case_images: PMC10868480_01
case_images: Clinical evolution. Timeline of the evolution of the case depicting the main events concerning the episode described, including onset of symptoms, hospital admission, diagnosis and management.
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case_images: PMC10868480_01_10.1177_20499361241231482-fig1.jpg
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case_images: Timeline of the clinical evolution of the case is summarized in Figure 1.
case_images: (a) Anterolateral X-ray of the left femur and the knee showing an osteolytic lesion of the distal metaphysis of the femur. (b) CT scan of both femurs and knees showing an osteolytic lesion of the distal metaphysis of the left femur. Arrows indicate the site of the lesion.. CT, computed tomography.
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case_images: PMC10868480_01_10.1177_20499361241231482-fig2.jpg
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case_images: (a) Culture sample of the excised femoral lesion. On the left, white colonies on chocolate agar media. On the right, cinnamon-brown colonies on PDA medium. (b) Lactophenol cotton blue preparation of culture sample of the excised femur lesion. At the top, relatively sparse conidiophores are seen with poorly defined phialides (20x). At the bottom, globose to elongated Hulle cells are seen in clusters (40x).. PDA, potato dextrose agar.
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case_images: fig3-20499361241231482
case_images: A filamentous fungus was cultured from the removed material (Figure 3).
case_images: (a) PET/CT of both femurs and knees after the surgical excision showing a nonspecific metabolic lesion in the left distal femur, with peripheral hypermetabolism and adjacent soft tissue, compatible with known fungal infection. (b) Chest PET/CT showing a focal uptake in the right retropectoral region, in the path of the axillary artery and vein. (c) CT angiography showing the remnant of the prosthetic graft sewn to the proximal third of the right axillary artery, located superficially to the pectoralis minor and in the interval between the sternocostal and clavicular heads of the pectoralis major (black arrow).. CT, computed tomography; PET, positron emission tomography.
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case_images: To rule out a potential disseminated invasive aspergillosis, a 18FFluoro-Deoxy-Glucose-PET CT (PET/CT) was performed on day +9, showing an increased metabolic gradient (defined as standardized uptake value, SUV) in the site of the excised femoral lesion (SUV max 6.78) and the right retropectoral region, in the path of the right axillary artery and vein with a maximum SUV of 8.02 [Figure 4(a) and (b)]. This find was then identified by CT angiography as a remnant of a prosthetic vascular graft sewn to the proximal third of the right axillary artery, through which a catheter-based micro-axial left ventricular assist device (Impella 5.0, Abiomed USA-Massachussetts) was previously implanted as bridge to transplant therapy [Figure 4(c)].
case_images: (a) Remnant of the prosthetic vascular graft sewn to the right axillary artery. (b) Thrombotic material found within the prosthetic vascular graft.
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case_images: Through a subclavicular incision, the remnant of the prosthetic vascular graft placed in the sinus of the right axillary artery and vein was identified [Figure 5(a)]; after proximal and distal control of the axillary artery, the graft remnant was removed, inside which thrombotic material was found [Figure 5(b)].