Subcutaneous and elbow joint infection with Scedosporium apiospermum in a patient with rheumatoid arthritis
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory systemic disease, which in its essence and treatment leads to a higher incidence of infections. We describe a rare case of a 63-year-old male patient with many years of history of RA (treated with corticosteroids and conventional synthetic disease-modifying antirheumatic drugs), who developed subcutaneous and joint infection caused by fungus Scedosporium apiospermum (perfect stage Pseudallescheria boydii) after fifteen years of RA.
Fungal agent from indolent subcutaneous lesions on his left forearm and right arm was found on microscopic and microbiological examination. The patient subsequently underwent a six-month cyclical treatment with voriconazole, which was alternated several times with itraconazole and terbinafine.
After several cycles of six-month treatment, usually after about a year, a relapse occurred with repeated manifestation in the subcutaneous tissue and finally percontinuitatem even in the joint. After seven years of repeated outbreaks of fungal infection the patient dies of a sudden death with a clinical picture of thromboembolic disease.
Autopsy results did not show active infection or overt infectious focus. Scedosporium apiospermum is fibrous, saprophytic fungus with relatively low virulence that is ubiquitously present in the environment, including soil and aquatic ecosystems.
It is one of the typical causes of subcutaneous mycoses, the presence of which is largely tied to the subtropical region. In case of an immunosuppressed patient, infection by S. apiospermum may develop into severe systemic infection.
Clinical observation completes the set of possible infectious complications in patients with RA.