Chronic Femoral Osteomyelitis due to Cladophialophora in an Immunocompetent Patient

Author(s):
Nirbhay Jain; Christopher Horn; Adrian Coleoglou Centeno; John Mazuski; Obeid Ilahi; Grant Bochicchio; Laurie Punch

Background:

Chronic osteomyelitis is a challenging condition to treat and is characterized by frequent relapses and long-term antibiotics. While gram positive cocci are the most common pathogens, fungal infections have been reported, usually in immunocompromised hosts. We present a case of Cladophialophora osteomyelitis in an immunocompetent patient.

Methods:

A 70-year-old male presented to our emergency room with complaints of fever, right hip pain and purulent drainage. He had a medical history of spinal ependymoma and multiple spinal surgeries resulting in T10 paraplegia. He had previously sustained a right intertrochanteric hip fracture repaired with a plate and lateral compression screws and subsequently developed a decubitus ulcer over the greater trochanter which was treated with a gracilis flap. Six months prior to presentation, he re-developed a greater trochanter ulcer with femoral osteomyelitis. He underwent hardware removal two months prior to admission. He denied immunosuppression, diabetes, recent trauma or recent burns. He endorsed significant weight loss and had an admission body mass index of 18kg/m². His labs showed a hypochromic, microcytic anemia and hypoalbuminemia. Computerized tomography showed chronic osteomyelitis and progressive destruction of the femoral head.

Results:

He underwent a Girdlestone with placement of Negative Pressure Wound Therapy with Instillation-Dwell. He was noted to have a pathological fracture and extensive bony destruction. Soft tissue cultures grew Pseudomonas; bone cultures grew Streptococcus dysgalactiae and Cladophialophora species. Postoperatively he was started on broad spectrum antibiotics. Delayed partial primary closure (DPC) was done over a closed suction drain four days later with placement of topical negative pressure. The remainder of his hospital course was uneventful and he was discharged 6 days post-DPC. He underwent 7-weeks of antibiotics but received no dedicated treatment for Cladophialophora as the involved bone was completely resected.  At his 2.5 month follow-up, he was healed.

Conclusions:

The Cladophialophora genus consists of darkly pigmented molds that cause cerebral abscesses and cutaneous infections in immunocompetent and immunocompromised hosts. While there have been reports of osteomyelitis due to Cladophialophora, to our knowledge this is the first case of osteomyelitis in an immunocompetent host without concomitant cerebral abscesses. We hypothesize that his malnutrition resulted in functional immunocompromise.