Chronic Candida Arthritis in Leukemic Patients

Abstract

SIR-We read with interest the report of Fainstein et al. [1] as well as their review on candida arthritis in patients with cancer. Since the data on the pathology of candidal arthritis in humans are very limited, we would like to draw attention to a case not included in their review; it involved a patient with acute myeloblastic leukemia [2]. Because of misdiagnosis despite positive joint cultures, this patient had a chronic arthritis of the knee due to C. albicans that evolved over a nine-month period during which there was no specific treatment. A synovial biopsy was performed four months after appearance of the first symptoms and revealed nonspecific histologic signs of inflammation and no visible fungi. Radiographs of the joint performed eight months after onset revealed patchy areas of rarefaction in the femoral epiphysis. There was transient improvement when amphotericin B was started eight months after onset, but the patient soon died of his underlying disease. At autopsy there was evidence of disseminated visceral fungal infection presenting as pseudotumoral nodules. The affected knee joint showed localized cartilaginous erosions; microscopic examination showed that these were riddled with numerous fungal filaments. The adjacent bone showed atrophy but no foci of infection. This case of a chronic C. albicans arthritis in a leukemic patient shows that radiologic abnormalities as well as cartilaginous lesions may develop with time. This observation is in contrast to the lack of cartilage and bone involvement observed by Fainstein et al. in their patients with acute C. albicans arthritis. In the latter group the lesions remained surprisingly limited despite the incompetence of the patients' host defenses.