Background: 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.
Case report: 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.
Conclusion: 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.
Keywords: chronic osteomyelitis; fungal infection; girdlestone arthroplasty; osteomyelitis.