Successful Surgical and Medical Treatment of Rhizopus Osteomyelitis Following Hematopoietic Cell Transplantation

Abstract

Mucormycosis has been reported in otherwise healthy individuals; however, it is primarily seen in immunocompromised patients, such as those with diabetes mellitus, malignancy, or chronic graft-versus-host disease, and has a high mortality rate. Because most cases of mucormycosis are associated with contiguous rhinocerebral infection, only 5 cases of isolated musculoskeletal Rhizopus infection have been reported in the literature. One patient underwent hematopoietic cell transplant, which resulted in a fatal outcome.This article describes the successful treatment of isolated Rhizopus osteomyelitis in a patient who underwent hematopoietic cell transplant using a combined surgical and medical approach. A 33-year-old woman with pre-B cell acute lymphoblastic leukemia underwent hematopoietic cell transplant with few complications but developed chronic graft-versus-host disease 8 months posttransplant. She was treated with high-dose steroids for 6 weeks before she was admitted for severe right tibial pain in the absence of trauma. Early detection, aggressive therapies, and a multidisciplinary surgical and medical team allowed for the microbiologically confirmed resolution of the infection. Treatment included multiagent antimicrobial therapy with amphotericin B, daptomycin, and ertapenem. Several surgical irrigation and debridement procedures were also performed, with the eventual placement of amphotericin-impregnated polymethylmethacrylate cement beads and small fragment titanium screws. The patient continued taking postoperative antifungal treatment for 7 months after discharge. Six months following the discontinuation of antifungal therapy, the team's multidisciplinary approach achieved a continued resolution of the patient's infection and a return to a fully ambulatory and radiographically proven recovery without limb loss.

Bone and joint infections caused by mucormycetes: A challenging osteoarticular mycosis of the twenty-first century

“…The most common pathogens of the Mucorales that caused bone and joint infections were Rhizopus species (15 cases) [19][20][21][22][23][24][25][26][27][28][29] followed by Apophysomyces elegans (four cases) [30][31][32][33] , Mucor species (three cases), [34][35][36] Cunninghamella bertholletiae (two cases), 37,38 and one case for each Lichtheimia (formerly Absidia) corymbifera 39 and Saksenaea vasiformis. 40 A genus was not specified in eight cases of histologically documented mucormycosis.…”

Difficult Diagnosis of Fungal Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction

“…In other reported cases, there were no instances where amphotericin-loaded cement spacers were used after arthroscopic ACL reconstruction; however, a unique colored cement (Fig. 4-C) has been used to treat Rhizopus osteomyelitis 9,12 . An in vitro study showed that amphotericin-impregnated cement generated a more stable long-term supernatant concentration than flucytosine and fluconazole 13 .…”

Clinical challenge: fatal mucormycotic osteomyelitis caused by Rhizopus microsporus despite aggressive multimodal treatment

“…Multimodal treatment led to eradication of the disease [12]. A successful treatment of RM osteomyelitis of the right tibia in an immunocompromised patient was presented by Vashi [9]. …”

“…The prognosis and outcome of invasive mucormycosis in patients with immune deficiency or hematologic malignancies is generally rather poor [1, 4, 8]. However in most reported cases fatal outcome could be prevented [8, 9]. …”