Case ReportCase report: Eumycetoma and mycotic arthritis of the knee caused by Arthrographis kalrae
Introduction
Mycetoma can be defined as a chronic, progressive, inflammatory, granulomatous infection of subcutaneous tissue, skin, and bones. It is most commonly caused by fungus (Eumycetoma) or actinomycetes (Actinomycetoma).1 It is considered an atypical cause of arthritis and is a rarely reported disease in Australia. It is more prevalent in African countries including Niger, Senegal, Sudan, Somalia, North Cameroon, Kenya and Chad.2
Arthrographis kalrae (A. kalrae) can commonly be isolated from soil and compost but has only rarely been reported to be an opportunistic pathogen of humans.1 A. kalrae has been described as a pathogen in infections of invasive sinusitis and meningitis,3 the dorsum of the hand (causing Eumycotic mycetoma),4 the lung (in bronchial alveolar lavage fluid),5 a corneal ulcer and keratitis.6
Patient history often reveals a penetrating mechanism of injury which allows for the inoculation of soil-based organisms into the subcutaneous tissue. Commonly, those at risk include labourers, those who work barefoot and those who live in rural areas.3 The characteristic findings are clinical subcutaneous swellings and the presence of hyphae and spores consistent with A. kalrae on histological examination.7 It is known to spread contiguously to involve adjoining skin with the formation of multiple sinuses.7
Section snippets
Initial presentation
A 33-year-old male sustained a penetrating injury to his right knee with sheet metal in May 2009. He presented to hospital two months later with unilateral right knee pain, an effusion and a healed 2 cm wound. Symptoms failed to resolve and he was investigated with diagnostic arthroscopy. When initial intra-operative specimens did not yield any microbiological growth the working diagnosis of inflammatory arthropathy was made. He was treated with multiple arthroscopic washouts (Jul 09, Nov 09,
Discussion
Fungal arthritis is often associated with a diagnostic delay due to difficulty in it's identification resulting in a longer duration of illness and chronic status,8, 9 as in this case. Furthermore, initial treatment for suspected inflammatory arthropathy with prednisolone, methotrexate and yttrium almost certainly aided disease progression.
The clinical management of Eumycetoma and mycotic arthritis remains largely undefined within the medical literature, with no specific guidelines available.
Conclusion
This case demonstrates that A. kalrae has the potential to cause invasive arthritis in an immunocompetent host. A three-stage total knee joint arthroplasty combined with suppressive antifungal therapy resulted in a pain free and good functional outcome at 2 years follow up.
Conflicts of interest
All authors have none to declare.
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Cited by (3)
General Assembly, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections
2019, Journal of ArthroplastyImmunomodulation over the course of experimental Arthrographis kalrae infection in mice
2016, Comparative Immunology, Microbiology and Infectious DiseasesCitation Excerpt :Arthrographis kalrae is a neurotropic, dimorphic fungus that has been described as a rare human pathogen, with diverse clinical manifestations throughout the world. A. kalrae was described in a case of eumycetoma in France [1], sinusitis and meningitis and two cases of keratitis in the USA [2–4], panophthalmitis and sinusitis in the People’s Republic of China [5], cases of onychomycosis in Slovakia and in Japan [6,7], endocarditis in Spain [8], eye infection in Germany [9], pulmonary infection in The Netherlands [10], a knee joint infection in Australia [11], keratomycosis in Malaysia [12], eumycetoma and arthritis of the knee in Australia [13] and arthritis in Italy [14]. Pichon et al. described a case of invasive fungal cerebral vasculitis that resulted in stroke and death in a non-immunocompromised patient [15].
Post-laser in situ keratomileusis interface Arthrographis kalrae keratitis
2020, Arquivos Brasileiros de Oftalmologia