Recurrent Arthritis by Candida glabrata, a Diagnostic and Therapeutic Challenge

Abstract

Infectious arthritis due to Candida glabrata is very rare. A 40-year-old Iranian man had developed a painful swelling on the left knee since a year ago. A surgery (meniscectomy) was performed on his knee. However, in follow-up visit after 2 months, the patient's condition was deteriorated. Direct examination of synovial fluid with Gram and hematoxylin-eosin stains were negative for any bacterial or fungal infection or crystal elements; however, inoculation into BACTEC™ Mycosis IC/F and Plus Aerobic/F culture bottles led to the isolation of a yeast strain. The macroscopic examination on CHROMagar™ Candida medium combined with microscopical examination on CMT80 agar made a presumptive identification of the isolate to be considered as C. glabrata, and it was later on confirmed by ITS sequencing. Initial empirical treatment was started with intravenous amphotericin B for 4 weeks followed by oral itraconazole which was unsuccessful. Prescription of an oral 150-mg tablet of fluconazole was considered for a 2-month course. All symptoms completely declined, and no recurrence of infection was detected. Antifungal susceptibility testing (AFST) was performed for this isolate, and the result showed sensitivity to both amphotericin B and itraconazole and less susceptibility to fluconazole while clinical recovery was achieved by fluconazole. In any suspected clinical case caused by infectious agents, application of an effective fungal diagnostic test should be considered to avoid complications due to misdiagnosis. The correlation of AFST result with real in vivo therapeutic responses can be strain or patient dependent, and this should be considered for a successive treatment.

Candida glabrata-Induced Refractory Infectious Arthritis: A Case Report and Literature Review

“…A total of 21 C. glabrata arthritis cases have been found available in the PubMed database retrieved by the keyword of ''Candida glabrata'' and ''fungal infection'' or ''arthritis'' [2,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The mean age at diagnosis was 61 (± SD 14) years, 16 of which (76.19%) are over 50 years.…”

“…Candida glabrata mainly causes systemic or mucosal infections in immunosuppressed patients due to the increased use of prophylactic antifungal treatment [1]. Infectious arthritis induced by C. glabrata after arthroscopic surgery has rarely been reported before [2,3]. Here we would like to share a refractory C. glabrata-induced infectious knee case with extensive cartilage damage following an arthroscopic surgery for treating a recurrent popliteal cyst.…”