A 92-year-old woman with a history of hysterectomy and bilateral salpingectomy at 20 years of age due to genital and peritoneal tuberculosis.
She also had an antral gastric lymphoma and underwent a subtotal gastrectomy at approximately 40 years of age, without recurrence.
She resided in the urban area of Santiago de Chile, in a solid construction house where she feeds signs living in the garden.
The patient was admitted to the Hospital Del Salvador recently diagnosed with fever and a psychiatric institution in which he had consulted a month before for a two-month history of pain and inflammation in the right knee with significant functional limitation, without any complication.
She had a right knee X-ray taken at the beginning of her disease, which showed a slight decrease in the femoral-rotulian space.
On physical examination at admission, a patient was afflicted with stable hemodynamics, malaise, palpitations, severe arterial stiffness in the right knee, pulse 78/min, respiratory distress 22/ limitation, and an increase in temperature.
Other fixtures.
Laboratory tests: Hematocrit: 32%, leukocytes: 7,000 albumin/HIV serum levels 3.6mm3, erythrocyte sedimentation rate 83 mm/hour, CRP 56 mg/dl (VN < 5 mg/dl), blood glucose levels
Due to the presence of monoarthritis, arthrocentesis was performed, obtaining only 1 ml of synovial fluid of cloudy appearance.
Cell count was 32,000 cells/mm3 without crystals.
Microbiological study of this joint fluid included direct examination with Gram stain, blood agar culture, chocolate agar, thioglycolate broth, brain-heart broth and Lowenstein-Jensen medium.
No bacteria or yeast elements were observed in direct Gram stain.
At 48 hours the growth of mucous colonies and ring-binders (AID and cream color system) was observed in blood and chocolate agars, which were identified as C. neoformans by the biochemical tests of urease plus Ramelrie
Given the unusual finding, a second sample of joint fluid was requested to confirm the diagnosis, which was obtained 7 days after the new dressing was removed. A single bottle of articular fluid was used for the first puncture, which showed growth disturbance.
Gram stain and Chinese ink were performed on the hemocultive bottle.
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Simultaneously, two new blood samples were collected for cultures, the same microorganism being unfolded 18 days after collection.
A serum sample for detection of Cryptococcus antigen by qualitative latex technique (Remel) was positive.
Susceptibility to amphotericin B, fluconazole, itraconazole and ketoconazole was determined in vitro by agar diffusion technique with Rosco tablets in Shadomy medium and by E-TestMR, resulting susceptible to all antifungal agents.
The MICs were: fluconazole 1.0 μg/ml at 24 h and 2.0 μg/ml at 48 h; itraconazole 0.094 μg/ml and ketoconazole 0.016 μg/ml at 24 h and 48 h, respectively
The radiological evolution showed a significant loss of the femoral-tibial space in two months, with some small erosive images in the articular margins and a marked increase in soft tissues.
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On the eighth day after admission, and once the in vitro susceptibility of the strain was known, treatment with oral fluconazole 200 mg/day was initiated. At the same time, an arthroscopy was performed, which showed significant synovial proliferation, pracectomy.
Histopathology showed a chronic granulomatous inflammatory process with foreign body giant cells and fragments of necrotic bone tissue.
A tissue infiltrate was observed, with abundant white and oval microorganisms, approximately 7.5 to 10 μm positive for mucus staining.
C. neoformans also grew in the culture of these synovial tissue samples.
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A clinical pulmonary focus was established by chest CT and an endocardial focus with transesophageal echocardiography.
We tried to obtain CSF for study but the lumbar puncture was frustrated.
A study was also performed to rule out osteoarticular tuberculosis, with PCR and culture for Mycobacterium in synovial tissue, and tuberculin test (PPD), all with negative results.
During hospitalization an upper endoscopy and biopsy were performed without evidence of recurrence of gastric lymphoma.
On the fifth day of admission, she presented with feverish elevation and an uroactive bladder with ceftriaxone-sensitive Proteus mirabilis, which was treated for 7 days and then maintained with good response.
After arthroscopy and initiation of medical treatment, there was significant regression of inflammatory signs in the right knee and recovery of mobility.
The patient was discharged after 3 weeks of antifungal treatment, with indication of maintaining oral fluconazole until completing 6 months.
The controls were terminated and the patient was informed of his death at home, three months later, due to unknown cause.
