Jain Nirbhay S, Horn Christopher B, Coleoglou Centeno Adrian A, Ilahi Obeid N, Mazuski John E, Bocchichio Grant V, Punch Laurie J
1 School of Medicine, Washington University in St. Louis , St. Louis, Missouri.
2 Department of Surgery, Washington University in St. Louis , St. Louis, Missouri.
Surg Infect (Larchmt). 2018 Jul;19(5):544-547. doi: 10.1089/sur.2018.046. Epub 2018 Jun 12.
Chronic osteomyelitis associated with a stage IV decubitus ulcer is a challenging condition to manage, characterized by frequent relapses and need for long-term anti-microbial therapy. Although gram-positive cocci are the most common causes, fungal infections have been reported, usually in immunocompromised hosts. We present a case of Cladophialophora osteomyelitis in a patient without known immunocompromised that was managed with a Girdlestone pseudoarthroplasty.
A 70-year-old male presented to our emergency room with fever, right hip pain, and purulent drainage from a right greater trochanter stage IV decubitus ulcer. His medical history was significant for T10 paraplegia secondary to spinal ependymomas and multiple spinal procedures, as well as significant recent weight loss. Past operations included multiple spinal procedures and repair of a right intertrochanteric femoral fracture with a plate and lateral compression screws. This led to post-operative decubitus ulcer formation over the right greater trochanter, requiring a gracilis flap. The flap remained intact for three years, then re-ulcerated. He subsequently developed femoral head osteomyelitis. To facilitate the treatment, the hardware was removed three weeks prior to presentation. With evidence of worsening osteomyelitis and a new soft-tissue infection, a Girdlestone procedure was performed. Intra-operatively, he was noted to have a pathological intertrochanteric fracture. Soft-tissue cultures yielded Pseudomonas aeruginosa; bone cultures grew Streptococcus dysgalactiae and Cladophialophora spp. Post-operatively, his wound was managed with negative pressure wound therapy with instillation and dwell (NPWTi-d). Delayed primary closure over a drain and topical negative pressure was done four days later. His course was uneventful, and he was discharged six days later. At his four-month follow-up, the wound was completely healed.
Invasive fungal infections are rare in immunocompetent individuals. Cladophialophora osteomyelitis has been found in immunocompromised individuals with concomitant cerebral abscesses. To our knowledge, this is the first case of osteomyelitis without previously known immunocompromise.
与IV期压疮相关的慢性骨髓炎是一种具有挑战性的病症，其特点是频繁复发且需要长期抗菌治疗。虽然革兰氏阳性球菌是最常见的病因，但也有真菌感染的报道，通常发生在免疫功能低下的宿主中。我们报告一例在无已知免疫功能低下患者中的枝孢菌属骨髓炎，该患者接受了吉氏成形术假关节置换术治疗。
一名70岁男性因发热、右髋部疼痛以及右大转子IV期压疮有脓性引流物而就诊于我们的急诊室。他的病史因脊髓室管膜瘤继发T10截瘫和多次脊柱手术以及近期明显体重减轻而具有重要意义。既往手术包括多次脊柱手术以及用钢板和外侧加压螺钉修复右股骨转子间骨折。这导致右大转子处术后形成压疮，需要股薄肌瓣移植。该肌瓣保持完整三年，然后再次溃疡。随后他发展为股骨头骨髓炎。为便于治疗，在就诊前三周取出了内固定物。由于有骨髓炎恶化和新的软组织感染的证据，实施了吉氏手术。术中，发现他有病理性转子间骨折。软组织培养结果为铜绿假单胞菌；骨培养结果为停乳链球菌和枝孢菌属。术后，他的伤口采用滴注式负压伤口治疗（NPWTi-d）处理。四天后在引流管上方进行延迟一期缝合并施加局部负压。他的病程平稳，六天后出院。在四个月的随访中，伤口完全愈合。
侵袭性真菌感染在免疫功能正常的个体中很少见。枝孢菌属骨髓炎已在伴有脑脓肿的免疫功能低下个体中发现。据我们所知，这是首例既往无已知免疫功能低下的骨髓炎病例。
