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For further information, see CMDT Part 22-39: Mycotic Infections of Bones & Joints

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

    • Prosthetic joints can also be infected by Candida

  • 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 or tissue obtained from the local lesion

  • Serologic tests provide presumptive support of the diagnosis

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

  • Coccidioidomycosis

    • Fluconazole or ketoconazole, 400 mg orally daily

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

    • May require operative excision of infected bone and soft tissue

    • Amputation may be the only solution for stubbornly progressive infections

    • Immobilization of joints by plaster casts and avoidance of weight bearing provide benefit

    • For more advanced joint infection

      • Synovectomy

      • Joint debridement

      • Arthrodesis

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