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 Table of Contents  
Year : 2022  |  Volume : 47  |  Issue : 3  |  Page : 224-226

Case report of Aspergillus septic arthritis in a patient with acute lymphocytic leukemia

1 Department of Medical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
2 Department of Microbiology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Date of Submission27-Feb-2021
Date of Acceptance30-Mar-2021
Date of Web Publication03-Jan-2023

Correspondence Address:
Gopan Gayatri
Senior Resident in Medical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejh.ejh_16_21

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Fungal septic arthritis can occur in immunosuppressed patients, and Aspergillus fumigatus is the most common pathogen involved. Here we describe a case of B-cell acute lymphoblastic leukemia with knee joint fungal septic arthritis. This differential should be kept in mind as late detection and treatment can lead to permanent disability.

Keywords: Aspergillus fumigatus, fungal septic arthritis, immunocompromised

How to cite this article:
Nair SG, Gayatri G, T V S, Vishnu H, Bijulal S. Case report of Aspergillus septic arthritis in a patient with acute lymphocytic leukemia. Egypt J Haematol 2022;47:224-6

How to cite this URL:
Nair SG, Gayatri G, T V S, Vishnu H, Bijulal S. Case report of Aspergillus septic arthritis in a patient with acute lymphocytic leukemia. Egypt J Haematol [serial online] 2022 [cited 2023 Mar 30];47:224-6. Available from: http://www.ehj.eg.net/text.asp?2022/47/3/224/366861

  Introduction Top

Septic arthritis is a rheumatologic emergency, and it denotes infection of the joint space by microorganisms. It can affect single or multiple joints and can occur byhematogenous spread, contiguous involvement, orby direct inoculation. The most common organism causing septic arthritis is Staphylococcus aureus. Fungal septic arthritis is rare and may occur in immunosuppressed patients.

  Case report Top

A 42-year-old gentleman with previous history of B-cell acute lymphoblastic leukemia treated elsewhere with BFM protocol presented to our department with complaints of fever and backache. He had an ECOG performance status of three, and clinical examination showed pallor and spinal tenderness at multiple levels. Vitals were stable. Other systems were within normal limits. Laboratory investigations gave the following values: Hb, 7; TC, 1700; and platelet count, 24 000. His biochemical parameters were within normal limits. Lactate dehydrogenase level was 414 mg/dl. Peripheral smear showed bicytopenia with few atypical cells. Bonemarrow and cytogenetic evaluation studies were suggestive of B-cell acute lymphocytic leukemia. Philadelphia chromosome was negative by cytogenetic studies. MRI spine done for evaluation of backacheshowed spondylodiscitis at multiple levels. Tuberculosis workup was negative. IgM Brucella was negative. We proceeded to treat him with HCVAD regimen (hyperfractionated cyclophosphamide, vincristine, adriamycin, and steroids), thinking the spondylodiscitis to be disease related.

After induction chemotherapy, he had persistent backache and right hip joint pain. Local examination of the right hip joint did not show local rise of temperature or tenderness, but all joint movements were restricted, and there was flexion deformity. MRI spine showed progression in spondylodiscitis with right hip joint effusion. Ultrasound-guided aspirate taken from the hip joint showed a total count of 62 000, with differential count showing predominant neutrophils.

Knee joint aspirate was sent for culture. Gram stain of thepus showed moderate pus cells and necrotic material. No bacteria or fungal elements were seen. The pus sample was inoculated onto routine bacteriological media and Sabouraud’s dextrose agar for detection offungal pathogens. On the third day, fungal growth was observed on Sabouraud’s dextrose agar and also in routine bacteriological media. Surface of the fungal colony was initially white, which turned to blue–green color and had a powdery texture. Lactose phenol cotton blue mount of the growth showed hyaline septate hyphae with short smooth conidiophore and vesicle with uniseriate phiallides bearing chains of round conidia covering the upper half of the vesicle. Macroscopic and microscopic features of the fungal growth were suggestive of Aspergillus fumigatus. Orthopedic consultation was sent, and conservative management was advised. CT thorax did not show any evidence of invasive aspergillosis.

We treated him with dual antifungals (liposomal amphotericin B+voriconazole) for a period of 3 weeks, and voriconazole was continued throughout the chemotherapy period. USG of the right hip repeated after 1 week of dual antifungals showed resolution of effusion. Further intensive chemotherapy was continued under antifungal cover.

Review of literature

Articular aspergillosis is rare and usually occurs in association with compromised host defense and intraarticular steroid injections. To our knowledge, only 24 cases of Aspergillus septic arthritis have been reported [1],[2],[3],[4]. The knee joint was most affected, followed by the shoulder; however, septic hip arthritis caused by Aspergillus was reported inonly one patient who had received a liver transplantation.

In most previously reported cases, Aspergillus septic arthritis was caused by disseminated diseases linked to hematogenous spread. A. fumigatus is the most common pathogen responsible for Aspergillus septic arthritis; however, Aspergillus terreus and Aspergillus flavus were also identified in the knee and shoulder joints. Identification was made after a synovial fluid aspiration and culture showing typical acute Aspergillus branching hyphae. In case review about joint infection by A. fumigatus, Golmia etal. [1] found that nine cases out of 14 were confirmed on basis of culture results and other four cases were diagnosed by tissue biopsy. They also reported that among four cases that had results of joint fluid analysis, two cases showed white blood cell count of joint fluid less than 50 000/mm3, and only one case showed differential count of neutrophil more than 90%. There is no consensus on the type of antifungal therapy for treatment of Aspergillus septic arthritis. Recently, voriconazole has become the drug of choice for invasive aspergillosis [1]; however, Stratov etal. [5] performed a literature review and highlighted the importance of surgery combined with the use of antifungal agents for Aspergillus osteomyelitis. Of the previous 24 patients with Aspergillus septic arthritis, 13 were treated by open synovectomy and four had arthroscopic surgery (three knees and one shoulder joint) [1],[2],[3],[4]. Septic arthritis caused by fungi tends to be more indolent than bacterial septic arthritis, and diagnostic tools routinely used for septic arthritis such as joint fluid analysis or culture may not be helpful [1]. This forces surgeons to be alert of the possibility of fungal joint infection, as late diagnosis is often followedby poor prognosis. Orthopedic surgeons should be aware that Aspergillus septic arthritis of the hip can occur even in an immunocompetent patient ([Figure 1][Figure 2][Figure 3]).
Figure 1: MRI spine showing multilevel spondylodiscitis.

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Figure 2: Aspergillus fumigatus macroscopy.

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Figure 3: Microscopic appearance of Aspergillus fumigatus.

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  Conclusion Top

Septic arthritis can occur commonly in immunosuppressed patients, and fungal arthritis is a differential. This case is being reported to highlight the rarity of this entity. Late diagnosis can lead to permanent disability. It can be managed with antifungals alone or with arthroscopic surgery.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Golmia R, Bello I, Marra A, Hamerschlak N, Osawa A, Scheinberg M Aspergillus fumigatus joint infection: a review. Semin Arthritis Rheum 2011; 40:580–584.  Back to cited text no. 1
Kim T, Lee SR, Cho OH, Park KH, Oh R, Lee SO, et al A case of septic hip arthritis caused by Aspergillus fumigatus in a liver transplant recipient. Infect Chemother 2008; 40:170–174.  Back to cited text no. 2
Yu OH, Keet AW, Sheppard DC, Brewer T Articular aspergillosis: case report and review of the literature. Int J Infect Dis 2010; 14:e433–e435.  Back to cited text no. 3
Dal T, Tekin A, Deveci Ö, Bulut M, Firat U, Mete M Septic arthritis caused by Aspergillus fumigatus in an immunosuppressive patient: a case report and review of the literature. J Microbiol Infect Dis 2012; 2:29–32.  Back to cited text no. 4
Stratov I, Korman TM, Johnson PD Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review. Eur J Clin Microbiol; 22:277–283.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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