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Abstract
BackgroundTraumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively.Case reportA 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels.ConclusionUnusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.
Highlights
Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms
Myceliophthora thermophila is a thermophilic phaeoid mould found in pasture soil, wood chips, straw, mouldy hay, compost piles and other environmental settings where heat is generated
We recently cared for a 4-1/2 year old boy who developed osteomyelitis of the distal femur caused by direct inoculation of Myceliophthora thermophila via a pitchfork injury to his knee
Summary
Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively. Case report: A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. The primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels
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