Rare case of Isolated Aspergillus Osteomyelitis of Toe: Presentation and Management

 

What to Learn from this Article?

1. Rare case of fungal osteomyelitis of terminal phalanx of second toe?

2.Presentation and management of isolated fungal osteomyelitis?


Case Report |  Volume 3 | Issue 2 | JOCR April – June  2013 | Page 29-31 | Pattanashetty OB, Dayanand BB, Bhavi SB, Bami M


Authors: O.B. Pattanashetty[1], Dayanand B.B.[1], Shushrut B Bhavi[1],  Monish Bami[1]

[1]Department of Orthopedics, Shri B M Patil Medical college, B.L.D.E University, Bijapur, India.

Address of Correspondence:

Dr. Monish Bami : Address: 1301/1302 Accord Nidhi, Link road, Malad west, Mumbai-400064, Maharashtra. Email- monishbami86@gmail.com


Abstract

Introduction: Fungal osteomyelitis is an uncommon diseases and generally present in an indolent fashion. Isolated bone affection due to fungi are rare and we present one such case with fungal osteomyelitis of terminal phalanx of second toe.

 Case Report: We present a rare case of fungal osteomyelitis of right second toe in a 30 year old Indian female who presented with swelling of 8 months duration. Diagnosis was based on the histo-pathological report and culture showing Aspergillus growth. The patient was treated with surgical debridement and amphotericin-B was given for 6 weeks after debridement. There was no recurrence one year post surgery.

 Conclusion: Isolated Aspergillus osteomyelitis of the bone are very rare and mostly seen in immunocompromised patients and larger bones like spine, femur and tibia. Treatment with wound debridement and subsequently followed up with a course of Amphotericin-B for 6 weeks provided good results. There was no recurrence noted at 1 year follow up. Fungi should be kept in mind for differential diagnosis of osteomyelitis and culture should be appropriately ordered.

 Keywords: Fungal osteomyelitis, Aspergillus osteomyelitis, terminal phalanx osteomyelitis


Introduction

Fungal osteomyelitis is a rare disease and generally present in an indolent fashion [1-4]. Incidence of fungal infection has been on rise with immunodeficiency diseases and invasive surgical procedures [5-7]. It is rare to find an isolated fungal bone affection in a immunocompetent person without any obvious predisposing factors. We report one such rare case with isolated affection of terminal phalanx of the second toe.

Case Report

A 30 year old female presented with swelling of right second toe for the past 8 months following direct trauma to the right foot when she hit a wooden door (Fig.1). Patient complained of persistent pain since the time of trauma. She consulted local doctors and was given pain medication but the symptoms did not subside. When she presented to us there was swelling of the toe with moderate tenderness and bogginess around the nail bed. There was no history of drug abuse or intake of immunosupressive drugs. No constitutional symptoms like fever, cough or chest pain were present. Radiographs of right foot was taken which showed irregular margins, lytic and sclerotic edges of the terminal end of distal phalanx of 2nd toe (Fig. 2). Routine blood investigations were within normal limits with a slightly elevated ESR (35mm/hr). A preliminary diagnosis of chronic osteomyelitis was made and decision for excision biopsy was taken. Under local anesthesia a fish mouth incision was taken (Fig. 3). Distal phalanx was found to be completely involved and a decision to excise the whole distal phalanx was taken. The excised bone was sent as a specimen (Fig.4) for the histo-pathological examination. Bacterial culture was negative but histology showed that bone contained fungal hyphae and subsequently the bone culture showed growth of Aspergillus. Treatment was started with Amphotericin-B according to her body weight for 6 weeks. Patient started to walk normally within 1 month and complained of no pain. There was no evidence of fungal infection elsewhere on examination. The patient was followed regularly at 1 month, 3 months, 6 months and one year and no signs of recurrence was noted.

Discussion

Fungii such as Aspergillus are known to be ubiquitus in nature and are the common commensals of the respiratory tract. In patient with immunosupression, these organisms multiply and cause widespread infection involving respiratory system and sometimes even skeletal system. There have been published accounts of fungal osteomylitis in literature but Aspergillus osteomyelitis is infrequently reported [3,7-12]. Fungi infections are common in cases of polytrauma where multiple surgeries cause a break in the natural barriers of skin and mucous membrane and compromises the patients immune system [5,6,13]. In such cases Staphylococcus aureus is the most common cause of osteomyelitis and the long bone metaphysis is the most common localization of osteomyelitis. However, fungi,anaerobes etc. are rare factors and foot bones are rare localitazition [14,15]. İn our case, the region and factor were both unusual.
Cases of fungal osteomylities in literature that were reviewed showed that surgery with systemic antifungals had a lower recurrence and higher success rate as compared to those that were treated with antimycotics alone, which may be due to the fact that penetration of most drugs into the bone tissue is low [9,10]. We treated our patient with surgical debridement along with Amphotericin-B with good results.

Conclusion

This is a rare case of Apsergillus osteomyelitis affecting the terminal phalanx of the toe. Diagnosis was confirmed only after culture and antifungal therapy lead to good results.

References

1.Kohli R,Hadley S.Fungal arthritis and osteomyelitis Infect Dis clin North Am 2005;19:831-851. citation_linking_graphic_18x80_trans

2. Holtom P D, Obuch AB, Ahlmann ER, Shepherd LE, Patzakis MJ. Mucormycosis of the tibia; a case report and revieve of the literature. Clin orthop relat res 2000; 381: 222-228. citation_linking_graphic_18x80_trans

3. Alvarez L ,Calro E,Abril C. Articular aspergillosis:case report. Clin Infect Dis 1995;20:457-460. citation_linking_graphic_18x80_trans

4. Sonin AH, Stern SH, Levi E. Primary Aspergillous osteomyelitis in the tibia of an immunosupressed man. Am J Roentgenol 1996;166 : 1277-1279. citation_linking_graphic_18x80_trans

5. Bodey G.P, Anaissie E.J. opportunistic infections a major problem in immunocompromised patients, in opportunistic fungal infections: focus on fluconazole. International congress and symposium series, 153.ed Richardson R.G. ( Royal society of medicine, London, United Kingdom ) 1989 ; pg:1-16

6. Howard R.J. infections in the immunocompromised patients. Surg. Clin. N. Am. 1994; 74: 620.citation_linking_graphic_18x80_trans

7. Bajracharya S, Ayaram M, Singh M.P. Fungal osteomyelitis of tibia and fibula. Nigerian Journal of Orthopedic and Trauma Dec 2006:5(2):56-57.citation_linking_graphic_18x80_trans

8. Casscellus S.W. aspergillous osteomyelitis of the tibia. J Bone Joint Surg. 1978;60: 994-995.citation_linking_graphic_18x80_trans

9. de Vuyst D. Surmont I, Vertaegen J, Vanhaeckej. Tibia osteomyelitis due to Aspergillus flavus in heart transplant patient. Infection. 1992 ; 20: 48-49.citation_linking_graphic_18x80_trans

10. Hoore K.D, Hoogmartens M. Vertebral aspergillosis. A case report and review of the literature. Acta orthopaed Belg. 1993; 59:306-314.citation_linking_graphic_18x80_trans

11. Tack K.J, Rhame F.S, Brown B, Thompson R.C. Aspergellus osteomyelitis. Report of four cases and review of the literature. Am J. Med. 1982; 73:295-300.citation_linking_graphic_18x80_trans

12. Raper K.B, Fennel D.I. The genus Aspergillus. The William and Wilkins company, Baltimore, Md. 1965.

13. Padhye A.A, Godfrey J.H, Chandler F.W, Peterson S.W. Osteomyelitis caused by Neosartorya pseudofischeri. J Clin. Microbiol. 1994;32:2832-2836.citation_linking_graphic_18x80_trans

14. Atay T, Aksoy OG, Aslan A. Chronic Calcaneal Actinomyces Osteomyelitis In Children With Cauda Equina Syndrome: Case Report. S.D.Ü. Tıp Fak. Derg. 2008;15(3):34-37.citation_linking_graphic_18x80_trans

15. Roy M, Sidhom S, Kerr KG, Conroy JL. Case report: Rhodococcus erythropolis osteomyelitis in the toe. Clin Orthop Relat Res. 2009;467(11):3029-31. citation_linking_graphic_18x80_trans


 

How to Cite This Article: Pattanashetty OB, Dayanand BB, Bhavi SB, Bami M. Rare case of Isolated Aspergillus osteomyelitis of toe: Presentation and Management. Journal of Orthopaedic Case Reports 2013 April-June;3(2): 29-31.Available from: http://www.jocr.co.in/wp/2013/04/13/2250-0685-098-fulltext/ 


(Figure 1) | (Figure 2) | (Figure 3) | (Figure 4)


Authur 


 [Abstract]         [Full Text HTML]         [Full Text PDF]


 

View ratings
Rate this article


Dear Reader, We are very excited about New Features in JOCR. Please do let us know what you think  by Clicking on the Sliding “Feedback Form” button on the  <<< left of the page or sending a mail to us at editor.jocr@gmail.com