Fungal osteomyelitis and soft tissue infections: Simple solutions to uncommon scenarios

Abstract

Introduction: Fungal osteoarticular/soft tissue infections (FOaSI) are an uncommon entity with protracted course due to variability in clinical picture, slow progression; resulting in misdiagnosis with empirical therapy. Recent studies have shown an alarming emergence of FOaSI in immunocompetent individuals with high mortality rates. This study recommends a protocol for managing these complex and confusing scenarios.
 Methodology: We have retrospectively analysed patients with FOaSI between January 2014 and December 2016, with a minimum 12 months follow up.
 Results: 8 cases (6 male, 2 female) with a mean age of 42.88 years (26-53) presented to us 45 days (3-365) after initial symptoms. They underwent mean 3 procedures before being diagnosed with a fungal infection. Deep tissue cultures grew 9 fungi and 6 bacteria, commonest fungus being Candida sp (n = 4), treated with appropriate antifungals and antibiotics. Infection remission was achieved in 7/8 (87.5%) cases at 27.1 months (19-45) follow-up with 1 mortality. Excellent functional results as per our criteria were seen in 5 cases (62.5%) with 1 talus excision, 1 ray amputation and 1 mortality.
 Conclusions: This study highlights the significance of implementing a simple rule such as obtaining fungal cultures in every case of bone and soft tissue infections. Standardisation of treatment may not be the ideal solution, since different fungi have different growth patterns and invasiveness. A simple protocol of customising the medico- surgical treatment with an open ended discussion between the surgeons, microbiologists, pathologists and infectious disease specialists forms the cornerstone to success.

Fungal Osteomyelitis due to Phaeoacremonium venezuelense

“…The use of antifungal impregnated depot materials, removal of hardware, and irrigation may be indicated. The literature has shown that despite intense debridement, recurrence may occur 19 .…”

“…F ungal infections of the musculoskeletal system are rare, but when present, they typically follow a chronic, low grade, persistent course 18,19 . A high level of suspicion and identification of the causal agent is a very important factor.…”

“…The overall approach to musculoskeletal fungal infections includes aggressive surgical debridement with a prolonged course of antifungal therapy [18][19][20] . The use of antifungal impregnated depot materials, removal of hardware, and irrigation may be indicated.…”

“…When in humans, Phaeoacremonium species cause cutaneous and subcutaneous lesions 4,[10][11][12] . Phaeoacremonium species are identified on malt extract agar, and colonies are then studied for color, texture, branched hyphae, conidiophores, phialides, and conidia 19 . Phaeoacremonium venezuelense is distinct from others because it has orange-brown colonies, longer and branched conidiophores, and prominent warts on hyphae 13,14 .…”

“…Phaeoacremonium venezuelense has been previously isolated from Vitis vinifera (common grapevine) and Prunus armeniaca (apricot tree) and has only been reported infecting humans in 5 cases to date 4,13,[15][16][17] . The 5 cases of Phaeoacremonium venezuelense include isolation from a mycetoma in Venezuela, from ankle soft-tissue specimens in Canada and the United States, from a subcutaneous infection in Brazil, and from the cervical spine in a patient with spondylitis 7,11,19 .…”