Perils of the Palm Tree

Abstract

Fusarium is a ubiquitous environmental mold soil. In immunocompetent hosts, keratitis and onychomycosis are the most commonly reported Fusarium infections, and osteomyelitis is rare. Eight detailed cases of Fusarium osteomyelitis have been reported in the English literature to date, all involving either the vertebrae or lower extremities. Inoculation of Fusarium into bone has occurred following trauma or via hematogenous dissemination.To the best of our knowledge, there have been no reported cases of Fusarium osteomyelitis involving the hand. We report a case of a Fusarium metacarpal osteomyelitis in an immunocompetent female patient, discuss the key management issues, and review the Fusarium osteomyelitis cases in the literature.A 72-year-old nondiabetic white woman with a history of stenosing tenosynovitis of the right thumb was referred by the hand surgery office after 2 weeks of right-hand swelling. She recalled that she had been trimming the needle-sharp fronds of a robellini palm tree (pygmy date palm or Phoenix roebelenii) in her garden just before the onset of her symptoms and had sustained 2 prick wounds to the dorsal aspect of her right hand. One injury was between the second and third metacarpals, and the second prick was in the flesh adjacent to the thumb and index finger. She washed the wounds with soap and water, but subsequently developed intermittent redness and swelling of the dorsal aspect of the right hand (Fig. 1). There was no associated skin streaking, and she denied fevers or chills. About 2 weeks after the injury, because of right-thumb pain in association with clicking and locking, she underwent in-office tenovaginotomy surgery to release the right-thumb tendon sheath. She did well immediately postoperatively and was able to make a full fist without difficulty. When the redness and swelling in her hand worsened a few days later, she was prescribed 10 days of trimethoprim/ sulfamethoxazole (1 tablet twice daily) and a subsequent methylprednisolone dose pack, which she took once daily for 6 days. Because of lack of improvement, she was referred to our infectious disease office.Because of concerns of osteomyelitis as a result of the trauma sustained to the patient's metacarpals, she was sent for a magnetic resonance imaging (MRI) the next day (Fig. 2), which demonstrated significant edema in the distal third metacarpal, with surrounding subperiosteal and soft tissue edema. These findings were felt consistent with probable osteomyelitis. The case was discussed with hand surgery physicians, and the REVIEW ARTICLE 12 www.infectdis.com