Candida arthritis: 18 cases report and literature review

Abstract

Objective To analyze the clinical features of candida arthritis and to conduct literature review to improve diagnosis and treatment. Methods From January 2008 to June 2018, eighteen patients (5 females and 13 males) with candida arthritis were admitted to two hospitals. The mean age at diagnosis was 59±8 (range 48-71 years). The diagnosis was determined based on joint fluid aspirate in all cases and on intra-operative samples in 1 patients. Seventeen patients received MR examination, and on epatient who underwent total knee arthroplasty underwent knee X-ray examination. The clinical features, risk factors, clinical manifestations, etiology, treatment and prognosis are recorded. Results Knee joints were involved in all patients as infection sites. Seventeen patients had risk factors for candida infection, including diabetes mellitus in 2 patients, artificial joint replacement in 1, and glucocorticoid injection in the joint cavity in 16. Swelling and pain were presented in all cases. Peripheral blood leukocytes were increased or normal, while C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were increased. Magnetic resonance showed joint effusion and slip membrane hyperplasia. Joint turbidity and synovial hyperplasia were presented by arthroscopy. X-ray demonstrated swelling of soft tissue around the prosthesis and bone absorption around the prosthesis. The most frequent species was non-candida albicans. Susceptibility to antifungals was tested in all cases. Thirteen patients underwent surgery combined with antifungal therapy, while 4 patients only received antifungal therapy and 1 patient refused to treat. The duration of antifungal therapy was from 6 weeks to 52 weeks (median, 12 weeks). Twelve cases were treated with fluconazole and 1 with voriconazole, 1 with voriconazole and fluconazole, 1 with fluconazole combined with lipid formulation amphotericin B, 1 with terbinatine and fluconazole, 1 with flucytosine combined with fluconazole. Seventeen cases were followed up for 3 to 72 months. At final follow-up, twelve patients were healed, while 1 case was amputated and 4 patients relapsed and refused further treatment. Conclusion As a rare disease, candida arthritis is usually happened after artificial joint replacement and in high-risk patients with diabetes and immunosuppressant applications. In immunocompetent patients without surgery, infection may be related to multiple injections into the joint cavity with glucocorticoids. The infection may be difficult to be diagnosed and with poor prognosis. Surgery with long-term antifungal therapy is required. Key words: Knee joint; Arthritis; Prosthesis-related infections; Candidiasis