We describe an osteomyelitis of the hand of unusual fungal aetiology: Candida parapsilosis, without associated immunodepression, and whose site of infection also differs from that most usual by this agent, the spine. A 47 year old woman with a suppurating inflammatory lesion in the first finger of the left hand, after an accident with a knife weeks before. Despite normal analytical results an osteolytic image was seen in radiology, leading to drainage and cleaning of the affected area, culture and antibiogram. Results: Candida parapsilosis. It was treated with fluconazole with significant improvement. We considered the case of interest due to its atypical location and the absence of association to usual processes such as endocarditis, fungaemia, septic arthritis, peritonitis, endophthalmitis or prosthesis. In spite of treatment with ketoconazole and/or its derivatives, curettages, plasties or amputations have also been described as necessary.
Osteomyelitis; Candida parapsilosis; hand; immunodepression
Our objective is to present a clinical case of an osteomyelitis
in the hand due to Candida parapsilosis in a non-immunodepressed
patient. We consider this clinical case of interest given the
low frequency, almost absence, of this agent as a producer of
osteomyelitis of the hand. In the bibliography for example,
Weems found 8 cases of arthritis due to Candida parapsilosis and
there was no case with affected hand1. Also for the exceptional
fact that the patient did not have any associated pathology that
predisposed to this infection such as immunodepression,
endocarditis, meningitis, endophthalmitis, septic arthritis,
peritonitis associated to invasive intravascular procedures2,
parenteral nutrition solutions, ophthalmic collyria or
prosthesis1. All this led us to record this clinical case and to
review the bibliography on this microorganism and others related
to osteomyelitis of the hand.
present the case report of a 47 year old woman, without
pathological history of interest, who went to Emergency Area
having suffered a cut with a sharp object 3 weeks earlier at the
level of the second phalange of the first finger of the left
hand, which continued with inflammation and suppuration, and had
been draining gradually. Despite antibiotic treatment with
cephalosporins and an attempt at drainage at her health centre,
she had been presenting fever for 3 days and complained of a
substantial increase in the pain and swelling.
the time of the exploration there was no fever. We observed a
significant swelling at the level of the first finger of the
left hand, with an increase of the temperature at the affected
zone, which presented an erythematous aspect with an area of
fluctuation at the level of the distal phalange. The presence of
active mobility, although painful in this finger, was noted,
thus discounting tendon injury. An increase of local sensitivity
and the absence of signs of necrosis were noted.
Osteolytic lesion with sclerotic margins without rupture of the
cortex, at the level of the base of the second phalange of the
first finger of the left hand.
osteolytic lesion with sclerotic margins that did not break the
cortex, in the base of the second phalange of the first finger
of the left hand, with an image compatible with bone
Recovery phase and asymptomatic state with persistence of some
lesions with residual osteolytic aspect.
leukocytes: 6.7 U/μl
(4.6-10.2), neutrophils: 51.6% (37-80), ESR: 6 mm/hour (0-16)
and C Reactive Protein (CRP): 7.3 mg/L (0-5). Haematocrit,
haemoglobin and other parameters were within normal ranges.
lesion was drained with debridement, and samples were taken and
sent to microbiology for culture and antibiogram. Empirical
treatment was established with gentamicin and cefazolin.
Result of the
microbiological study: “Isolated microorganism: Candida parapsilosis, sensitive to amphotericin-B, fluorocytosine,
fluconazole and itraconazole”.
of the second phalange of the first finger of the left hand due
to Candida parapsilosis
in a non-immunodepressed patient.
patient was studied by the Infectious Service of our hospital,
verifying the absence of an immunosuppressed state. After
receiving the culture and antibiogram results it was decided to
start treatment with fluconazole at a dose of 200 mg per day
spread over two intravenous doses of 100 mg, along with local
dressing daily, for 15 days. The patient experienced clinical
improvement with the suppuration stopping and the wound evolving
favourably. At 15 days oral treatment was started consisting of
a 50 mg tablet of fluconazole every 12 hours, and 1 month after
her admission the discharge report was issued continuing with
the oral treatment.
at one month from discharge the culture was negative and she was
passed on to the Rehabilitation Service of our hospital which
reports a hyperextension and rigidity of the left thumb at the
level of the interphalangeal joint without any movement towards
the flexion, with the scar adhered to deep planes which prevents
the movement, with swelling and hypersensitivity in the scar
zone. Rehabilitation Service recommended active assisted
mobilization of the trapeziometacarpal, interphalangeal and
metacarpophalangeal joints of the thumb, with circular massage
in the scar, with percussion and in zigzag.
month later the asymptomatic state of the patient was clear,
although we observed a slight limitation of the function of the
left thumb. An improvement in the radiographic image has been
observed, although a lytic image persists in the control
radiograph, and also CRP values at 0.57 mg/L (0-5) and an ESR of
4 mm/hour (0-16), which is due to she has been discharged by the
Infectious Service after completing 4 months of antibiotic
treatment and by the Orthopaedic Surgery and Traumatology
Service, with the advice that if signs of the reactivation of
the process such as fever, pain or suppuration are observed, she
is a rarely described entity, normally associated to a late
manifestation of a disseminated candidiasis, this being more
frequent in immunodepressed patients, where the clinical course
is sometimes not controlled by amphotericin B.
In fact, Candida’s osteomyelitis has been described
exceptionally in locations such as the zygomatic arch in a
diabetic patient with oral candidiasis and possible direct
inoculation3; or at vertebral level, where it is also not
common4, and is very infrequent in the hand.
Also it has been noted after predisposing circumstances such as
previous trauma, treatments with multiple antibiotics after
surgery and non-lymphocytic leukaemia, in which case
amphotericin B has been effective and it has been considered as
an alternative to the use of other medications such as 5
fluorocytosine and/or ketoconazole.
Candida parapsilosis, in particular, is a fungus
associated to endocarditis in patients addicted to drugs by the
parenteral route, and is more and more considered as a
nosocomial pathogen, with clinical manifestations such as
fungaemia (up to 23% of cases, more frequent in men and with an
11% mortality)5, endocarditis, meningitis, endophthalmitis,
septic arthritis and peritonitis associated to invasive
intravascular procedures2, parenteral nutrition solutions,
ophthalmic collyria and prosthesis6.
As far as arthritis is described they are normally monoarticular
and sometimes located in the large joints, such as the knee, hip
or shoulder, and related to arthroplasties, arthrocentesis etc.
In a review, Weems found 8 cases of arthritis due to Candida
parapsilosis but in no case did he see an infected hand1.
There are cases where the infection does not precede from a
direct aggression of the joint as in the cases of addicts to
drugs by the parenteral route. Candida has also been isolated in
patients who were not addicted to drugs by the parenteral route;
thus, a study by Cuende et al., identified 3 cases of septic
arthritis: a case originating in a popliteal cyst infected by
Candida albicans, a case in a patient with acute myelogenous
leukaemia with arthritis of the knee and chemotherapy, and a
case of oligoarthritis in a patient with a cardiac transplant7.
It has also been found in the oropharynx of healthy neonates and
in asymptomatic diabetics.
Candida parapsilosis has been identified as a frequent
colonizing agent of the skin and particularly of the subungueal
space, with a predilection for media that contain glucose
solutions. The nosocomial acquisition of Candida parapsilosis
has been considered with interest, for which 98 patient were
studied in the ICU having presented evidence of the acquisition
of Candida parapsilosis through direct contact by means of the
hands of hospital personnel8. In fact, direct inoculation of the
fungus has been more frequently seen in the case of Candida
parapsilosis, with a better prognosis than in the case of
disseminated candidiasis. Its predilection for vaginal or buccal
epithelium, endothelial cells, fibrin clots or the inert
surfaces of catheters or similar is emphasised. Candida’s
osteomyelitis is sometimes associated to an infection of a
postoperative wound with intense local pain.
The most reliable diagnosis is by fine needle aspiration
puncture or open biopsy, also by later study by means of
enzymatic restriction analysis (ERA) and the study of the
With regard to infections of the hand, studies have been made on
infections of the metacarpals and phalanges and the presence of
fungal infections in 12% of the cases has been stated, Candida
parapsilosis being exceptional.
The entry points for the infection are considered to be
post-traumatic in 57% of cases, postoperative in 15% of cases,
haematogenous in approximately 13%, contiguous infections in 9%
of cases and 6% of cases of unidentified origin.
With regard to other agents, gram negatives have been stated in
15% of cases, mycobacteria in 3% and mixed infections in 35%.
All of them would form 74% of positive isolations9. In the same
way it is interesting to consider that infections of the
phalanges or metacarpals by various agents have also been
described such as:
- Mucormycosis, associated to a periungueal infection from local
trauma, open fractures, burns, fractures or intramuscular
injections, that require debridements, occasional biopsies and
treatment with amphotericin-B10.
- Staphylococcus Aureus in patients with severe atopic
dermatitis with infection of the distal phalanges, with
swelling, erythema and pain in the fingers, and even with the
isolation of Streptococcus viridans. Probably, skin already
harmed by a dermatitis could be a field of culture, as opposed
to smaller injuries of the fingers, to cause subungueal
micro-abscesses of these agents which would affect underlying
- Actinomycosis in metacarpals with the presence of sulphur-like
granules, strictly anaerobic conditions of growth, and limitable
with treatment with penicillin11.
- Tuberculosis at the level of the middle phalange of the hand.
Mycobacterium marinum in fish and/or seafood handlers.
- Anaerobes, especially Bacteroides, Fusobacterium,
Propionibacterium acnes, Clostridium from contiguous infection,
bites, peripheral neuropathy, traumas etc. Also Prevotella and
Porphyromonas from bites. Here it turns out especially useful to
know that among the factors that most influence the development
of osteomyelitis after a bite it is the delay of more than 24
hours in the debridement and the beginning of a suitable
- Salmonella, Coccidioides immitis, Varicella.
All of them would contribute to the wide aetiologic spectrum of
osteomyelitis of the hand. In most of the cases the treatment is
usually medical and surgical.
Candida parapsilosis would be treated with ketoconazole or its
derivatives and always having 5 fluorocytosine or amphotericin-B
as alternatives, also having certain control of the
microorganism with allylamine SF86-327, chlorpromazine and
As far as surgical treatment is concerned it is interesting to
emphasize curettage of the area of the lesion, and even possible
amputation, with a frequency of 39% in some studies9. Also other
procedures have been used in cases of infection of the
metatarsals such as the extensive debridement of the lesion,
reconstruction using an external fixing and spacer with
antibiotics and methyl methacrylate, following a bone graft13,
and sometimes fixing the autologous iliac crest graft with a
Herbert scaphoid screw 14. In other cases after curettage a
plasty is made with the interossei muscles 15.
of the hand requires a combined treatment, with antibiotherapy
and various surgical procedures. The taking of samples at the
beginning of the clinical picture or at the drainage of the
injury can be crucial at the time of approaching this pathology.
osteomyelitis of the hand is exceptional and we must especially
think about its appearance in cases of immunosuppression.
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