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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2016;146:e13-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Primary cutaneous amyloidosis of the external ear: A peculiar, unusual and benign entity" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e13" "paginaFinal" => "e14" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Amiloidosis cutánea primaria del oído externo: una entidad peculiar, inusual y benigna" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1131 "Ancho" => 1500 "Tamanyo" => 443388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a. Clinical picture of lesions in the pinna (triangles). b. An intact but wave-like shape epidermis caused by the accumulation of hyaline material (marked with a star) in the dermis (H&E, ×20) is observed. The accumulated material is positive for Congo red. c. Showed positivity for high molecular weight cytokeratin (34βE12, ×20) using immunohistochemistry. d. Dermal deposit is negative for cytokeratin 5/6 (CK5/6, ×20).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Claudia Ramos-Rodríguez, Lucía González-López, Guillermo Romero-Aguilera" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Claudia" "apellidos" => "Ramos-Rodríguez" ] 1 => array:2 [ "nombre" => "Lucía" "apellidos" => "González-López" ] 2 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Romero-Aguilera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775315004510" "doi" => "10.1016/j.medcli.2015.07.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775315004510?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616301565?idApp=UINPBA00004N" "url" => "/23870206/0000014600000003/v1_201605310104/S2387020616301565/v1_201605310104/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Infectious arthritis with osteomyelitis due to <span class="elsevierStyleItalic">Scedosporium prolificans</span> in an immunocompetent patient" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e15" "paginaFinal" => "e16" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alfredo Jover-Saénz, Victoria Altermir-Martínez, Fernando Barcenilla-Gaite, Sònia Garrido-Calvo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alfredo" "apellidos" => "Jover-Saénz" "email" => array:1 [ 0 => "ajover.lleida.ics@gencat.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Victoria" "apellidos" => "Altermir-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Fernando" "apellidos" => "Barcenilla-Gaite" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Sònia" "apellidos" => "Garrido-Calvo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad Funcional para el Control de la Infección Nosocomial, Hospital Universitari Arnau de Vilanova, Lleida, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitari Arnau de Vilanova, Lleida, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Arnau de Vilanova, Lleida, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Atención Primaria, Área Básica de Salud Balàfia-Secà-Pardinyes, Lleida, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Artritis infecciosa con osteomielitis debida a <span class="elsevierStyleItalic">Scedosporium prolificans</span> en un paciente inmunocompetente" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The number of pathogenic filamentous fungi has increased in recent years. The genus <span class="elsevierStyleItalic">Scedosporium</span> is among the most prolific and accounts for up to 5% of total surveillance isolates in Spain,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> highlighting <span class="elsevierStyleItalic">Scedosporium prolificans</span> (<span class="elsevierStyleItalic">S. prolificans</span>) as the most aggressive and resistant species. The association with human infections of this ubiquitous dematiaceous fungus present in soil, water and potting soil, was unknown until 30 years ago.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It specifically affects immunosuppressed subjects (especially haematological) and, usually in a systemically disseminated manner, which entails a high mortality.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> However, its presence in healthy population is rare, and osteoarticular involvement even rarer. We report the case of a septic arthritis with osteomyelitis caused by <span class="elsevierStyleItalic">S. prolificans</span> after casual accident.</p><p id="par0010" class="elsevierStylePara elsevierViewall">16-Year-old male without medical history, who had fever of 38.5<span class="elsevierStyleHsp" style=""></span>°C and non-limiting serositis in the knee, of 4 days’ duration, after incisional wound with jardinière. An X-ray of both knees was normal. Blood test highlighted a PCR of 139<span class="elsevierStyleHsp" style=""></span>mg/l with normal blood counts. Arthrocentesis showed a blood fluid, 36,000<span class="elsevierStyleHsp" style=""></span>white blood cells/mm<span class="elsevierStyleSup">3</span> (96% polymorphonuclear [PMN]) and glucose of 53<span class="elsevierStyleHsp" style=""></span>mg/dl. In the fluid microbiological culture <span class="elsevierStyleItalic">Enterobacter cloacae</span> was isolated, pan-susceptible, treated with amoxicillin-clavulanate. The patient was readmitted for persistent arthritis 4 weeks later, despite the antimicrobial treatment, showing a triple white blood cell increase in the blood test (93% PMN) in joint fluid compared to the previous figure. This prompted a synovial debridement, arthroscopic lavage and a new culture, identifying by mass spectrometry (MALDI-TOF) <span class="elsevierStyleItalic">S. prolificans</span> resistant to itraconazole and fluconazole (MIC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>μg/ml), and amphotericin B (MIC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>μg/ml), and sensitive to voriconazole (MIC 2<span class="elsevierStyleHsp" style=""></span>μg/ml). Oral treatment was established with voriconazole 4<span class="elsevierStyleHsp" style=""></span>mg/kg/12<span class="elsevierStyleHsp" style=""></span>h plus terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg/day. A week after, joint effusion with inflammation still persisted, although the PCR was normalized, performing an MRI that showed a synovitis with loculated joint effusion and osteochondral fracture of the tibial plateau with osteomyelitic bone oedema. Given this result, a new and extensive cleaning debridement was performed by medial arthrotomy. Progression was positive after rehabilitation physiotherapy and antifungal treatment, monitored for 6 months, with full functional recovery of joint and muscle balance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Scedosporium</span> genus includes 2 species of clinical relevance: <span class="elsevierStyleItalic">Scedosporium apiospermum</span> (asexual form of the ascomycete <span class="elsevierStyleItalic">Pseudoallescheria boydii</span>) and <span class="elsevierStyleItalic">S. prolificans</span>. The latter is epidemiologically linked to temperate areas of southern Europe, especially Spain, where most infections have been described.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a><span class="elsevierStyleItalic">S. prolificans</span>, an opportunistic species, causes many entities in neutropenic subjects, ranging from skin infections, pneumonia, peritonitis and endophthalmitis to disseminated infections with target organ involvement, in about 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Osteoarticular involvement, in the form of septic arthritis and/or osteomyelitis, is rare, usually affecting young immunocompetent patients who have previously experienced a penetrating trauma. Its low suspicion and the temporal variability of its manifestations from the time of injury–in the case of osteomyelitis can be from 13 days to a decade<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>–may delay and even mask the detection of the fungus if other microorganisms are present. The diagnosis is based on the cytopathology and histopathology of the samples and fungus isolation in cultures, supported by molecular techniques, when the morphological features of the conidiophores are not observable under the microscope.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These infections are difficult to approach and the clinical knowledge about their progression is limited. According to the series, and in our case, treatment success lies in combining the systemic antifungal agents with extensive surgical debridement, sometimes repeated, with resection of necrotic material. Less than 10% of patients require amputation.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7</span></a> The high virulence of <span class="elsevierStyleItalic">S. prolificans</span>, as well as its high heteroresistance to most antifungals, limit the medical treatment options. The association of azoles and terbinafine has demonstrated <span class="elsevierStyleItalic">in vitro</span> synergy.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This coupled with the success described in the use of voriconazole in other infectious entities caused by this fungi genus,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> means that, at present, such a combination may be considered the first choice, unless the strains are pan-resistant. Intraarticular instilled polyhexamethylene biguanide can be added as adjuvant for greater effectiveness.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Since treatments over two months in patients aged <30, decrease the voriconazole concentration, and excessive amounts of antifungal agents produce neurological damage, plasma monitoring should be done in order to obtain adequate levels, between 1 and 5.5<span class="elsevierStyleHsp" style=""></span>μg/ml.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, the emerging presence of new fungi with high aggressiveness, such as <span class="elsevierStyleItalic">S. prolificans</span> requires early entity recognition and combined medical-surgical therapeutic application, which must be necessarily monitored.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jover-Saénz A, Altermir-Martínez V, Barcenilla-Gaite F, Garrido-Calvo S. Artritis infecciosa con osteomielitis debida a <span class="elsevierStyleItalic">Scedosporium prolificans</span> en un paciente inmunocompetente. Med Clin (Barc). 2016;146:e15–e16.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population-based survey of filamentous fungi and antifungal resistance in Spain (FILPOP Study)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Alastruey-Izquierdo" 1 => "E. Mellado" 2 => "T. Peláez" 3 => "J. Pemán" 4 => "S. Zapico" 5 => "M. 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Journal Information
Vol. 146. Issue 3.
Pages e15-e16 (February 2016)
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Vol. 146. Issue 3.
Pages e15-e16 (February 2016)
Letter to the Editor
Infectious arthritis with osteomyelitis due to Scedosporium prolificans in an immunocompetent patient
Artritis infecciosa con osteomielitis debida a Scedosporium prolificans en un paciente inmunocompetente
Alfredo Jover-Saénza,b,
, Victoria Altermir-Martínezc, Fernando Barcenilla-Gaitea, Sònia Garrido-Calvod
Corresponding author
a Unidad Funcional para el Control de la Infección Nosocomial, Hospital Universitari Arnau de Vilanova, Lleida, Spain
b Servicio de Medicina Interna, Hospital Universitari Arnau de Vilanova, Lleida, Spain
c Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
d Atención Primaria, Área Básica de Salud Balàfia-Secà-Pardinyes, Lleida, Spain
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