Introduction:
Despite being uncommon, fungal septic arthritis is a serious and occasionally even fatal condition. It necessitates long-term medical management, often involving surgery. Invasive fungal infections (IFIs) have dramatically increased over the last few years. This is mostly due to the increase in immunocompromised patients, such as those receiving immunosuppression or broad-spectrum antibiotics, neutropenia, indwelling prosthetics, HIV, diabetes mellitus, burns, and long-term parenteral nutrition. The early and speedy discovery of these illnesses has also been made possible by a significant advancement in diagnostic tools, including genetic approaches. Bone and joint fungal infections can progress in a variety of ways, from mild to extremely aggressive.
Due to the high vascularity of synovial tissue, spread typically occurs through direct extension from an adjacent infective site or direct inoculation. Due to the lack of a systemic inflammatory response and the presence of usual imaging findings, an indolent infection may be difficult to detect. However, a fungal etiology may be indicated if there is no periosteal response and new bone growth at the osteomyelitis site. Therefore, a comprehensive history and physical examination may be quite important in making a diagnosis in such circumstances. Depending on the particular fungus species and the host variables, the clinical course and results differ.
What Results in Fungal Arthritis?
In most cases, the fungus that causes inflammatory arthritis enters the joint through the bloodstream. Hematogenous spread is the term used to describe this method of infection through the blood. Alternatively, fungus-contaminated medicine can cause rheumatoid arthritis if it is injected directly into the joint. Exogenous inoculation is the term used to describe this method of infection, which involves injecting the fungus directly into the joint. Rarely a contaminated prosthesis used during joint replacement surgery can cause a fungal infection. The fungi Candida, Aspergillus, and Exserohilum species can all result in fungal arthritis.
What Are the Conditions That May Cause Fungal Arthritis?
Conditions that can cause fungal arthritis include:
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Blastomycosis - An infection brought on by inhaling the fungus Blastomyces dermatitidis. The fungus can be found in soil and decaying wood.
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Candidiasis - Infection caused by the fungus Candida albicans.
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Coccidioidomycosis - When the spores of the fungus Coccidioides immitis enter the human body through the lungs, it can result in an infection known as valley fever.
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Cryptococcosis - Infection with the fungus Cryptococcus neoformans or Cryptococcus gattii causes Cryptococcosis.
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Histoplasmosis - Inhaling the spores of the fungus Histoplasma capsulatum causes the infection known as histoplasmosis.
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Sporotrichosis - A fungus known as Sporothrix schenckii is the source of the long-lasting (chronic) skin infection known as sporotrichosis.
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Exserohilum rostratum (from injection with contaminated steroid vials).
What Are the Symptoms of Fungal Arthritis?
The fungus can harm the tissue in the joints or the bones. One or more joints may be affected, with the knees and other big, weight-bearing joints being most frequently afflicted. Any of the following signs could be present:
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Fever.
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Joint discomfort.
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Stiff joints.
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Swelling of a joint.
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Ankle, foot, and leg swelling.
What Are the Chances of Getting Fungus-Related Arthritis?
Rarely do patients with healthy immune systems get fungal arthritis. The unintentional injection of drugs that are contaminated with fungus microorganisms in the used vials increases the chance of these persons acquiring fungal arthritis. In September 2012, tainted pharmaceutical vials made by a compounding pharmacy (New England Compounding Center) led to an outbreak of rare fungal meningitis and fungal arthritis that spread across many states.
Infections with fungi, notably arthritic fungi, can be a risk for those whose immune systems are unusually weakened. This includes those with HIV, injectable drug users, critically low white blood cell counts (neutropenia), and those taking long-term corticosteroid therapy.
What Are the Different Tests and Methods Used in Diagnosing Fungal Arthritis?
When a patient with an impaired immune system experiences joint inflammation, fungus arthritis is taken into account. White blood cell count, inflammatory markers (sedimentation rate, ESR, and C-reactive protein, or CRP), and blood cultures are among the blood tests that can be performed. The kind and severity of joint damage can be assessed using x-rays, CAT scanning, and magnetic resonance imaging (MRI) scanning. In order to diagnose the condition, joint fluid is ultimately extracted from the joint using a needle and syringe, and this fluid is then examined in a lab to identify the particular fungus organism present. The following tests may be requested:
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Joint fluid removal for microscopic fungal inspection.
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Joint fluid is cultured to search for fungus.
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Joint X-ray showing changes in the joints.
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Positive serology (antibody) test for fungus.
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Biopsy of the synovium reveals fungus.
How Is Fungal Arthritis Treated?
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Pharmacological Management: The cornerstone of treatment for fungal arthritis is antifungal therapy, which is combined with surgical procedures. Historically, Amphotericin B (Amp B), with or without Flucytosine, has been the main clinical treatment for invasive fungal arthritis. However, recently echinocandins (Caspofungin, Micafungin, and Anidulafungin) and azoles (Fluconazole and extended-spectrum triazoles such as Voriconazole, Posaconazole, and Isavuconazole) have been added to the list of available therapeutic options. Fluconazole and echinocandins are recommended as the first medications of choice for Candida infections in the most recent clinical practice guideline for the management of osteoarticular candidiasis updated by the Infectious Diseases Society of America (IDSA) in 2016, considering their strong efficacy and better safety profile. As an alternative, Liposomal amp B has been suggested.
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Surgical Management: Surgery (debridement) may be necessary to remove the contaminated tissue in cases of chronic or advanced bone or joint infection. For best results, a combination of medicinal and surgical therapy is often preferred in cases of fungal native joint arthritis. Irrigation and surgical debridement are required in the majority of instances of septic arthritis and fungal osteomyelitis. Tissue or fluid samples might be gathered concurrently for histopathological analysis. In the established diagnosis of cryptococcal infections, drainage and debridement are frequently not required.
Debridement of the bone and soft tissues, removal of the sinus tracts, and, if necessary, the insertion of antifungal beads are all steps in the surgical procedure. Since spinal instability and nerve root compression are frequent complications of fungal vertebral osteomyelitis, arthrodesis and spinal stabilization are frequently necessary. Early surgical procedures have been shown to shield such patients from brain damage.
Can Fungus Arthritis Be Prevented?
By reducing the dangers of immune suppression and staying away from intravenous drug addiction, fungus arthritis can be avoided. Active sterilization procedures used by organizations that make injectable drugs can also stop fungus arthritis.
Conclusion:
Fungal arthritis is an uncommon but challenging disease. As predisposing variables are more frequent in the general population, the prevalence of the fungal disease is rising. Surgery and a protracted course of antifungal medications are required for the treatment of fungal arthritis. Joint preservation, infection elimination, and prevention of recurrence are the three main goals of the treatment.
