosuppressive therapy, intravenous drug use, malignancy, prolonged use of broad-spectrum antimicrobials, and trauma or open wounds [1,8,10]. In most cases, Candida sp.…”

“…arthritis of native joints, adequate drainage is recommended [15]. However, in one study, only 36% of patients underwent adjunctive surgical intervention including drainage, irrigation, debridement, and amputation, and 62% of patients were treated with medical therapy alone [10]. In most cases with Candida sp.…”

Recurrent arthritis caused by Candida parapsilosis: a case report and literature review

“…Candida arthritis is extremely rare and also represents a major challenge of diagnosis and treatment because the clinical manifestations, laboratory and radiologic findings are not specific and not well defined [1, 2]. Among Candida species, Candida albicans contributes the highest incidence of cases with Candida arthritis [3]. Whereas, the reports of C. parapsilosis arthritis was infrequent and limited to individual case descriptions.…”