Osseous Infections Caused by Aspergillus Species.

BACKGROUND: Osteomyelitis caused by Aspergillus spp. is a severe, but rare, clinical entity. However, clear guidelines regarding the most effective medical management have not yet been established. The present study is a literature review of all such cases, in an effort to elucidate epidemiology, as well as the therapeutic management and the infection's outcome. METHODS: A thorough review of all reports of osteomyelitis of the appendicular and the axial skeleton, without the skull and the spine, caused by Aspergillus spp. was undertaken. Data about demographics, imaging techniques facilitating diagnosis, causative Aspergillus, method of mold isolation, antifungal treatment (AFT), surgical treatment, as well as the infection's outcome were recorded and evaluated. RESULTS: A total of 63 cases of osseous infection due to Aspergillus spp. were identified. The studied population's mean age was 37.9 years. The most commonly affected site was the rib cage (36.8%). Most hosts suffered immunosuppressive conditions (76.2%). Regarding imaging methods indicating diagnosis, computer tomography (CT) was performed in most cases (42.9%), followed by plain X-ray (41.3%) and magnetic resonance imaging (MRI) (34.9%). The most frequent isolated mold was Aspergillus fumigatus (49.2%). Cultures and/or histopathology were used for definite diagnosis in all cases, while galactomannan antigen test was additionally used in seven cases (11.1%), polymerase chain reaction (PCR) in four cases (6.3%), and beta-d-glucan testing in three cases (4.8%). Regarding AFT, the preferred antifungal was voriconazole (61.9%). Most patients underwent surgical debridement (63.5%). The outcome was successful in 77.5%. DISCUSSION: Osteomyelitis due to Aspergillus spp. represents a severe infection. The available data suggest that prolonged AFT in combination with surgical debridement is the preferred management of this infection, while identification of the responsible mold is of paramount importance.

Native Joint Infections by Aspergillus Species.

BACKGROUND: Septic arthritis due to Aspergillus spp. represents a rare, but severe disease. Nevertheless, clear guidelines regarding most effective medical treatment have not yet been established. The present study is a literature review of all reported cases of fungal septic arthritis due to Aspergillus spp, in order to clarify epidemiology, as well as the medical and operative management and their outcome. METHODS: A meticulous review of all published septic arthritis infections due to Aspergillus has been conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical intervention, as well as the infection's outcome were recorded and evaluated. RESULTS: A total of 30 Aspergillus spp. strains from 29 hosts have been studied. The patients' mean age was 45.8 years. The most commonly affected joint was the knee (45.7%), while the predominant symptom was joint pain (62%). Most patients were immunocompromised (72.4%). Diagnosis was established through cultures and/or histopathology. Aspergillus fumigatus was the most common responsible fungi (63.3%), followed by A. flavus (16.6%) and A. terreus (10%). Regarding AFT, the preferred agent proved to be Amphotericin B (14 cases; 48.3%), followed by voriconazole (11; 37.9%), while the mean AFT duration was 5.6 months. In most cases surgical treatment was also performed (in 4 cases no surgery was reported). Treatment was effective in 20 cases (69%). CONCLUSIONS: Septic arthritis caused by Aspergillus spp. represents a severe clinical entity. It seems that, with the available data, prolonged AFT along with surgical intervention is the preferred management of this infection, while identification of the responsible fungus is of utmost importance.

Spondylodiscitis Caused by Aspergillus Species.

BACKGROUND: Spondylodiscitis caused by Aspergillus spp. is a rare but life-threatening clinical entity. However, a consensus on diagnostic criteria and most effective medical management is still missing. The present study is a review of all published cases of spondylodiscitis caused by Aspergillus spp., in an effort to elucidate epidemiology, patients' characteristics, andand the medical and surgical treatment options and their effectiveness. METHODS: A thorough review of all existing spondylodiscitis cases caused by Aspergillus was performed. Data regarding demographics, responsible fungus, time between symptoms' onset and firm diagnosis, antifungal treatment (AFT), surgical intervention, andand the infection's outcome were investigated. RESULTS: A total of 118 Aspergillus spondylodiscitis cases, yielding 119 Aspergillus spp. isolates, were identified in the literature. The patients' mean age was 40.6 years. Magnetic resonance imaging (MRI) (after its introduction) indicated the diagnosis in most cases (66.7%), while definite diagnosis was established through cultures in the majority of cases (73.7%). Aspergillus fumigatus was isolated in most cases (73; 61.3%), followed by Aspergillus flavus (15; 12.6%) andand Aspergillus nidulans and terreus (7; 5.9%, each). The mean time between symptoms' onset and diagnosis was 5.7 months. Amphotericin B was the preferred antifungal regiment (84 cases; 71.2%), followed by voriconazole (31; 26.3%), and the mean AFT duration was 6.1 months. The final outcome was successful in 93 cases (78.8%). Furthermore, 77 patients (65.3%) underwent surgery. CONCLUSIONS: Spondylodiscitis caused by Aspergillus spp. represents a clinical challenge, requiring a multidisciplinary approach. The present review has shown that prolonged AFT has been the standard of care of the studied cases, while surgical treatment seems to play an important role in selected patents.

Non-Candida Fungal Prosthetic Joint Infections.

BACKGROUND: Fungal prosthetic joint infections (PJIs) are rare, especially those caused by non-Candida species. Treatment has not been fully elucidated, since a plethora of antifungal and surgical interventions have been proposed. Τhis study represents an effort to clarify the optimal management of non-Candida fungal PJIs, by reviewing all relevant published cases. METHODS: A thorough review of all existing non-Candida fungal PJIs in the literature was conducted. Data regarding demographics, responsible organisms, antifungal treatment (AFT), surgical intervention, time between initial arthroplasty and onset of symptoms, and time between onset of symptoms and firm diagnosis, as well as the infection's outcome, were evaluated. RESULTS: Forty-two PJIs, in patients with mean age of 66.2 years, were found and reviewed. Aspergillus spp. were isolated in most cases (10; 23.8%), followed by Coccidioides spp. (7; 16.7%) and Pichiaanomala (5; 11.9%). Fluconazole was the preferred antifungal regimen (20 cases; 47.6%), followed by amphotericin B (18 cases; 42.9%), while the mean AFT duration was 9.4 months (SD = 7.06). Two-stage revision arthroplasty (TSRA) was performed in 22 cases (52.4%), with the mean time between stages being 5.2 months (SD = 2.9). The mean time between initial joint implantation and onset of symptoms was 42.1 months (SD = 50.7), while the mean time between onset of symptoms and diagnosis was 5.8 months (SD = 14.3). CONCLUSIONS: Non-Candida fungal PJIs pose a clinical challenge, demanding a multidisciplinary approach. The present review has shown that combination of TSRA separated by a 3-6-month interval and prolonged AFT has been the standard of care in the studied cases.