Fungal periprosthetic joint infection following total elbow arthroplasty: a case report and review of the literature

Abstract

BackgroundWith improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections.Case presentationWe present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus, is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty.ConclusionsArthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.

Periprosthetic hip joint infection with Aspergillus terreus : A clinical case and a review of the literature

“…The majority of these were caused by Aspergillus fumigatus (77%) , followed by Aspergillus flavus (13%) [4] . To our knowledge, ours is only the 2nd PJI due to A. terreus described in the literature [5] . While other reviews have reported on cases of A. terreus osteoarticular infections, these were not specifically attributed to a PJI [6] .…”

“…Gamaletsou et al reported that 10% of the 31 reported cases of Aspergillus septic arthritis occurred in prosthetic joints [4] . The other reported Aspergillus terreus PJI occurred in a total elbow arthroplasty [5] . Therefore, ours is perhaps one of the first cases of Aspergillus terreus involving a total hip arthroplasty.…”

“…However, these guidelines address all invasive Aspergillus infections and are not specific for native or prosthetic joint infections. In case reviews of Aspergillus joint infections, triazoles , amphotericin B, and echinocandins have all been used in conjunction with surgical management [4] , [5] , [7] .…”

“…While there are no established guidelines, the majority of available literature recommends systemic antifungal therapy along with surgical management for maximal chance of cure of fungal PJIs, thus this was the management strategy we employed [5] , [7] . A study by Deelstra et al describes successful use of an antifungal cement spacer as adjunctive treatment to augment activity of systemic antifungals [17] .…”

Indications and results of primary and revision total elbow arthroplasty (literature review)

“…The patient ultimately required definitive resection arthroplasty. The authors concluded that fungal infection made the treatment more complicated and was likely to reduce success of reimplantation [50].…”