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Fungal Arthritis 690 Annals ofthe Rheumatic Diseases 1992; 51: 690-697 REVIEW Ann Rheum Dis: first published as 10.1136/ard.51.5.690 on 1 May 1992. Downloaded from Fungal arthritis Marta L Cuellar, Luis H Silveira, Luis R Espinoza There are 50 000-200 000 species of fungi, but Candida infections, both focal and generalised, only about 100 of these cause infectious diseases have been increasing rapidly in recent years. (mycoses) in humans.' Fungal infections are not These organisms become pathogens when there readily recognised, do not advertise their is an interruption of the normal defence mech- presence in a characteristic fashion, and the anisms of the host by naturally occurring or causative organism is generally not easy to iatrogenic factors.4 Candida species are the most demonstrate in tissue.2 Musculoskeletal infection common fungi associated with opportunistic by fungi was once rare, but its incidence has infections.3 increased in the past few years. Although Septic arthritis caused by candida species is healthy subjects may host fungal diseases, uncommon and its true incidence is unknown.5 various predisposing factors that depress the It can be divided into two clinical syndromes. immune system have been implicated in most The first is an isolated monarthritis caused by patients developing fungal infections or fungal the direct intra-articular inoculation of fungi arthritis, or both.3 Alcoholism, cirrhosis, that inhabit the skin. The second is the develop- diabetes, tuberculosis, cancer, prematurity, ment of a monarthritis or pauciarthritis as a treatment with corticosteroids, cytotoxic drugs, complication of haematogenously disseminated prolonged use of intravenous antibiotics, intra- candidiasis. venous drug abuse, granulocytopenia, and The first manner of introducing the organism marrow hyperplasia are among the predisposing to the joint is by injection. The common factors. denominator is repeated aspiration, usually with Fungal arthritis usually follows a chronic injection of corticosteroids, of a previously indolent course of several months that leads to damaged knee joint.5 6 This type of arthritis is delays in diagnosis and to inappropriate treat- extremely rare and only eight cases have been ment such as intra-articular and systemic described. The diagnosis is by means of a steroids. Consequently, it is important to know positive culture or biopsy sample. Synovial fluid http://ard.bmj.com/ the epidemiology and extra-articular manifesta- white blood counts range from 9 to 43 x 109/l tions of fungal disease to be aware of the with a predominance of polymorphonuclear possibility of musculoskeletal infection and to leucocytes. Uncommon species of candida have establish an appropriate treatment. The table been isolated from joints: C guilliermondi twice, gives the main characteristics of fungal arthritis. C parapsilosis four times, and unspecified candida species twice. The onset of this type of the course arthritis is insidious and indolent, on September 25, 2021 by guest. Protected copyright. Candidiasis chronic, and relatively benign. The patients are Candida organisms are normal commensals of afebrile and have normal blood cell counts. humans and are commonly found on diseased Candida may also enter the joint by con- skin, the gastrointestinal tract, expectorated tamination during surgery.7 ' Eleven episodes sputum, the female genital tract, and in urine of of fungal arthritis by candida complicating patients with indwelling Foley catheters.4 Most knee, hip, and shoulder reconstructive arthro- candida infections are of endogenous origin, but plasty have been reported in nine patients. All human to human or animal to human trans- patients had only pain with a limited range of mission is possible, which is a unique property motion and swelling, and there was no evidence among the mycoses affecting humans. There is of systemic disease. The onset of symptoms also evidence that candida infection can be occurred as late as two years after the initial acquired from the hospital environment. surgery with an average interval of 14 months. Department of Medicine, Section ofRheumatology, All peripheral white blood cell counts reported Louisiana State were normal. The white blood cell counts in University Medical Fungal arthritis: demographic and clinical charactenrstics joint fluid ranged from 4 to 15 x 109/1. The Center, New Orleans, LA, USA Worldwide distribution in most instances cultures yielded C albicans in two patients, C Affects neonates, old, or immunocompromised hosts tropicalis in three, C parapsilosis in three, and C M L Cuellar Prevalence is variable, ranging from 0 4 to 20% of disseminated L H Silveira mycosis glabrata in one. Treatment requires the removal L R Espinoza More common in men, and may be an occupational hazard of the components with debridement. Joint disease occurs by contiguous or haematogenous spread prosthetic Correspondence to: common cause of Dr Luis R Espinoza, Usually monarthritis or oligoarthritis, with the knee joint most Although infection is the most LSU Medical Center, commonly affected biological failure of joint arthroplasty, fungal Department of Medicine, Systemic disease often absent rare. Section of Rheumatology, Pulmonary and cutaneous disease are the extra-articular infection in this setting remains extremely 1542 Tulane Ave, manifestations most often present Arthritis complicating haematogenously dis- Diagnosis is based on direct visualisation of the organism or New Orleans, synovial fluid and membrane cultures, or both seminated candidiasis occurs in patients with LA 70112, USA. Combined medical (antimycotic) and surgical treatment often factors.5 Patients are sick and the Accepted for publication necessary predisposing 12 December 1991 inflammation usually occurs in normal joints. Fungal arthritis 691 Neonates are the first group of patients in Microscopically, thesynoviumshowsa thickened whom haematogenously originated candida membrane with non-specific mononuclear cell arthritis can occur.5 9 The illness is a hospital infiltration. Isolated synovial fluid lymphocytes Ann Rheum Dis: first published as 10.1136/ard.51.5.690 on 1 May 1992. Downloaded from acquired disease of sick children with underly- show greater stimulation to candida antigens ing diseases such as the respiratory distress syn- than peripheral blood lymphocytes, and CD4 drome, and gastrointestinal defects. C albicans, positive T lymphocyte clones with specificity which is responsible for more than 80% of the for candida antigens have been characterised reported cases, and C tropicalis are the species and further propagated in vitro.'8 responsible for this disease. Arthritis is usually The use of amphotericin B, either alone or present with accompanying metaphysial osteo- in combination with joint drainage, is associated myelitis. Bone infection might originate from with clinical and mycological cure in 90% of the infected synovium or via the metaphysial patients.9 Amphotericin B is used intravenously vessels. Polyarthritis occurs in most patients at dosages of 0-3-0-5 mg/kg/day.5 A total dose and the knee is the joint most often affected. of 1-3 g during a period of six to ten weeks is Physical examination shows a febrile child with given, although cures have been obtained with swollen and tender joints. Radiographs show lower doses. Amphotericin B can also be used in joint effusion, dislocation of the joint in some combination with 5-fluorocytosine, which instances, irregularities and punched out lesions seems to have a synergistic interaction with the at the metaphysis, and, less commonly, perio- former. The latter should never be used alone steal reactions. because of the emergence of resistance. 5- Diagnosis is achieved by isolating the organism Fluorocytosine is available only for treatment by culture of the aspirated joint fluid or bone. by mouth and it is given at doses of 150 Treatment against candida is effective and mg/kg/day divided into four doses. Intra- reduced joint function occurs in only a small articular amphotericin B is a useful adjunctive percentage of cases. treatment in infections restricted to the joint Arthritis originated by haematogenous dis- capsule and not disseminated, as in pyarthrosis semination beyond the neonatal period is usually following direct inoculation of candida,6 9 as a complication of disseminated candidiasis in well as in haematogenously spread infections patients with serious underlying disorders or that have not responded well to systemic treat- intravenous drug abusers.5 '° " C albicans is ment.9 Other treatment options include keto- again the causative organism in about 80% of conazole and fluconazole.5 6 19 cases, and C tropicalis is responsible for most of Patients with HIV infection deserve special the remaining cases. Isolated cases of knee consideration because, in spite of the profound arthritis caused by C parapsilosis,'2 C kruset,'3 state of immunodeficiency present, only isolated and C zeylanoides'4 have been reported. cases of septic arthritis have been reported.20 Two distinct clinical presentations can be Among these cases, candida arthritis is rare. observed: (a) acute onset of constitutional and Arthritis and osteomyelitis have been reported http://ard.bmj.com/ synovial symptoms (about two thirds ofpatients), in the sternoclavicular joint,2' and in the costo- with the aetiological diagnosis established with- sternal and hip joints22 of HIV infected intra- in the first week, and (b) indolent presentation, venous drug abusers. The reported patients had
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