Candida septic Arthritis of the hip in a young patient without predisposing factors

734 CASE REPORTS

THE JOURNAL OF BONE AND JOINT SURGERY

CANDIDA SEPTIC ARTHRITIS OF THE HIP IN A YOUNG PATIENT WITHOUT

PREDISPOSING FACTORS

K. Kawanabe, H. Hayashi, M. Miyamoto, J. Tamura, M. Shimizu, T. Nakamura

From Kyoto Senbai Hospital and Kyoto University, Kyoto, Japan

e present a case of septic arthritis of the hip caused by

Candida albicans in a 24-year-old woman. This is the

first report of a Candida infection of the hip in a patient

without any predisposing factors. She underwent a two-stage

total hip arthroplasty three years after the onset of the

infection. An elevated plasma level of β-D-glucan suggested

Candida as the infecting organism and the diagnosis might

have been made earlier if this test had been undertaken at

presentation.

J Bone Joint Surg [Br] 2003;85-B:734-5.

Received 26 September 2002; Accepted after revision 19 December 2002

Septic arthritis caused by Candida species has been described

infrequently and there are usually associated predisposing factors.

1-6 We describe a previously healthy young patient who developed

septic arthritis of the hip caused by Candida albicans and

who underwent a two-stage total hip arthroplasty (THA).

Case report

A 24-year-old woman, with no previous significant medical history,

presented with a three-month history of pain in the right hip.

No specific investigations were undertaken and two years later she

was referred to our hospital. On examination there was tenderness

over the right femoral triangle without erythema, warmth, or swelling.

The movements of the hip were limited. She was afebrile. The

ESR was 56 mm/hr and the level of C-reactive protein 0.5 mg/dl

(normal <0.2 mg/dl). Tests for antinuclear antibodies (ANA),

human immunodeficiency virus and rheumatoid factor were negative.

The levels of serum immunoglobulins and CH50, C3 and C4

were normal.

A radiograph of the hip was normal apart from some osteopenia

of the femoral head. MRI revealed an effusion and synovial hypertrophy.

Culture of synovial fluid revealed a limited growth of Candida

albicans which was thought to be a skin contaminant. The

pain and radiographic destruction of the hip progressed and within

six months she required crutches for walking. There was narrowing

of the joint space and cyst formation (Fig. 1). A resection

arthroplasty of the hip was performed. The synovium and femoral

head grew Candida albicans, the presence of which was confirmed

by the Pas and Grocott stain (Fig. 2). The serum level of β-D-glucan,

which is a marker for fungal infection with a normal value is

<20 pg/ml, was measured by the Fungitec G test MK (Seikagaku

Corp, Tokyo, Japan) and found to be 210 pg/ml two days before

surgery. It decreased to 107 pg/ml ten days after surgery. Treatment

with oral fluconazole (200 mg/day) was started preoperatively.

She continued to use crutches and the level of β-D-glucan

W

Fig. 1

Radiograph of the right hip just before the resection surgery, three years after

the onset of the infection.

Fig. 2

K. Kawanabe, MD, PhD, Associate Professor Candida albicans and synovium (Grocott stain × 248).

J. Tamura, MD, PhD, Assistant Professor

M. Shimizu, MD, PhD, Assistant Professor

T. Nakamura, MD, PhD, Professor

Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University,

54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.

H. Hayashi, MD, PhD, Orthopaedic Surgeon

M. Miyamoto, MD, Orthopaedic Surgeon

Department of Orthopaedic Surgery, Kyoto Senbai Hospital, 447 Maegawacho,

Myohoin, Higashiyama-ku, Kyoto, 605-0932, Japan.

Correspondence should be sent to Dr K. Kawanabe.

©2003 British Editorial Society of Bone and Joint Surgery

doi:10.1302/0301-620X.85B5.13879 $2.00

CASE REPORTS 735

VOL. 85-B, No. 5, JULY 2003

decreased gradually to 22 pg/ml two and half years later, when she

underwent THA. At operation, 100 mg of amphotericin B was

added to 80 g of Endurance bone cement (DePuy CMW, Blackpool,

UK). Specimens of fibrous tissue obtained at surgery showed

no growth of Candida albicans. She was asymptomatic when

reviewed nine months after the operation.

Discussion

Patients who develop septic arthritis with Candida usually have

predisposing factors such as treatment with broad-spectrum

antibiotics1,3,6 or steroids,3,6 immunosuppressive therapy,3,5,6

malignancy,5,6,7 rheumatoid arthritis,2,8 joint aspiration7 or arthroplasty.

9,10 Romero et al11 described a case of Candida septic

arthritis of the knee in an immunocompetent patient who was not a

drug abuser and who had no other predisposing factors. The signs

and symptoms of Candida septic arthritis differ from those of other

causes of septic arthritis. Pain and swelling are present in all

patients but fever, warmth and erythema are rare in those with

Candida septic arthritis.1 The knee is more frequently involved

than the hip or shoulder.6 This case is the first report of involvement

of the hip in a previously healthy young patient without predisposing

factors.

Candida species can be isolated in healthy subjects from the

oral cavity, gastrointestinal tract, vagina, throat, sputum and

perineal skin,1 but rarely from exposed skin.12 The clinical

diagnosis of septic arthritis due to Candida may be difficult

because of the absence of specific signs and symptoms, and the

unusual nature of the organism. However, the presence of a positive

culture for Candida in the synovial fluid should not be

interpreted as a contaminant1,2,6,8 since this delays diagnosis

and treatment.2

β-D-glucan is a constituent of fungi and elevated plasma levels

are common in patients with mycosis or fungaemia.13 Serological

kits with proven clinical application have been developed for the

rapid diagnosis of mycoses.14 In this case, early diagnosis and a

better prognosis might have been possible if the serum β-D-glucan

level had been measured at the time of presentation.

No benefits in any form have been received or will be received from a commercial

party related directly or indirectly to the subject of this article.

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