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Candida albicans Prosthetic Joint Infection After Total Knee Arthroplasty: A Rare
Case Report

Article in Advanced Biomedical Research · December 2022

DOI: 10.4103/abr.abr_302_21

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Mohammad Mahdi Sarzaeem Reza Tavakoli Darestani

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Mojtaba Baroutkoub Alireza Manafi

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Case Report

Candida albicans Prosthetic Joint Infection After Total Knee

Arthroplasty: A Rare Case Report
Mohammad Mahdi Sarzaeem, Amin Norouz Beigi, Reza Tavakoli Darestani, Farzad Amuzadeh Omrani, Mojtaba Baroutkoub, Alireza Manafi Rasi
Department of Orthopedic, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract
In this article, a 75‑year‑old patient with pain in left knee and restricted range of motion following total knee arthroplasty (TKA) is presented.
Serological evaluation and aspiration of knee joint suggested a fungal prosthetic joint infection. After the diagnosis was confirmed, treatment
started with antifungal drugs, removing prosthesis, exhaustive debridement, and revision of TKA after efficient antifungal treatment. At one‑year
follow‑up, she has a painless motion range of 10 to 90 degrees, and there was no recurrence of infection observed.

Keywords: Arthroplasty, Candida, infections, joint, knee, prosthetic

Address for correspondence: Dr. Alireza Manafi Rasi, 7th Floor, Bldg No. 2 SBUMS, Arabi Ave, Daneshjoo Blvd, Velenjak ‑19839‑63113, Tehran, Iran.
E‑mail: drmanafi54@[Link]
Submitted: 30‑Sep‑2021;   Revised: 16‑Jul‑2022;   Accepted: 20‑Jul‑2022;   Published: 26-Dec-2022

Introduction Case Report

Prosthetic joint infections (PJIs) are dreaded complications In January 2020, a female patient with 75 years of age was
following total joint arthroplasty, which causes revision surgery. referred to our hospital with swelling, pain in the left knee, and
Gram‑positive bacteria, including staphylococci, are the major difficulty in walking for the last four weeks. She had history
inducers of PJIs[1] but fungal infection are rare yet devastating and of left total knee arthroplasty (TKA) surgery in April 2019
represents 1% of all PJIs and the prevalence has increased in recent for post‑traumatic degenerative joint disease. She had car
decade.[2‑4] Risk factors of the fungal PJI are immunosuppressive accident two years earlier in January 2016. After 2.5 months,
conditions due to disease and drugs, drug abuse, prolonged use she presented with pain in left knee (following exertion the
of antibiotics, and many more.[5,6] The diagnosis of fungal PJI pain incremented and it was reduced with rest) and restricted
may be challenging and repetitious joint aspiration might be range of motion and during the past days, the pain markedly
required.[7] Furthermore, managing fungal PJI can be associated increased. The patient went through a healthy period after
with further challenges considering the difficult treatment and the TKA. She was also diagnosed with diabetes mellitus
high possibility of persistent infection.[8‑11] Also, considering and ischemic heart disorder and had no history of cancer,
its low frequency, no standard guidelines are described for rheumatoid diseases, renal diseases, tuberculosis, hepatitis, or
diagnosing and treating these infections.[7] Relatively different human immunodeficiency virus infection. Her drug history was
treatment regimens have been described in few literary reviews metformin, glibenclamide, metoral, nitrocantin, and aspirin.
and case reports for fungal PJI.[7‑11]
On physical examination, a 15‑cm vertical healed surgical
Therefore, fungal PJI is rare complication of total joint scar of the primary TKA was observed on the anterior side of
arthroplasty that has not been frequently investigated. In this left knee [Figure 1]. Her body temperature was 37.8 cg, blood
study, a case of fungal PJI with Candida tropicalis is reported,
who was successfully treated despite all the challenges. This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
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How to cite this article: Sarzaeem MM, Norouz Beigi A, Tavakoli Darestani R,
DOI: Amuzadeh Omrani F, Baroutkoub M, Manafi Rasi A. Candida albicans
10.4103/abr.abr_302_21 prosthetic joint infection after total knee arthroplasty: A rare case report.
Adv Biomed Res 2022;11:111.

© 2022 Advanced Biomedical Research | Published by Wolters Kluwer - Medknow 1

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Sarzaeem, et al.: Fungal infection in TKA

pressure 135/80 mmHg and heart rate 96 bpm. The cardiac

sounds had no anomalies or murmurs, and the lung fields were
clear to auscultation. The electrocardiography demonstrated
normal sinus rhythms. The local skin temperature was raised
with wound drainage and the motion range was limited in
flexion. Also, flexion of the knee caused pain. There was no
sign of malformation. The patient’s neurological health was
observed to be unharmed, and distal pulses were clearly felt.
An inflammatory syndrome was observed via the laboratory tests;
white blood cell (WBC) was 12000 mm3, polymorphonuclear
leucocytes (PMN) 87%, C‑reactive protein (CRP) 81 mg/L,
and erythrocyte sedimentation rate (ESR) 46 mm/hr). Also,
negative results were observed regarding antinuclear antibody,
rheumatoid factor, anti‑streptolysin O, and human leukocyte
antigens–B27.
Figure 1: Swelling and vertical midline healed surgical scar
Radiological evaluation showed the osteolysis over the
posterior femoral condyles, anterior femoral cortex, and under
the tibial base plate.
Therefore, PJI of the knee was suspected according to the
laboratory results, radiological and physical evaluations.
Aspiration of knee joint was performed in sterile conditions and
5 ml of the fluid was sent for analyzes. The fluid was dull with
low viscosity, WBC count was 16,000/cubic mm, with 72%
PMN. Gram staining was negative, however, 10% KOH mount
was positive, which suggested possible fungal infections.
Then, device removal and debridement with local antibiotics and
local antifungals including vancomycin, amphotrypsin done,
and finally, a spacer with cement containing gentamicin (4.8 g),
vancomycin (4 g), and targocid (1.2 g) was placed.
Figure 2: X‑rays showing antibiotic impregnated PMMA (polymethyl
For the patient during hospitalization antibiotic in methacrylate) spacer and intramedullary rods as after prosthesis removal
cloud (vancomycin (4 g), imipenem, meropenem, and
rifampin) plus antifungal (amphotericin B and voriconazole)
was done [Figure 2]. Fungal culture was positive for Candida
tropicalis and bacterial culture was negative. After almost
4 months, including Six weeks of injectable antibiotics and
ten weeks of oral antibiotics, including fluconazole 150 mg
twice a day, ciprofloxacin 500 mg orally three times a day, and
clindamycin 150 mg three times a day with the subsidence of
the patient’s symptoms and negative inflammatory markers
TKA was reimplanted after the spacer was removed with a
new hinged prosthesis [Figure 3]. Also, several tissue samples
were obtained preoperatively and sent for culture.
After surgery, the patient received antibiotic with combination
of intravenous voriconazole (with a loading dosage of 6 mg/kg a b
two times a day and a maintenance dosage of 4 mg/kg two
Figure 3: Anteroposterior (a) and lateral (b) radiography of left knee
times a day). The patient was discharged after seven days,
joint at 12 months follow‑up showing implantat 12 months follow-up
and follow‑up was performed at weekly intervals. Following showing implant
14 weeks, the ESR and CRP were within normal limits.
Adequate improvements at the surgical wound site and after
physiotherapy, a motion range of the knee was associated with Discussion
no pain and functional impairments. Now, the swelling and PIJ is a devastating complication which threatens
effusion was seen on knee examination and the patient is under both function and life. Fungal PJI is rarely reported
antifungal (Fluconazole 150 mg/daily) therapy. worldwide especially in Iran and occur in patients with

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Sarzaeem, et al.: Fungal infection in TKA

immunocompromised condition, such as underlying systemic frequently implemented antifungal agents; however, their
illness (diabetes mellitus, rheumatoid arthritis), malignancy, complications are greater than itraconazole and voriconazole
or inappropriate use of antibiotics, indwelling catheters, and in toxicity.[8] In a recent report, Brooks DH et al.[13] studied a
many others.[11‑14] and our patient had diabetes mellitus as a risk patient with Candida PJI after TKA, and the therapy with a
factor. Moreover, Wu and Hsu studied a case with preoperative combination of micafungin and voriconazole was successful.
cutaneous candidiasis who had fungal PJI,[14] while no initial In another article, a long‑term study of Candida demonstrated
source of fungal infections was observed in our case; therefore, that fluconazole has an appropriate antifungal efficacy with
underlying systemic illness was the main risk factor for fungal fewer complications.[11] The related discrepancies in terms
PJI in our case. of the types of antifungal treatment demonstrate that more
studies are required in this regard for optimizing the protocols
In previous case reports, Candida albicans was observed to be
of managing fungal PJI.
the most frequent pathogen in fungal PJI followed by Candida
parapsilosis.[6] While, we found Candida tropicalis as agent Various findings were obtained in this study. Initially, in
for fungal PJI in our case. case of suspecting a primary fungal PJI, we should perform
a comprehensive evaluation for confirming the diagnosis,
Established studies have shown that the major clinical signs
such as a thorough serological evaluation (e.g., ESR, CRP),
and symptoms of fungal PJI include pain, erythema, swelling
radiographic exploration, and knee joint aspiration to obtain
or wound discharge, fever, or shivering.[11] In the present study,
joint fluid for culture. Following confirmation of the diagnosis,
the patient’s primary symptoms were clear and we observed
treatment must be initiated with antifungals. After that, if the
pain and restricted range of motion with increased local skin
infection disappears, revision of TKA can be carried out.
temperature and wound discharge with low grades of fever.
Due to insufficient study and data on the specific serological
parameters, we could not evaluate or perform. However,
Conclusion
some studies showed that following a fungal PJI, nonspecific In general, it was concluded that fungal PJI is a serious
serological infectious parameters (CRP, ESR, and WBC count) complication and its management may be associated with
increase.[11‑14] Fungus culture is not performed as a routine test more challenges than bacterial PJI. Candida PJI after TKA can
in various hospitals like ours. In most cases with negative be appropriately treated by antifungals, prosthesis removal,
bacterial culture from synovial fluid aspiration, especially exhaustive debridement, and revision of TKA after efficient
Mycobacterium tuberculosis, may not be excluded but antifungal treatment.
based on patient condition and risk factors for developing Declaration of patient consent
fungal PJI (such as immunosuppressants, catheterization, The authors certify that they have obtained all appropriate
and cutaneous fungal infections), we should consider fungal patient consent forms. In the form the patient(s) has/have
infection. As mentioned in our study, aspiration of the given his/her/their consent for his/her/their images and other
respective knee is the major method of detecting fungal PJI, clinical information to be reported in the journal. The patients
especially with a sufficient incubation duration of 5‑14 days. understand that their names and initials will not be published
Suitable media for promotion fungal isolations are Sabouraud and due efforts will be made to conceal their identity, but
Dextrose Agar and ChROMagar Candida.[13] anonymity cannot be guaranteed.
Considering low prevalence of fungal PJI, there are no
Financial support and sponsorship
guidelines on the suitable treatment of fungal PJI. [12]
Nil.
Moreover, fungal PJI is difficult to eradicate, due to indolent
clinical presentation and delayed diagnosis. But several Conflicts of interest
different treatment methods with variable outcomes have There are no conflicts of interest.
been reported including administration of antifungal agents,
resection arthroplasty, debridement with maintained prosthesis,
single‑stage or double‑stage exchange arthroplasty, and
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