case_images: PMC9410996_01
case_images: Initial presentation in 2019:large fluid collection distal to the right knee on the medial aspect of calf.
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case_images: fig1
case_images: Trinidad presented to the emergency department at a large tertiary care academic medical center in 2019 with an area of fluctuance over her right proximal calf (Figure 1). The patient described a notable fluid collection on her right lower extremity for several months prior to presentation but experienced an acute episode of pain and increased swelling while visiting her daughter in the United
case_images: In Trinidad in 2017 before her primary total knee arthroplasty:large collection on the proximal, medial side of her calf distal to the knee.
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case_images: fig2
case_images: She did note that in the weeks prior to her primary right TKA in 2017, she had a similar appearing fluctuance in the same location that spontaneously "popped" (Figure 2) and resolved without treatment.
case_images: Preoperative total knee prosthesis.
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case_images: fig3
case_images: Radiographs were taken and were without fracture, dislocation, or gross signs of infection (Figure 3).
case_images: Histoplasma lactophenol cotton blue tape preps, 1000x, from the right knee joint aspirate culture.
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case_images: fig4
case_images: A lactophenol cotton blue tape mount was subsequently used to determine mold morphology for further diagnostic clarification:this preparation demonstrated characteristic findings of Histoplasma capsulatum on microscopic analysis, including numerous tuberculate macroconidia and septate hyphae (Figures 4-6).
case_images: Lactophenol cotton blue tape prep from the right knee joint aspirate culture, 1000x, with labeling of the morphologic structures used for organism identification.
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case_images: fig5
case_images: A lactophenol cotton blue tape mount was subsequently used to determine mold morphology for further diagnostic clarification:this preparation demonstrated characteristic findings of Histoplasma capsulatum on microscopic analysis, including numerous tuberculate macroconidia and septate hyphae (Figures 4-6).
case_images: (a) Right knee joint aspirate on BHI agar. (b) Right knee joint aspirate on IMA agar. (c) Right knee joint aspirate on Sabouraud dextrose agar.
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case_images: PMC9410996_01_CRIOR2022-8998996.006.jpg
case_images: fig6
case_images: A lactophenol cotton blue tape mount was subsequently used to determine mold morphology for further diagnostic clarification:this preparation demonstrated characteristic findings of Histoplasma capsulatum on microscopic analysis, including numerous tuberculate macroconidia and septate hyphae (Figures 4-6).
case_images: Right knee antibiotic spacer.
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case_images: PMC9410996_01_CRIOR2022-8998996.007.jpg
case_images: fig7
case_images: Postoperative X-rays demonstrated satisfactory alignment of the dowels (Figure 7).
case_images: Postop after the second stage of the TKA revision.
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case_images: fig8
case_images: Additionally, a fracture of the anterior femoral cortex was noted, requiring cerclage wires and a screw to prevent migration, as seen on X-ray (Figure 8).