Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases.

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment. LAY SUMMARY: Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

The Role of Adjunctive Therapies in the Management of Invasive Sino-Orbital Infection.

OBJECTIVE: Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection. METHOD & RESULTS: Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described. CONCLUSION: Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis.

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

Recommendations for managing Aspergillus osteomyelitis and joint infections based on a review of the literature.

OBJECTIVES: To produce recommendations for the management of Aspergillus osteomyelitis and joint infections. METHODS: Published literature was surveyed to identify both case reports of Aspergillus osteomyelitis and joint infections and anti-fungal pharmacology of anti-fungal agents. Included in the pharmacological review was an assessment of new and investigational anti-fungals to consider their potential role in the management of this infection. RESULTS: Successful treatments, identified from the cases reviewed, were based on combination anti-fungal therapy with one agent having good bone penetration and one having reliable anti-Aspergillus activity. CONCLUSIONS: For the management of serious Aspergillus osteomyleitis/joint infections amphotericin B in combination with flucytosine is recommended. A number of second line treatment combinations are identified. Monotherapy is appropriate with an azole in clinically stable patients.

Invasive fungal and bacterial infections of the temporal bone.

OBJECTIVES/HYPOTHESIS: Objectives were to highlight the importance of surgical therapy in treating invasive polymicrobial infections of the temporal bone, to discuss the importance of antifungal therapy, and to review the differential diagnosis of ear canal granulomatous disorders. STUDY DESIGN: Retrospective case review at a tertiary care medical center. METHODS: A retrospective chart review of all patients diagnosed with invasive polymicrobial temporal bone infections was performed. Four patients were identified. All patients required surgical therapy for definitive management. All patients were followed for at least 1 year or until death. RESULTS: Three of four patients had invasive fungi as pathogens. One patient had an occult squamous cell carcinoma. At the time of writing, one patient was free of disease, two were dead of disease, and one was alive with disease. CONCLUSION: Invasive polymicrobial temporal bone infections can occur in immunocompromised patients and can possibly harbor an occult malignancy. Surgical debridement may be necessary to arrive at a correct diagnosis. Modified radical mastoidectomy with parenteral antibiotic therapy and other adjunctive measures may be necessary for disease resolution.

Trans-superior meatal approach to the sphenoid sinus.

We have recently operated on patients with isolated lesions of the sphenoid sinus using the trans-superior meatal approach that we developed. This may be one of the least traumatic methods for treating the isolated lesions of the sphenoid sinus. Though it has a few limitations, this approach provides a direct and safe short-cut to the sphenoid sinus and is well tolerated by the patient under local anesthesia. We present our experience with transnasal trans-superior meatal approach to the sphenoid sinus and introduce the technique with case reports.

Successful treatment of simultaneous pulmonary Pseudallescheria boydii and Aspergillus terreus infection with oral itraconazole.

Pseudallescheria boydii and Aspergillus terreus are unusual opportunistic fungal pathogens that are often resistant to chemotherapy with amphotericin B. We report a case of simultaneous invasive pulmonary infection with these organisms occurring in a bone marrow transplant recipient who was successfully treated with the oral azole itraconazole.