Elsevier

Journal of Orthopaedics

Volume 12, Supplement 1, October 2015, Pages S140-S144
Journal of Orthopaedics

Case Report
Case report: Eumycetoma and mycotic arthritis of the knee caused by Arthrographis kalrae

https://doi.org/10.1016/j.jor.2013.12.004Get rights and content

Abstract

A 33-year-old male presents following a penetrating injury to his right knee. Clinically he demonstrated pain, an effusion and fevers. At diagnostic arthroscopy, no microbiological growth was cultured. Delayed growth yielded the fungus Arthrographis kalrae. He was treated with a three-stage total knee arthroplasty. The first stage consisted of soft tissue debridement. The second stage involved femoral and tibial osteotomies and insertion of antifungal-impregnated cement spacers. Definitive total knee joint prosthesis were implanted during stage three. At 2 years follow up, he demonstrated a pain free range of motion and has returned to competitive tennis. To the authors' knowledge this is the first report implicating A. kalrae as an invasive pathogen of the knee in an immunocompetent host.

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.

References (12)

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Cited by (3)

  • Immunomodulation over the course of experimental Arthrographis kalrae infection in mice

    2016, Comparative Immunology, Microbiology and Infectious Diseases
    Citation 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].

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