Bone & Joint Mycotic Infections

Key Features

• Candidal osteomyelitis

  • Occurs in malnourished patients undergoing prolonged hospitalization for cancer, neutropenia, trauma, complicated abdominal surgical procedures, or injection drug use

  • Infected intravenous catheters frequently serve as a hematogenous source

• Coccidioidomycosis

  • Usually secondary to a primary pulmonary infection

  • Arthralgia with periarticular swelling, especially in the knees and ankles, occurring as a nonspecific manifestation of systemic coccidioidomycosis, should be distinguished from actual bone or joint infection

  • Osseous lesions commonly occur in cancellous bone of the vertebrae or near the ends of long bones at tendinous insertions; these lesions are initially osteolytic and thus may mimic metastatic tumor or myeloma

Clinical Findings

• Joint and bone pain and swelling

Diagnosis

• Culture studies of synovial fluid

• Coccidioidomycosis

  • Recovery of Coccidioides immitis from the lesion or histologic examination of tissue obtained by open biopsy

  • Rising titers of complement-fixing antibodies also provide evidence of the disseminated nature of the disease

Treatment

• Candidal: fluconazole, 200 mg twice daily orally, is probably as effective as amphotericin

• Coccidioidomycosis

  • Fluconazole or ketoconazole, 400 mg daily orally

  • Itraconazole, 200 mg twice daily orally for 6–12 mo

  • May require operative excision of infected bone and soft tissue

  • Amputation may be the only solution for stubbornly progressive infections