Successful Treatment of Saksenaea sp. Osteomyelitis by Conservative Surgery and Intradiaphyseal Incorporation of Amphotericin B Cement Beads
Résumé
Osteoarticular mucormycosis cases are quite rare and challenging infections that are mostly due to direct inoculation during traumatic injury among immu-nocompetent patients. Classic management includes a combination of aggressive surgical debridement, which may lead to amputation, and long-term systemic lipo-somal amphotericin B therapy. This article describes the successful treatment of Sak-senaea sp. osteomyelitis in a patient with diabetes mellitus, using a combination of systemic antifungal therapy and conservative surgery with insertion of amphotericin-impregnated cement beads. KEYWORDS Mucorales, amphotericin B, antifungal agents, osteomyelitis M ucorales osteomyelitis still presents diagnostic and therapeutic challenges and is associated with high mortality rates despite a combined therapeutic strategy involving antifungal treatment and surgery (1). Members of the order Mucorales are present in soil and plant debris and could be responsible for osteoarticular mucormy-cosis as a consequence of contamination through disrupted cutaneous barriers after traumatic injury (2). Surgical management is classically aggressive and complicated, with poor functional outcomes or even amputation. We report the first successful conservative orthopedic treatment of Saksenaea sp. osteomyelitis in a patient with diabetes mellitus, using in situ amphotericin-impregnated cement beads in combination with systemic posaconazole therapy. A 63-year-old man was admitted for a painful and swollen right ankle. He had well-controlled diabetes mellitus, hypertension, and degenerative arthritis. He lived in France and had never travelled overseas. Seven years earlier, he had suffered ankle trauma due to a rockfall and developed a necrotic subcutaneous abscess and a diaphyseal periosteal reaction seen on X-ray films. He underwent surgical drainage of the abscess; the sample cultures remained sterile and the surgical wound outcome was marked by a purple painless cutaneous infiltration. Seven years after the first operation, the patient's ankle became painful again and a bone biopsy was performed, which revealed no microorganisms in cultures. Empirical broad-spectrum antibiotherapy was initiated, without efficacy. Lower leg pain, erythema, and edema worsened and a satellite, 4-cm, right inguinal area of lymphadenopathy appeared. The patient was afebrile and had moderate biological inflammatory syndrome (C-reactive protein level, 50 mg/liter). Magnetic resonance imaging (MRI) showed decreased signal intensity on Citation Parize P, Mamez A-C, Garcia-Hermoso D, Dumaine V, Poirée S, Kauffmann-Lacroix C, Jullien V, Lortholary O, Lanternier F. 2019. Successful treatment of Saksenaea sp. osteomyelitis by conservative surgery and intradiaphyseal incorporation of amphotericin B cement beads.