Fungal Osteomyelitis in the Context of Immunosuppression

Abstract

BACKGROUNDFungal osteomyelitis is a rare pathology with the most commonly reported etiologic agents being the Candida spp. and Aspergillus genera. Its incidence is higher in immunocompromised patients, using permanent central venous catheters, and using broad-spectrum antibiotics or injecting drug users. Sometimes, diagnosis is delayed for weeks to months because of the difficulty of isolation and slow growth of the pathogen on culture media. The following is a report of a fatal development of the condition. CASE REPORTA 49-year-old female patient, being followed-up in rheumatology for overlapping diseases: limited cutaneous systemic sclerosis, rheumatoid arthritis and Sjögren's syndrome, under use of prednisone 5 mg/day and monthly tocilizumab due to joint and lung conditions. The patient evolved with a report of a periungual lesion in the third left finger. Magnetic resonance imaging of the hand was performed, which showed acrosteolysis of the third finger, followed by skin irregularity, subcutaneous edema and intense osteitis of the remaining distal phalanx and subchondral/medial diaphysis of the intermediate phalanx-images compatible with a possible infectious process on the bone and distal interphalangeal joint. Endovenous antimicrobial treatment was initiated and disarticulation was proposed. The patient refused, and only surgical cleaning and collection of material for cultures were performed. Despite multiple antimicrobial regimens, the patient gradually worsened and died due to disseminated intravascular coagulation. One day after her death, there was growth of Candida albicans in culture, as well as pathogen growth in pathology. CONCLUSIONThe rheumatologist should be aware of the possibility of fungal osteomyelitis, especially in immunosuppressed patients and in the absence of response to conventional antimicrobial therapy.